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BACKGROUND: The diagnosis of erythema migrans (EM), the characteristic rash of early Lyme borreliosis, is based primarily on its clinical appearance since it often occurs prior to the development of a specific antibody response. Other skin disorders, however, may be confused with EM. METHODS: Between June 1991 and September 1993, a prospective study was conducted at the Lyme Disease Diagnostic Center of the Westchester County Medical Center to isolate Borrelia burgdorferi systematically from patients with EM, and to characterize the clinical manifestations of patients with culture-documented infection. Skin biopsies and/or needle aspirates of the advancing margin of primary lesions, and blood specimens from adult patients were cultured for B burgdorferi in modified Barbour-Stoenner-Kelly medium at 33[Degrees]C. RESULTS: B burgdorferi was recovered from 79 patients (49 [62%] males) ranging in age from 16 to 76 years old (mean, 43 [+ or -] 14 years old). Maximum EM diameter (mean, 16 [+ or -] 10 cm; range, 6-73 cm) was.a function of EM duration (mean 6.7 [+ or -] 6.4 days; range, 1-39 days)(correlation coefficient = 0.7; P / =37.8[Degrees]C), seven (9%) with tender neck flexion, six (8%) with joint tenderness, and 1 each with joint swelling, nuchal rigidity, and facial nerve palsy. No patient had new electrocardiogram evidence of atrioventricular block. Liver function assays were abnormally elevated in 37% of patients. Thirty-four percent of patients were seropositive by enzyme-linked immunosorbent assay at presentation. Most others rapidly seroconverted so that 69 of 78 evaluable patients (88%) were seropositive at some point during the first month after diagnosis. CONCLUSIONS: We describe the largest group of culture-positive patients with EM from the United States to date. Although systemic symptoms were present in most patients, objective evidence of advanced disease was uncommon. Our patients with culture-confirmed EM were less sick than those described in the days before culture confirmation was possible. The ability to isolate B burgdorferi from lesional skin of large numbers of patients with EM should make culture-positive patients the standard by which to define manifestations of early Lyme borreliosis associated with this rash. Microbiologic documentation of Lyme borreliosis will help delineate the manifestations of this illness, and should form the framework for research directed at pathophysiology, diagnosis, treatment, and prevention.

Objective: To catalog the paraspinal skin lesions of early childhood that are associated with occult spinal dysraphism. Research Design: Retrospective review of a series of patients. Setting: Tertiary care referral center. Patients: Fifteen patients who had significant paraspinal skin lesions were identified from the personal files of the authors who saw them. Results: The skin lesions included various combinations of hyperpigmentation, hypopigmentation, hypertrichosis, acrochordons, dimples, lipomas, hemangiomas, or teratomas. Not all lesions were evaluated with the same tests, which included plain roentgenography, ultrasonography, myelography, computed tomography, and magnetic resonance imaging. Of the 15 patients, six had spinal anomalies, eight had no apparent spinal dysraphism, and one had insufficient results of the evaluation to assess the spinal column. Conclusions: Early recognition of paraspinal skin lesions is essential to prevent neurologic damage. Urinary or fecal incontinence, recurrent urinary infections, muscle atrophy, foot deformities, weakness, pain, or decreased sensation in the lower extremities may eventually develop in these patients. Magnetic resonance imaging appears to be the single best screening test for dysraphism. (Arch Pediatr Adolesc Med. 1994;148:740-748), Children with skin lesions over the spine should undergo radiologic study of the spinal column because skin lesions may signal abnormalities of the spinal cord. Early recognition and treatment can avert neurologic problems. Skin lesions occur during pregnancy when the back of the embryo fails to fuse properly. The types of skin lesions that should be imaged include benign fat cell tumors, abnormal hairy patches, deep dimples and sinuses, hemangiomas and telangiectases (lesions formed by abnormal blood vessel clusters), dark skin pigmentation or no pigmentation, skin tags and tails, and teratomas (mixed cell tumors that may become malignant) and neurofibromas (benign nerve cell tumors). Fifteen patients with skin lesions are described, of whom six had underlying defects of the spinal column.

Pemphigus vulgaris, a rare disease characterized by large blisters of mucocutaneous surfaces, is often fatal if left untreated. This disease is mediated by Immunoglobulin G antibodies. A 40-year-old Puerto Rican woman developed painful erosions of the mouth and tongue, and blisters on the trunk and extremities over a six week period. A skin biopsy diagnosed pemphigus vulgaris. Immunofluorescent study revealed heavy deposits of Immunoglobulin G in the epidermis of the skin. The patient was treated with prednisone, but when followed-up four weeks later she had difficulty swallowing and chest pain. She was admitted to the hospital and endoscopy revealed severe esophagitis with exudate (inflammation of the esophagus with pus). The prednisone dose was increased, and the patient quickly improved. Nine other cases of pemphigus vulgaris are reported. The patients were middle-aged women and none had skin lesions when the disease of the esophagus was diagnosed. Five were considered to be improved with neither skin nor mucosal lesions, when the esophagus became affected by the disease. Fiberoptic endoscopy, which uses a flexible tube with a magnifying lens and light to visually examine the esophagus and stomach, appears to be a safe procedure in these patients. It is recommended that endoscopy be performed on any patient with pemphigus vulgaris or a history of this disease who has esophageal symptoms and does not respond appropriately to corticosteroid or other therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Members of my staff were after me to clean out a drawer in one of the exam rooms. Sure enough, it was full of out-of-date vacutainers and butterfly needles, even [...]

• Five infants with sacral hemangiomas and a particular constellation of congenital abnormalities are described. Three of the five infants had an imperforate anus associated with a fistula. Three of the five had renal anomalies; four had bony abnormalities of the sacrum, and three of these also had a lipomeningomyelocele. Four had skin tags, three of which were in the genital and sacral areas. Two of the five also had abnormalities of the external genitalia. This constellation of defects associated with a sacral hemangioma has not been, to our knowledge, elaborated previously.(Arch Dermatol 1986;122:684-687)

• A 76-year-old man developed a generalized orangered nodular eruption associated with constitutional symptoms. A biopsy specimen of a nodule revealed an extensive infiltration of histiocytes with relatively abundant cytoplasm and folded nuclei. Electron microscopy showed Langerhans' cell granules, which confirmed the diagnosis of histiocytosis X. Results of immunohistochemical studies revealed a pattern of antigen expression usually found in histiocytosis X, including la, T6, and S100. Analysis of the DNA content of the cells with flow cytometry revealed an aneuploid peak. The patient responded partially to topical mechlorethamine hydrochloride therapy.(Arch Dermatol 1986;122:446-450)

TO THE EDITOR.— Del Giudice and Nydorf1 describe an infant with cutis marmorata telangiectatica congenita (CMTC) and multiple congenital anomalies in the September 1986 issue of the Archives. These anomalies include an imperforate anus, rectovaginal and urethrovaginal fistulas, spina bifida, bilateral syndactyly, and a sacral lipoma. Cutaneous changes included a reddish-purple marbled pattern of livedo reticularis with prominent telangiectasias over the right lower extremity and hemipelvis. No mention is made of a neurologic examination or neurologic deficits. The authors conclude by stating that patients with CMTC should be examined for other developmental defects, as they appear to have an increased risk for these abnormalities.We reported similar changes in five infants2 in an effort to emphasize the need for radiologic and neurologic evaluations to rule out underlying anomalies. Del Giudice and Nydorf1 describe the presence of a sacral lipoma, but no mention is made of tomograms, myelograms,

TO THE EDITOR.— Pruritic urticarial plaques and papules of pregnancy (PUPPP) is a distinct dermatosis of pregnancy that has recently been associated with abdominal skin distention.1 We describe two cases, a triplet pregnancy and a case of polyhydramnios, that support this association. These are the first reported cases of PUPPP associated with in vitro fertilization. REPORT OF CASES.—CASE 1.— A 36-year-old woman (gravida 1, para 0) carrying triplets who were the result of in vitro fertilization developed an intensely pruritic rash over her abdomen during the 35th week of pregnancy. The rash started in the striae of her abdomen and spread to cover her inner arms, ankles, and wrists with urticarial plaques. The rash was treated with topical steroids.She went into labor the day of her dermatology consultation and was delivered of healthy triplets by cesarean section. The infants had no skin lesions. A skin biopsy

TO THE EDITOR.— This letter describes the occurrence of erosions at sites of wax epilation on the face in areas being treated with topical tretinoin (Retin-A) in two patients. REPORT OF CASES.—CASE 1.— A 27-year-old woman with type II skin, mild comedonal acne, and mild to moderate photodamage was treated with Retin-A cream (0.05% ) every third night. One month later, she had a "facial" and wax epilation of her eyebrows. The patient denied the presence of any erythema or irritation in the area prior to epilation. She had had both procedures performed multiple times in the past without problems, and was using no other topical medications at the time. On this occasion removal of the wax resulted in shiny, moist, fiery red, confluent erosions of the skin around both eyebrows, with marked periorbital edema. The wounds were treated with a topical antibiotic ointment and both areas healed without