ERYTHEMA MIGRANS-LIKE RASH ILLNESS AT A CAMP IN NORTH-CAROLINA - A NEW TICK-BORNE DISEASE

Background: Borrelia burgdorferi, the causative agent of Lyme disease, has never been isolated from a patient thought to have acquired Lyme disease in any southeastern state. Objective: To investigate 14 cases of an erythema migrans (EM)-like rash illness that occurred during 2 s ummers at an outdoor camp in central North Carolina in an effort to de termine the etiologic, epidemiological, and clinical aspects of this i llness. Methods: Using active surveillance, we identified cases of cli nically diagnosed EM in residents and staff of the camp. We collected clinical and demographic information; history of exposure to ticks; ac ute and convalescent serum antibodies to B burgdorferi, Rickettsia ric kettsii, and Ehrlichia chaffeensis; and cultures for spirochetes from biopsy specimens of skin lesions. Serum samples from a group of reside nts and staff who did not develop rashes were tested for the same anti bodies. We speciated ticks removed from people and collected from vege tation. Results: We identified 14 cases of EM-like rash illness during the 2 summers. Of the 14 case-patients, 10 had associated mild system ic symptoms and 1 had documented fever. All 14 case-patients had remov ed attached ticks, and 8 remembered having removed a tick from the sit e where the rash developed a median of 12 days earlier (range, 2-21 da ys). One tick removed from the site where a rash later developed was i dentified as Amblyomma americanum, the Lone Star tick; 97% of ticks co llected from vegetation and 95% of ticks removed from people were A am ericanum. No spirochetes were isolated from skin biopsy specimens. Pai red serum samples from 13 case-patients did not show diagnostic antibo dy responses to B burgdorferi or other tick-borne pathogens. Conclusio ns: This investigation suggests the existence of a new tick-associated rash illness. We suspect that the disease agent is carried by A ameri canum ticks. In the southern United States, EM-like rash illness shoul d no longer be considered definitive evidence of early Lyme disease.