Figure 6

Classic bull's eye EM with initial misdiagnosis as urinary tract infection. A 78 year old women presented to an urgent care center with 3 days of fever, mild headache and the absence of rhinitis, cough or typical upper respiratory viral symptoms. The physical exam showed a temperature of 102 degrees Fahrenheit and a skin rash was not noted. Urinalysis showed 5–10 WBCs, a diagnosis of pylonephritis was made, and ciprofloxacin was initiated. The patient returned the following day when she noticed a large, red rash on her side. The patient was referred to one of the authors (JA) who confirmed the diagnosis of Lyme disease. Ciprofloxacin was discontinued, doxycycline initiated and the rash resolved. Serology returned with a positive ELISA and confirmatory western blot.