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Periumbilical Erythema Migrans

An 80-year-old man presented to the dermatology emergency department in August with a 4-day history of a rash on his abdomen. Five days before the onset of the rash, the patient had been working in his garden. Skin redness had first developed around his umbilicus and then had gradually spread outward. He had no associated fevers, chills, fatigue, or myalgias. Physical examination was notable for periumbilical erythema and a small gray protrusion in the umbilicus (Panel A). With the use of surgical forceps, the protrusion was grasped securely at its attachment site at the base of the umbilicus and extracted, revealing an engorged adult female tick (Panels B and C) that was identified as Ixodes ricinus. A diagnosis of erythema migrans, a cutaneous manifestation of early Lyme disease, was made. Erythema migrans does not always manifest with central clearing or systemic symptoms. The diagnosis of erythema migrans is made clinically, because infected persons are usually seronegative early in the course of Lyme disease. Treatment with doxycycline was given. After 10 days, the patient’s rash had resolved.
Paul Bellmann, M.D., and Barbara C. Böckle, M.D.
Published December 29, 2025
N Engl J Med 2026;394: e3
DOI: 10.1056/NEJMicm2512486
VOL. 394 NO. 1


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