Challenging Diagnoses

I enjoy reading Lisa Sanders’ column on Diagnosis that appears bi-weekly in the New York Times magazine, and yesterday’s clinical story: She Had a Long and Strange Rash on Her Arm.  What Was It? packed its usual surprise punch.  Because the 41 year-old patient in question had been spending time rehearsing dance choreography in an old barn in Martha’s Vineyard, infectious disease specialists who saw pictures of it were betting on Lyme Disease.  But when she sent the photo to her doctor through her patient portal, she referred her to a local infectious disease specialist for closer evaluation despite having started her immediately on an antibiotic prescription.  Examining her in person, the infectious disease specialist recognized the rash immediately.  “Were you drinking Coronas on the beach?” he asked.


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Turns out she wasn’t drinking Coronas on the beach, but because she was dancing for so many hours each day she was drinking lots of water into which she’d squeeze some lime to add flavor.  At some point the lime juice must have dripped down her arm, and when she didn’t rinse it off the chemicals in the juice (furocouomarins) it caused a classic skin rash (phytophotodermatitis) when activated by sunlight.  Because the rash takes up to 24 hours to emerge, the cause and effect between the juice and the rash isn’t always obvious to the patient or to the doctor.  It was entirely reasonable, at first blush, to attribute the skin rash to Lyme rather than lime or what has become known as margarita dermatitis.


Last year I blogged about Mei, a patient in our practice diagnosed with Lyme Disease.  She and her mother helped me to become considerably more Lyme literate.  As a reader of this blog communicated to me regarding his wife who has chronic Lyme, many of us have only touched the surface.  So my eyes are always open to learning more about the condition, and in that vein I can heartily recommend a new book recently published on the subject.


As Fallon and Sotsky note, the immune response to Lyme commonly gives rise to joint pain or swelling, muscle pain, marked fatigue, headaches, irritability, cognitive problems, and less often to cranial nerve palsy.  Particularly if the patient lives in or has recently spent time in a Lyme endemic area, antibiotic treatment should be started immediately for presumed Lyme disease.  However the impact of chronic Lyme on the visual system is often left untreated.  Dr. William Padula has written a nice blog addressing this issue.  In addition, Dr. Padula will headline a multi disciplinary symposium at this year’s NORA meeting on the Consquences of Lyme-Related Disease on Visual Processing.

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