LAUSR

An otherwise healthy 78-year-old woman presented with a diffuse, mildly itchy rash of 5 days’ duration with associated fatigue, chills, decreased appetite, and nausea. She reported waking up with her arms “feeling like they weigh a ton.” She denied any pain, bleeding, or oozing and was unsure if new spots were continuing to develop. The patient reported having allergies to numerous medications but denied any new medications or recent illnesses. She had recently spent time on a farm in Minnesota, and upon further questioning she recalled a tick bite 2 months prior to presentation. She stated that she removed the nonengorged tick and that it could not have been attached for more than 24 hours. Her medical and family history were unremarkable. Physical examination showed multiple annular pink plaques with a central violaceous hue in a generalized distribution involving the face, trunk, arms, and legs with mild erythema of the palms. The plantar surfaces were clear, and there was no evidence of lymphadenopathy. The remainder of the physical examination and review of systems was negative. Laboratory screening was notable for an elevated erythrocyte sedimentation rate and C-reactive protein level with negative antinuclear antibodies.