The first stage of infection is frequently manifested as an erythema migrans rash. The rash occurs in 70 - 80% of those infected. It begins 7-10 days after the tick bite (range: 3-30 days) and the tick must have been attached 36-48 hours for transmission to occur.
The lesion expands over days to weeks and some develop the classical central clearing appearance called the "bull's eye." Constitutional symptoms occur as a flu-like illness with lymphadenopathy, although it may be asymptomatic. Death is rare, especially at this stage.