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A 26-year-old male with no past medical history was evaluated for a rash resembling erythema migrans (EM) in the context of recent travel to Brazil. He had travelled to Brazil for 17 days, first visiting urban areas of Sao Paulo, then rural regions near Florianopolis and lastly urban areas of Rio de Janeiro. During his travels, he ate prepared meals in restaurants, drank bottled water and stayed in local budget hotels. The patient noted an EM like-rash on his right thigh (Figure 1) while in Rio de Janeiro 6 days after leaving Florianopolis, however he did not recall any tick bites during his trip. He had no evidence of systemic illness while travelling or upon his return to Canada. He was asymptomatic when evaluated in clinic 1 week following his return and his physical examination and routine lab work (complete blood count, electrolytes, liver enzyme testing, creatinine) were unremarkable at that time apart from his resolving EM lesion. Of note, he had no history of prior Lyme infection or travel to a Lyme-endemic region. Serologic studies drawn at his clinic visit were negative for rickettsia, however Lyme serology (performed at the Ontario Public Health Laboratories) demonstrated positive IgM and IgG enzyme-linked immunosorbent assay (EIA), a positive IgM Western blot (bands 24 and 39 reactive), and negative IgG Western blot (bands 41, 66 and 93 reactive; band 45 weakly reactive), consistent with acute borreliosis infection. Five reactive bands are considered diagnostic for a positive Lyme IgG.1 Given his compatible epidemiologic exposure, dermopathy and serologic results, he was treated for Lyme or the Lyme-like Baggio–Yoshinari syndrome (BYS) with 3 weeks of doxycycline (100 mg PO BID). The patient tolerated his medications without issue and remained asymptomatic 1 month later. His EM-like lesion completely resolved.

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