title: Microbiologic evaluation of patients from Missouri with erythema migrans.
abstract: BACKGROUND
  Borrelia lonestari infects Amblyomma americanum, the tick species that is the most common cause of tick bites in southeast and south-central United States, and this spirochete has been detected in an erythema migrans (EM)-like skin rash in 1 patient. Therefore, B. lonestari is considered to be a leading candidate for the etiologic agent of EM in this region.
  
  
  METHODS
  Skin biopsy specimens obtained from patients from the Cape Girardeau area of Missouri who had EM-like lesions were cultured in Barbour-Stoenner-Kelly medium and evaluated by polymerase chain reaction (PCR) targeting multiple genes. Serum specimens were tested by enzyme-linked immunosorbent assay for antibodies against sonicated whole-cell Borrelia burgdorferi. Results were compared with those obtained over the same period for patients from New York State who had EM.
  
  
  RESULTS
  B. lonestari was not detected by PCR in any of 31 skin biopsy specimens collected from 30 Missouri patients. None of 19 cultures of Missouri skin samples that were suitable for evaluation were positive for B. burgdorferi, compared with 89 (63%) of 142 cultures of samples collected from New York State patients (P<.001). None of the 25 evaluable Missouri patients were seropositive for antibodies against B. burgdorferi, compared with 107 (75%) of 143 New York State patients (P<.001).
  
  
  CONCLUSIONS
  Neither B. lonestari nor B. burgdorferi is likely to be the cause of EM-like skin lesions in patients from the Cape Girardeau area of Missouri. The etiology of this condition remains unknown.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, NY 10595, USA. gary_wormser@nymc.edu
authors.forename: Gary P
authors.initials: GP
authors.lastname: Wormser
authors.forename: Edwin
authors.initials: E
authors.lastname: Masters
authors.forename: Dionysios
authors.initials: D
authors.lastname: Liveris
authors.forename: John
authors.initials: J
authors.lastname: Nowakowski
authors.forename: Robert B
authors.initials: RB
authors.lastname: Nadelman
authors.forename: Diane
authors.initials: D
authors.lastname: Holmgren
authors.forename: Susan
authors.initials: S
authors.lastname: Bittker
authors.forename: Denise
authors.initials: D
authors.lastname: Cooper
authors.forename: Guiqing
authors.initials: G
authors.lastname: Wang
authors.forename: Ira
authors.initials: I
authors.lastname: Schwartz
mesh_terms: D001898:Borrelia / Q000145:classification* / Q000302:isolation & purification*; D001899:Borrelia Infections / Q000453:epidemiology / Q000382:microbiology*; D015787:Erythema Chronicum Migrans / Q000453:epidemiology / Q000382:microbiology*; D006801:Humans; D008923:Missouri / Q000453:epidemiology; D010802:Phylogeny; D012867:Skin / Q000382:microbiology; D017282:Tick-Borne Diseases / Q000453:epidemiology / Q000382:microbiology*