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The conclusion by Kirkland et al¹ in their recent article that "In the southern United States, EM [erythema migrans]–like rash illness should no longer be considered definitive evidence of early Lyme disease" is both premature and unwarranted. As a clinician in Missouri who has identified, treated, followed up, reported, studied, presented, and published on these southern EM cases for a decade, I find this negative conclusion unsubstantiated by the authors' data. Proving a negative (null hypothesis) appropriately requires a high methodological standard, which was not met in the article by Kirkland et al.

Around the world, EM is considered the hallmark clinical finding associated with Lyme disease. It has been described in the literature at a minimum as "characteristic" and again and again as "pathognomonic,"² most recently in a January 1998 article coauthored by Dennis,³ who is also a coauthor with Kirkland et al.

Absence of proof is not proof . . . [Full Text of this Article]

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