Image 5. Returned to Montreal after 2 weeks in West Africa where he had noted the onset of malaise, low grade fever and an erythematous non-indurated 6 inch diameter patch in the right groin. Over the subsequent week new patches appeared, while the original patch persisted but slowly faded. The diagnosis is:

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Image 5.        This was Lyme disease (erythema chronicum migrans), proven serologically. Just before he travelled to Africa he had visited his sister in Philadelphia. She had a house on the fringe of a central park where there were deer. He remembered no tick bite. he responded to appropriate antibiotics.