Children who are Black are more likely to present with arthritis instead of cutaneous signs of Lyme disease, resulting in increased diagnostic disparities, according to study findings published in Clinical Infectious Diseases.1
Erythema migrans, the rash characteristic of Lyme disease which appears as a bullseye or in varying shapes, may not be as recognizable in individuals with darker skin tones. Other factors may reduce the ability to accurately diagnose Lyme disease, including atypical presentation, rashes over areas with limited visibility, and preconceptions associated with exposure risk. Previous study findings indicate that the bullseye rash occurs among only ~20% of infected patients, and up to 70% of infected patients may develop a rash of varying shapes.2
To analyze factors influencing the diagnosis of Lyme disease among children, researchers in the United States conducted a prospective cohort study across 8 emergency departments (EDs) between June 2015 and August 2022. They studied the relationship between race/ethnicity and the diagnosis and presentation of Lyme disease using data captured from 4003 children who were evaluated for infections suggestive of Lyme disease. The primary outcome was incident Lyme disease, defined as either a 5-cm sized erythema migrans lesion and/or positive 2-tiered Lyme disease serologic findings.
Among patients included in the analysis, 56.6% were boys and the median age was 8 (IQR, 5-13) years. Self-reports of race were completed by 3948 (98.6%) patients, of whom 77.9% were White, 12.3% were Black, 10.2% were Hispanic, and 2.4% were Asian.
A total of 957 patients (23.9%) were diagnosed with Lyme disease, with most (n=869; 90.8%) demonstrating positive 2-tiered serology alone. The remaining patients with Lyme disease had diagnostic erythema migrans lesions alone (8.6%), and a small percentage of patients (0.6%) had both positive 2-tiered serology and erythema migrans. Of patients diagnosed with Lyme disease who were Black (n=487) and those of other races/ethnicities (n=3461), 35.1% and 45.4% had neurologic symptoms, respectively, including headache, meningismus, and facial palsy.
After adjustments for age and county-level Lyme disease incidence, the researchers found that patients who were Black were less likely to receive an accurate diagnosis of Lyme disease in the ED compared with patients of other races/ethnicities (adjusted odds ratio [aOR], 0.63; 95% CI, 0.48-0.81).
Further analysis of patients after stratification by race/ethnicity showed that those who were Black were also less likely to have cutaneous manifestations of Lyme disease (aOR, 0.34; 95% CI, 0.14-0.79). However, Black patients with Lyme disease were more likely to present with edema of the joints (aOR, 3.68; 95% CI, 2.13-6.36)
Study limitations include a lack of generalizability, potential selection bias, and the reliance on county-level data for Lyme disease incidence.
“There are several potential reasons for differences in rates of Lyme diagnosis by race,” the researchers noted. “Improving education and guidelines around Lyme diagnosis across different skin types is warranted to reduce disparities in Lyme,” they concluded.
Editor’s note: The second paragraph of this article was updated on December 19, 2022, with additional information about the clinical presentation of Lyme disease.
Disclosures: Several authors reported affiliations with industry. Please see the original reference for a full list of disclosures.
- Hunt KM, Michelson KA, Balamuth F, et al. Racial differences in the diagnosis of Lyme disease in children. Clin Infect Dis. Published online October 31, 2022. doi:10.1093/cid/ciac863
- Aucott JN, Crowder LA, Yedlin V, Kortte KB. Bull’s-eye and nontarget skin lesions of Lyme disease: an internet survey of identification of erythema migrans. Dermatol Res Pract. Published online October 24, 2012. doi:10.1155/2012/451727