Photo Quiz

An Annular Rash

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Am Fam Physician. 2014 Apr 1;89(7):581-582.

A 72-year-old woman presented with an insect bite on her right upper extremity. She first noticed the bite approximately five days before presentation. Over the subsequent five days, the rash enlarged and became more red, swollen, and painful. The center of the rash was warm and tender. She had nausea that began two days after the bite. She did not have fever, sore throat, joint aches, or body aches. She had a history of hypertension, gastroesophageal reflux disease, hyperlipidemia, and osteoarthritis. She had no history of atopic dermatitis.

Examination revealed a solitary, 9-cm, indurated, violaceous, mildly tender plaque on the right anteromedial portion of the deltoid. A 14-cm red ring surrounded the central tender area of the rash (see accompanying figure). She did not have lesions on her palms, soles, feet, or elbows.



Based on the history and physical examination findings, which one of the following is the most likely diagnosis?

A. Erythema multiforme.

B. Granuloma annulare.

C. Lyme disease.

D. Nummular eczema.

E. Rheumatic fever.


Address correspondence to Timothy Owolabi, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Feder HM Jr, Ables M, Bernstein M, Whitaker-Worth D, Grant-Kels JM. Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol. 2006;24(6):509–520.

2. Centers for Disease Control and Prevention. Signs and symptoms of Lyme disease. Accessed April 9, 2012.

3. Bacon RM, Kugeler KJ, Mead PS; Centers for Disease Control and Prevention. Surveillance for lyme disease—United States, 1992–2006. MMWR Surveill Summ. 2008;57(10):1–9.

4. Volcheck GW. Clinical evaluation and management of drug hypersensitivity. Immunol Allergy Clin North Am. 2004;24(3):357–371.

5. Aurelian L, Ono F, Burnett J. Herpes simplex virus (HSV)-associated erythema multiforme (HAEM): a viral disease with an autoimmune component. Dermatol Online J. 2003;9(1):1.

6. Dabski K, Winkelmann RK. Generalized granuloma annulare, clinical and laboratory findings in 100 patients. J Am Acad Dermatol. 1989;20(1):39–47.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

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