Discrepancy between IDSA and ESGBOR in Lyme disease: Individual participant meta-analysis in Türkiye

BACKGROUND

The evidence on the prevalence of Lyme borreliosis (LB) is limited, but there is a suspicion of overdiagnosis of LB in recent years. We reviewed the LB diagnosis and treatment-related data in Türkiye, based on the Infectious Diseases Society of America (IDSA) 2020 and European Society of Clinical Microbiology and Infectious Diseases Study Group for Lyme Borreliosis (ESGBOR) 2018 guidelines. By detecting the disagreements between these two, we outlined the areas to be improved for future guidelines.

METHODS

We performed a literature search according to the PRISMA guidelines in PubMed, Ovid-Medline, Web of Science, Turkish Medline, Scopus, CINAHL, ULAKBIM TR Index, Google Scholar and Cochrane Library databases. We included the published cases in a database and evaluated according to IDSA and ESGBOR guidelines. We outlined the reasons for misdiagnoses and inappropriate uses of antibiotics.

RESULTS

We included 42 relevant studies with 84 LB cases reported from Türkiye between 1990 and December 2022. Among 84 cases, the most common clinical findings were nervous system findings (n = 37, 44.0%), erythema migrans (n = 29, 34.5%) and ophthalmologic findings (n = 15, 17.9%). The IDSA 2020 and ESGBOR 2018 guidelines agreed on the diagnosis of 71 (84.5%) cases; there was an agreement that 31 cases (36.9%) were misdiagnosed and 40 cases (47.6%) were correctly diagnosed, and there was disagreement for 13 cases (15.5%). Serum immunoglobulin M (IgM), IgG measurements by ELISA and western blot were widely performed, and they were effective in definitive diagnosis merely when used according to guidelines. Inappropriate use of antibiotics was detected in 42 (50.0%) of cases which were classified in the following categories: incorrect LB diagnosis, inappropriate choice of antibiotic, inappropriate route of drug administration and prolonged antibiotic treatment.

CONCLUSION

Overdiagnosis and non-adherence to guidelines is a common problem. The discordance between seroprevalence and clinical studies necessitates a consensus over the best clinical approach.

An Abnormal Presentation of Rocky Mountain Spotted Fever: A Case Report

The intracellular coccobacilli Rickettsia rickettsii causes Rocky Mountain Spotted Fever, a potentially fatal illness. This bacterium is transmitted to humans through a tick vector. Patients classically present with a triad of symptoms, including fever, headache, and a rash that begins on the extremities and spreads proximally to the trunk. Diagnosis of this disease can prove difficult when patients have unusual symptoms, such as hypertensive crisis. In this case report, we present a 29-year-old male who arrived at the emergency room with altered mental status and a hypertensive crisis after his family reported one week of changes in his behavior. The patient had no evidence of ticks, tick bites, fever, or rash. Positive findings in the emergency room included a WBC of 14.9 × 109. All other physical exams, imaging, and laboratory findings were non-contributory. The patient was promptly given IV hydralazine to control his blood pressure and empiric IV ceftriaxone for potential infection, and he was admitted for observation. Over the course of three days, WBC levels decreased, and his altered mental status improved. On day 3, the patient remembered a tick crawling across his hand, and this prompted the ordering of immunoglobulin levels for tick-borne illnesses. IgM for RMSF was positive. This case presentation illustrates the need for clinicians to keep the potential diagnosis of RMSF high on the differential, even in the presence of a paucity of symptoms, as prompt treatment with doxycycline can be lifesaving. This case may also be one of the first reported in the literature of hypertension being a symptom of Rocky Mountain Spotted Fever. It is plausible, however, that this patient's hypertension was due to an acute stress response.

An 'Exo-Tick' Problem: A Sudden Increase in Tick Bite - A Case Series

Ticks are blood-sucking arthropod ectoparasites of vertebrates, which are vectors of many diseases. They cause varied skin manifestations, which occur either due to the attachment of the tick to the host or due to the infections it spreads. Dermoscopy serves as a precise diagnostic tool for tick bites and also helps in ensuring complete removal of the tick. Prompt removal and identification of the tick, along with appropriate antibiotic therapy, are important aspects of the management of this condition. Herein, we present a case series of nine patients with tick bites, by ticks of similar morphology but at different body sites and with varied predisposing factors.

Big Epidemic of Small City: Crimean-Congo Hemorrhagic Fever

Objective

Crimean-Congo hemorrhagic fever (CCHF) is the most common tick-borne viral hemorrhagic fever in our country and the world. While investigating the etiology of fever, tick contact should be questioned, especially in rural areas, and CCHF should be remembered. This study aimed to review the characteristics of the cases detected in Bayburt, one of the cities where CCHF is endemic.

Methods

A total of 100 patients aged 16 years and older who were diagnosed with CCHF in our clinic between April 2020 and October 2022 were included in the study. Demographic, epidemiological, and clinical characteristics, treatments, and prognoses of the patients were reviewed retrospectively through the hospital automation system and CCHF information system of The Ministry of Health.

Results

Sixty one (61%) of the patients included in the study were male, and their primary age (± standard deviation) was 50.4±15.7. 77% of the patients engaged in farming and or animal husbandry, and 71% were living in rural areas. The highest number of cases was in June and July. 63% of the patients had a history of a tick bite. At the first presentation, there were complaints of fatigue (95%), generalized body pain (84%), headache (67%), and fever (65%), in order of frequency. Ribavirin was started in 52 (52%) patients. One patient admitted in the late period died, and 99 patients were discharged with good recovery.

Conclusion

CCHF is an important public health problem that has been causing seasonal epidemics in our country for nearly two decades. Although sporadic cases have been reported from almost every region, the disease is endemic in some areas. Since signs and symptoms are not specific, the disease can be easily missed when tick contact is not questioned. Therefore CCHF should be considered in patients presenting with fever and thrombocytopenia in rural areas, especially in the spring and summer months.

Empirical Administration of Doxycycline for Rocky Mountain Spotted Fever: A Case Report

Rocky Mountain spotted fever (RMSF) is a tick-borne illness that can cause extreme sickness, even death, in otherwise healthy individuals. Sometimes, it is difficult to confirm the diagnosis as the rash often lags behind other symptoms of the illness and may not occur at all. Other symptoms of RMSF are nonspecific, such as fever, headache, and malaise. Besides the confirmatory serology test, antibody titers remain negative in the early phase of the illness. Here, we reported a case of a 21-year-old male who presented with fever, mild headache, body aches, joint pain, dry cough, and characteristic maculopapular rash after visiting a tick-prone area. Doxycycline was started because symptoms and laboratory values heightened our suspicion for the diagnosis of RMSF. His condition improved gradually, and his labs became normal. Our study supports the empirical use of doxycycline in suspected RMSF cases.

Tick-Bite "Meteo"-Prevention: An Evaluation of Public Responsiveness to Tick Activity Forecasts Available Online

Until causal prophylaxis is available, the avoidance of ticks and personal protection provide the best insurance against contracting a tick-borne disease (TBD). To support public precaution, tick-activity forecasts (TAFs) based on weather projection are provided online for some regions/countries. This study-aimed at evaluating the efficacy of this preventative strategy-was conducted between 2015 and 2019, and included two countries where TAFs are issued regularly (Czech Republic, Germany) and two neighbouring countries for reference (Austria, Switzerland). Google Trends (GT) data were used to trace public concern with TAFs and related health information. GTs were compared with epidemiological data on TBD cases and tick bites, wherever available. Computer simulations of presumable effectiveness under various scenarios were performed. This study showed that public access to TAFs/preventive information is infrequent and not optimally distributed over the season. Interest arises very early in midwinter and then starts to fall in spring/summer when human-tick contacts culminate. Consequently, a greater number of TBD cases are contracted beyond the period of maximum public responsiveness to prevention guidance. Simulations, nevertheless, indicate that there is a potential for doubling the prevention yield if risk assessment, in addition to tick activity, subsumes the population's exposure, and a real-time surrogate is proposed.

Alpha-gal syndrome-Food or drug allergy: A case report

Alpha-gal syndrome is an immunoglobulin E-mediated hypersensitivity characterized by delayed allergic reactions to ingested products containing alpha-gal carbohydrate. We present a patient with recurrent urticaria and suspected repaglinide hypersensitivity, who was eventually diagnosed with alpha-gal syndrome, wanting to emphasize possible drug allergy misdiagnosis and required caution with the medication choice.

Nonanaphylactic Variant of Alpha-Gal Syndrome as an Etiology for Chronic Gastrointestinal Symptoms in Children

We report 3 pediatric patients who presented with only nonanaphylactic symptoms of alpha-gal syndrome. This report highlights the necessity of not discounting alpha-gal syndrome from a differential diagnosis for patients with recurrent gastrointestinal distress and emesis after consuming mammalian meat, even in the absence of an anaphylactic reaction.

The AxBioTick Study: Borrelia Species and Tick-Borne Encephalitis Virus in Ticks, and Clinical Responses in Tick-Bitten Individuals on the Aland Islands, Finland

The AxBioTick study was initiated to investigate the prevalence of ticks and tick-borne pathogens and their impact on antibody and clinical responses in tick-bitten individuals on the Aland Islands. This geographical area is hyperendemic for both Lyme borreliosis (LB) and Tick-borne encephalitis (TBE). Blood samples and ticks were collected from 100 tick-bitten volunteers. A total of 425 ticks was collected, all determined to Ixodes ricinus using molecular tools. Of them 20% contained Borrelia species, of which B. garinii and B. afzelii were most common. None contained the TBE virus (TBEV). Blood samples were drawn in conjunction with the tick bite, and eight weeks later. Sera were analyzed for Borrelia- and TBEV-specific antibodies using an ELISA and a semiquantitative antibody assay. In total 14% seroconverted in Borrelia C6IgG1, 3% in TBEV IgG, and 2% in TBEV IgM. Five participants developed clinical manifestations of LB. The high seroprevalence of both Borrelia (57%) and TBEV (52%) antibodies are likely attributed to the endemic status of the corresponding infections as well as the TBE vaccination program. Despite the similar prevalence of Borrelia spp. detected in ticks in other parts of Europe, the infection rate in this population is high. The AxBioTick study is continuing to investigate more participants and ticks for co-infections, and to characterize the dermal immune response following a tick bite.

Epidemiological study of ticks harbouring Aeromonas hydrophila in areas endemic and non-endemic to Japanese-spotted fever

OBJECTIVES

Aeromonas spp. often cause life-threatening diseases, including necrotizing fasciitis, which may lead to septic shock and ultimately death. Aeromonas infections are believed to be transmitted via minor wounds or the consumption of fresh fish. However, after the detection of Aeromonas hydrophila in ticks in areas endemic to Japanese-spotted fever (JSF), a novel transmission route of A. hydrophila (i.e., via tick bites) has been proposed. We investigated the prevalence of A. hydrophila in ticks in areas endemic and not endemic to JSF in the Mie Prefecture, Japan.

METHODS

We collected ticks from endemic and nonendemic areas in summer and winter and assessed them for presence of A. hydrophila using polymerase chain reaction.

RESULTS

Six A. hydrophila isolates were obtained from 95 ticks in endemic areas, whereas one A. hydrophila isolate was obtained from 142 ticks in non-endemic areas, in summer. All ticks that harboured A. hydrophila were Haemaphysalis longicornis (H.L); these ticks were almost at the larval stage and also carried Rickettsia spp. in the endemic area. In contrast, 51 and 41 ticks in the endemic and non-endemic areas were captured in winter, respectively; A. hydrophila was not detected in these.

CONCLUSIONS

This study revealed the prevalence of tick-borne A. hydrophila. Therefore, the risk of transmission of A. hydrophila via a tick bite should be considered in the following conditions: areas abundant in H. L. harbouring Rickettsia spp., in areas endemic for JSF, presence of ticks in the larval stage and during the summer season.

Clinical and laboratory features of patients diagnosed with alpha-gal syndrome-2010-2019

BACKGROUND

Alpha-gal syndrome (AGS) is an IgE-mediated allergy to galactose-alpha-1,3-galactose. Clinical presentation ranges from hives to anaphylaxis; episodes typically occur 2-6 h after exposure to alpha-gal-containing products. In the United States, lone star tick bites are associated with the development of AGS. To characterize features of AGS, we evaluated a cohort of patients presenting for care at the University of North Carolina, focusing on symptoms, severity, and identifying features unique to specific alpha-gal-containing product exposures.

METHODS

We performed a chart review and descriptive analysis of 100 randomly selected patients with AGS during 2010-2019.

RESULTS

Median age at onset was 53 years, 56% were female, 95% reported White race, 86% reported a history of tick bite, and 75% met the criteria for anaphylaxis based on the involvement of ≥2 organ systems. Those reporting dairy reactions were significantly less likely to report isolated mucocutaneous symptoms (3% vs. 24%; ratio [95% CI]: 0.1 [0.1, 0.3]) than those who tolerated dairy, and were more likely to report gastrointestinal symptoms (79% vs. 59%; ratio [95% CI]: 1.3 [0.7, 2.6]), although this difference was not statistically significant. Dairy-tolerant patients demonstrated higher alpha-gal sIgE titers (as a percentage of total IgE) than dairy-reactive patients (GM 4.1 [95% CI: 2.7, 6.1] vs. GM 2.5 [95% CI: 1.3, 4.8], respectively; ratio -1.6 [95% CI: -1.0, 3.9]).

CONCLUSION

While tick exposure is common in the southern United States, nearly all AGS patients reported a tick bite. Gastrointestinal symptoms were prominent among those reporting reactions to dairy. Anaphylaxis was common, underscoring the severity and need to raise awareness of AGS among patients and providers.

Knowledge, Attitudes, and Behaviors Regarding Lyme Borreliosis Prevention in the Endemic Area of Northeastern Poland

(1) Background: The incidence of Lyme borreliosis (LB) is increasing in Europe. The new LB vaccine is still in clinical development, thus the dissemination of knowledge about the disease is essential. We assessed the knowledge, attitudes and preventive practices (KAP) against tick-borne diseases (TBDs) of people living in the endemic area in northeastern Poland. (2) Methods: We surveyed 406 adults using a 37-item anonymous paper survey. The data were analyzed with regression models. (3) Results: The two most popular knowledge sources were the Internet and doctors, selected by 77.8% and 53.4%, respectively. Respondents felt moderately knowledgeable about TBDs and tick bite prophylaxis (median scores 5/10, and 6/10, respectively), considered TBDs to be a significant health threat (median 8/10), attributed high risk to tick mouthparts remaining in the skin after tick removal (median 10/10), and shared multiple misconceptions regarding LB transmission, symptoms, and management. General knowledge scores (GKS) about TBDs and tick protection practices scores (TPS) were moderate (65.0%; IQR, 55.8−71.7%, 63.6%; 54.5−72.7%, respectively). Only 48.0% had a positive attitude towards TBE vaccination. A recent tick-bite was associated with higher GKS (OR, 2.55; 95% CI, 1.27−5.10; p = 0.008), higher TPS (OR 4.76, 95% CI, 2.0−11.1; p < 0.001), and a positive attitude towards TBE vaccine (OR 2.10, 1.07−4.10, p = 0.030). A positive vaccine attitude was also associated with obtaining TBD knowledge from doctors and other verified sources (OR, 2.654, 1.66−4.23; p < 0.001). Age, place of residence, and frequent exposure to ticks in green areas were not associated with GKS, TPS, nor vaccine attitude. (4) Conclusions: Increased risk perceptions are associated with adoption of behaviors preventing TBDs. Medical professionals play an important role in communicating knowledge about TBDs. There is a need to revise current communication strategies with respect to tick bites and prevention of LB and other TBDs.

Tick bite as a risk factor for alpha-gal specific IgE antibodies and development of alpha-gal syndrome

BACKGROUND

The disaccharide galactose-α-1,3-galactose (alpha-gal) is expressed in mammals other than humans, apes, and old-world monkeys. In humans, elevated immunoglobulin-E (IgE) antibodies specific for alpha-gal can result in allergic hypersensitivity known as alpha-gal syndrome (AGS). Case reports and series suggest that tick bites can induce alpha-gal specific IgE antibodies.

OBJECTIVE

Evaluate tick exposure as a risk factor for AGS and elevated alpha-gal specific IgE (sIgE).

METHODS

We conducted a case-control study comparing AGS patients from a North Carolina allergy clinic with controls who were patients at a nearby internal medicine clinic. Cases and controls were administered a questionnaire to obtain information about demographics, home environment, outdoor activities, and recollection of tick bite. Serum samples taken at the time of enrollment were tested for total IgE, alpha-gal sIgE, and antibodies to other tickborne pathogens.

RESULTS

AGS patients were more likely to recall finding a tick on themselves (OR=11.20, 95% CI 4.97-25.15), live near wooded forest (OR=2.27, 95% CI 0.92-5.55), and spend 17 or more hours per week outdoors in wooded areas (OR=5.58, 95% CI 2.56-12.19). AGS patients were also more likely to report 4 or more tick bites (OR=33.05, 95% CI 9.92-155.12) and reactions at the site of tick bites (OR=7.93, 95% CI 3.74-16.80). Elevated alpha-gal sIgE was also observed in 33% of controls and was also associated with tick exposure in the controls (OR=4.25, 95% CI 2.21-8.18).

CONCLUSION

The results define tick bite as a risk factor for AGS and elevated alpha-gal sIgE.

The Evolution of a Tick Bite Lesion

Hard ticks (Acari: Ixodidae) use their mouthparts to cut through the epidermis and insert a barbed hypostome, leading to deep inflammation of local tissues. Herein, we describe cutaneous lesion development resulting from a tick bite at seven time points over a 30-day period. This case highlights the fact that ticks may produce lasting cutaneous lesions, which may persist for at least 30 days, even without any obvious pathology or complications.

A pediatric case of tick-bite-Induced meat allergy and recall urticaria

Alpha-gal syndrome should be suspected also in children in case of typical allergic symptoms in the evening or night during tick seasons and the event of recall urticaria. It is, however, still a challenge for both patients and clinicians.

Penile cancer after a tick bite: A possible association

Penile cancer is a rare cancer in Western countries, but is more common in parts of the developing world. Usually, it is associated with older uncircumcised men who have a long-term phymotic preputium. Here, we report a case of penile cancer in a circumcised patient, occurring 3 months after a tick bite on the head of the penis. To the best of our knowledge, this is the first report that suggests a possible association between Lyme disease and occurrence of “de novo” penile cancer. Further studies are needed to confirm this hypothesis.

Infections with Tickborne Pathogens after Tick Bite, Austria, 2015-2018

Knowledge about outcomes of tick bites is crucial because infections with emerging pathogens might be underestimated.

The aim of this prospective study was to assess the risk for tickborne infections after a tick bite. A total of 489 persons bitten by 1,295 ticks were assessed for occurrence of infections with Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Rickettsia spp., Babesia spp., Candidatus Neoehrlichia mikurensis, and relapsing fever borreliae. B. burgdorferi s.l. infection was found in 25 (5.1%) participants, of whom 15 had erythema migrans. Eleven (2.3%) participants were positive by PCR for Candidatus N. mikurensis. One asymptomatic participant infected with B. miyamotoi was identified. Full engorgement of the tick (odds ratio 9.52) and confirmation of B. burgdorferi s.l. in the tick by PCR (odds ratio 4.39) increased the risk for infection. Rickettsia helvetica was highly abundant in ticks but not pathogenic to humans. Knowledge about the outcome of tick bites is crucial because infections with emerging pathogens might be underestimated because of limited laboratory facilities.

Investigation of Tick-Borne Pathogens in Ixodes ricinus in a Peri-Urban Park in Lombardy (Italy) Reveals the Presence of Emerging Pathogens

Ticks are important vectors of a great range of pathogens of medical and veterinary importance. Lately, the spread of known tick-borne pathogens has been expanding, and novel ones have been identified as (re)emerging health threats. Updating the current knowledge on tick-borne pathogens in areas where humans and animals can be easily exposed to ticks represents a starting point for epidemiological studies and public awareness. A PCR screening for tick-borne pathogens was carried out in Ixodes ricinus ticks collected in a peri-urban recreational park in Ticino Valley, Italy. The presence of Rickettsia spp., Borrelia burgdorferi senso latu complex, Anaplasma spp. and Babesia spp. was evaluated in a total of 415 I. ricinus specimens. Rickettsia spp. (R monacensis and R. helvetica) were detected in 22.96% of the samples, while B. burgdorferi s.l. complex (B. afzelii and B. lusitaniae) were present in 10.94%. Neoehrlichia mikurensis (1.99%) and Babesia venatorum (0.73%) were reported in the area of study for the first time. This study confirmed the presence of endemic tick-borne pathogens and highlighted the presence of emerging pathogens that should be monitored especially in relation to fragile patients, the difficult diagnosis of tick-borne associated diseases and possible interactions with other tick-borne pathogens.

Diagnosis, Treatment, and Prevention Practices for Lyme Disease by Clinicians, United States, 2013-2015

OBJECTIVES

Although tick-borne diseases account for a large number of health care visits in the United States, clinical practices for tick bite and Lyme disease treatment and prevention are not well understood. The objective of this study was to better understand factors associated with clinical practices related to tick bites and Lyme disease.

METHODS

In 2013-2015, questions about tick-bite evaluation, Lyme disease diagnosis and treatment, appropriate use of Lyme disease testing, and tick-bite prevention were included in Porter Novelli's DocStyles survey, a nationally representative annual web-based survey of health care providers. We performed analyses of responses by provider license type and state-level incidence (high or low) of Lyme disease in 2019.

RESULTS

A total of 4517 providers were surveyed across the 3 study years. Overall, 80.9% of providers reported that they had evaluated at least 1 patient for a tick bite, 47.6% had diagnosed at least 1 patient with Lyme disease, and 61.9% had treated at least 1 patient for Lyme disease in the previous year. Providers from states with a high incidence of Lyme disease saw more patients for tick bites and Lyme disease than providers from states with a low incidence of Lyme disease. Few providers correctly chose Lyme disease testing as clinically useful in the hypothetical case of a patient from a state with a high incidence of Lyme disease with an arthritic knee (36.0%) or with new-onset atrioventricular block (39.5%), and respondents across all provider types incorrectly chose testing when not clinically indicated. Most providers (69.7%) reported routinely recommending tick-bite prevention methods to patients.

CONCLUSIONS

Many providers evaluate patients for tick bites and treat patients for Lyme disease, but knowledge about appropriate testing is low. Providers may benefit from tailored education about appropriate Lyme disease diagnosis, testing, and effective tick-bite prevention.

First Recognized Human Bite in the United States by the Asian Longhorned Tick, Haemaphysalis longicornis

We present the case summary of the first human recognized to have been bitten by the Haemaphysalis longicornis tick in the United States, which occurred in New York State. Subsequent field studies confirmed that this tick was present in multiple geographic locations near the patient's residence, including on manicured lawns.

Spatial tick bite exposure and associated risk factors in Scandinavia

Tick-borne diseases are emerging and re-emerging threats causing public health concerns in Europe and North America. Prevention and control requires understanding of human exposure and behaviour. The aim was to measure exposure to tick bites across Scandinavia, its spatial distribution and the associated risk factors. Methods We sent a web-based survey to a randomly chosen population and analysed answers by Principal Component Analysis and Chi-Square. Individual responses were aggregated at the municipality level to assess the spatial distribution of bites. Results Nearly 60% of adults reported bites at low levels (1-5 bites); however, the majority were not in their resident municipality. We found two spatial profiles: In their home municipalities, people were most often bitten in less, but not the least, urbanized areas. When visiting other municipalities, people were most frequently bitten in peri-urban areas. Running/walking in the forest, gardening, and paddling/rowing were activities most strongly associated with bites. Conclusion Tick bites affect the entire Scandinavian population, with a higher risk in Sweden compared to Denmark and Norway. The frequency of observation of ticks in the environment or on pets might be used as a proxy for the actual risk of exposure to tick bites. Our results indicates that urban-dwelling outdoor enthusiasts and inhabitants of rural areas must be equally targeted for prevention campaigns.

Tick anaphylaxis triggered by pulling out the tick

Background

Reports of tick anaphylaxis are extremely rare in Asian countries, with poor awareness in these regions. Herein, we report a case of tick anaphylaxis that was triggered by pulling out the tick.

Case Presentation

A 66-year-old man developed pruritus in his left toes after returning from a mountain. Three days later, he found a swollen tick biting at the skin between the second and third toes and pulled it out. Approximately 30 min after pulling out the tick, he started to feel a burning sensation in his chest and was brought to our hospital. He was diagnosed with anaphylactic shock (systolic blood pressure, 60 mmHg) and immediately received intramuscular adrenaline.

Conclusion

To our knowledge, this is the first case of tick anaphylaxis triggered by tick removal in an Asian country. A tick should be removed without pressure on its body, especially in patients with tick or bee allergy.

Comparison of Skin Lesions Caused by Ixodes ricinus Ticks and Lipoptena cervi Deer Keds Infesting Humans in the Natural Environment

Background: The territorial expansion and increased population size of haematophagous arthropods (i.e., the castor bean tick Ixodes ricinus (Ixodida: Ixodidae) and the deer ked Lipoptena cervi (Diptera: Hippoboscidae)) has enhanced the risk of human infestations in Europe. The aim of our study was to present skin lesions induced by tick and deer ked bites in patients from recreational forest regions in southeastern Poland and pay attention to features of skin changes that may be useful in differential diagnosis. Methods: We compare the skin lesions after I. ricinus and L. cervi bite and draw attention to the biological and ecological traits of both ectoparasites, which may be diagnostically relevant for determination of the cause of skin symptoms reported by patients. Results: I. ricinus bites lead to development of erythematous-infiltrative poorly demarcated lesions with a centrally located bite mark, which usually disappears within one to several days. In turn, L. cervi bites leave irregularly shaped scattered erythematous papules. The papules may persist for up to one year and are accompanied by itching. Conclusions: Correct assessment of the clinical picture and its association with an arthropod bite (e.g., tick or deer ked) is highly important for further diagnostic procedures (i.e., differentiation of skin lesions developing in tick-borne diseases and, consequently, correct choice of pharmacological therapy). I. ricinus and L. cervi differ in their developmental cycles and rhythms of activity, which indicates that both species should be considered potential causative agents in the differential diagnosis of skin lesions when the patient has been bitten by an arthropod in autumn and winter months.

Serologic evidence of rickettsial diseases associated with tick bites in workers of urban veterinary clinics

Background & objectives

Rickettsial and other zoonotic diseases are a latent risk for workers of veterinary clinics. The objective of this study was to evaluate the prevalence and the associated risk factors of parasitosis caused by Rhipicephalus sanguineus, and to estimate the seroprevalence of rickettsial diseases in workers of urban veterinary clinics of Juárez city, México.

Methods

The participants of the study were recruited from 63 private veterinary clinics and hospitals. The serological analysis of the blood samples collected was carried out using immunofluorescence assay (IFA). The statistical analysis for prevalences, risk factors, and correlation was performed with the SAS program.

Results

In total, 167 veterinary workers were included in the study. The prevalence of tick bites was 40% (67/167), and the risk factors associated with the occurrence of bites included the activities performed in the clinic and the number of labour hours spent per week. About 21% (35/167) of participants were seropositive to R. rickettsii, 28% (47/167) to Ehrlichia chaffeensis, and 24% (40/167) to Anaplasma phagocytophilum. A correlation was observed between: the number of workers in the clinics and the proportion of tick bites (r² = 0.865); the prevalence of bites and the seropositivity of the participants to at least one pathogen (r² = 0.924); and the number of bites per individual and infection to pathogens (r² = 0.838).

Interpretation & conclusion

Workers in urban veterinary clinics are highly exposed to tick bites and, therefore, to the diseases they transmit. Hence, it is important to implement prevention measures and perform constant monitoring of these diseases.

Crimean-Congo haemorrhagic fever in a Greek worker returning from Bulgaria, June 2018

We report a tick-borne case of severe Crimean-Congo haemorrhagic fever (CCHF) imported into Greece from Bulgaria. The patient presented severe thrombocytopenia, hemophagocytosis, haemodynamic instability, large haematomas and altered mental status. Supportive treatment and ribavirin were administered. Symptoms started one day after the tick was removed; the patient was discharged from the hospital 26 days after symptom onset. No secondary cases were observed. Phylogenetically the CCHF virus strain belongs to clade Europe 1.

Tick Bites Induce Anti-α-Gal Antibodies in Dogs

Due to the functional inactivation of the gene encoding for the enzyme that is involved in the oligosaccharide galactose-α-1,3-galactose (α-Gal) synthesis, humans and Old-World primates are able to produce a large amount of antibodies against the glycan epitope. Apart from being involved in the hyperacute organ rejection in humans, anti-α-Gal antibodies have shown a protective effect against some pathogenic agents and an implication in the recently recognized tick-induced mammalian meat allergy. Conversely, non-primate mammals, including dogs, have the ability to synthetize α-Gal and, thus, their immune system is not expected to naturally generate the antibodies toward this self-antigen molecule. However, in the current study, we detected specific IgG, IgM, and IgE antibodies to α-Gal in sera of clinically healthy dogs by an indirect enzyme-linked immunosorbent assay (ELISA) for the first time. Furthermore, in a tick infestation experiment, we showed that bites of Ixodes ricinus induce the immune response to α-Gal in dogs and that the resulting antibodies (IgM) might be protective against Anaplasma phagocytophilum. These findings may help lead to a better understanding of the underlying mechanisms involved in mammalian meat allergy and tick-host-pathogen interactions, but they also open up the question about the possibility that dogs could develop an allergy to mammalian meat after tick bites, similar to that in humans.

Serosurvey of Coxiella burnetii in high risk population in Turkey, endemic to Crimean-Congo haemorrhagic fever virus

Background & objectives

Q fever caused by Coxiella burnetii is a zoonotic infection that spreads to human beings from animals. This study was aimed to demographically examine the C. burnetii seroprevalence in the people living in villages where Crimean-Congo haemorrhagic fever virus (CCHFV) is endemic, in terms of various risk factors such as tick bites, tick contact, and occupational groups.

Methods

A total of 440 serum samples from those living in rural areas of Sivas and Tokat regions in Turkey were included in the study as a risk group; 387of them were serologically CCHFV positive (as confirmed in our previous research). Serums of the control group composed of 110 people living in urban areas. In all serum samples, IgG antibodies of C. burnetii against phase-I and phase-II antigens were diagnosed using the ELISA method.

Results

Coxiella burnetii seropositivity was detected in 19.09% of those living in rural areas and 4.55% of those living in urban areas (p < 0.001, OR = 4.96). In terms of their approach to the ticks, no statistical difference was observed between the risk groups in the chi-square test (p = 0.787). However, according to univariate analysis, the absorbance means of antibodies reactive to C. burnetii was statistically higher for the rural people who have made contact with ticks than those who have not (p = 0.017). No seroepidemiological relation was found between CCHFV and C. burnetii serology (p = 0.787), and the rate of co-seropositivity between them was 5.43% (21/387).

Interpretation & conclusion

The findings of the study showed that C. burnetii infection is epidemic especially in the people living in rural areas. Contact with ticks in various ways might have resulted in the increased risk of C. burnetii infection in the study. Personal protective measures against tick bites may be important for reducing Q fever risk as in other tick-borne infectious disease.

The prevalence and clinical characteristics of tick-borne diseases at One Sentinel Hospital in Northeastern China

Northeastern China is a region of high tick abundance, multiple tick-borne pathogens and likely human infections. The spectrum of diseases caused by tick-borne pathogens has not been objectively evaluated in this region for clinical management and for comparison with other regions globally where tick-transmitted diseases are common. Based on clinical symptoms, PCR, indirect immunofluorescent assay and (or) blood smear, we identified and described tick-borne diseases from patients with recent tick bite seen at Mudanjiang Forestry Central Hospital. From May 2010 to September 2011, 42% (75/180) of patients were diagnosed with a specific tick-borne disease, including Lyme borreliosis, tick-borne encephalitis, human granulocytic anaplasmosis, human babesiosis and spotted fever group rickettsiosis. When we compared clinical and laboratory features to identify factors that might discriminate tick-transmitted infections from those lacking that evidence, we revealed that erythema migrans and neurological manifestations were statistically significantly differently presented between those with and without documented aetiologies (P &lt; 0.001, P = 0.003). Twelve patients (6.7%, 12/180) were co-infected with two tick-borne pathogens. We demonstrated the poor ability of clinicians to identify the specific tick-borne disease. In addition, it is necessary to develop specific laboratory assays for optimal diagnosis of tick-borne diseases.

Infection Kinetics and Tropism of Borrelia burgdorferi sensu lato in Mouse After Natural (via Ticks) or Artificial (Needle) Infection Depends on the Bacterial Strain

Borrelia burgdorferi sl is a complex of pathogen bacteria transmitted to the host by Ixodes ticks. European Ixodes ricinus ticks transmit different B. burgdorferi species, pathogenic to human. Bacteria are principally present in unfed tick midgut, then migrate to salivary glands during blood meal and infect a new host via saliva. In this study, efficiency of transmission in a mouse model of three pathogen species belonging to the B. burgdorferi sl complex, B. burgdorferi sensu stricto (B31, N40, and BRE-13), B. afzelii (IBS-5), and B. bavariensis (PBi) is examined in order to evaluate infection risk after tick bite. We compared the dissemination of the Borrelia species in mice after tick bite and needle injection. Location in the ticks and transmission to mice were also determined for the three species by following infection kinetics. After inoculation, we found a significant prevalence in the brain for PBi and BRE-13, in the heart, for PBi, in the skin where B31 was more prevalent than PBi and in the ankle where both B31 and N40 were more present than PBi. After tick bite, statistical analyses showed that BRE-13 was more prevalent than N40 in the brain, in the bladder and in the inguinal lymph node. When Borrelia dissemination was compared after inoculation and tick bite, we observed heart infection only after tick inoculation of BRE-13, and PBi was only detected after tick bite in the skin. For N40, a higher number of positive organs was found after inoculation compared to tick bite. All European B. burgdorferi sl strains studied were detected in female salivary glands before blood meal and infected mice within 24 h of tick bite. Moreover, Borrelia-infected nymphs were able to infect mice as early as 12 h of tick attachment. Our study shows the need to remove ticks as early as possible after attachment. Moreover, Borrelia tropism varied according to the strain as well as between ticks bite and needle inoculation, confirming the association between some strains and clinical manifestation of Lyme borreliosis, as well as the role played by tick saliva in the efficiency of Borrelia infection and dissemination in vertebrates.

Tick bite-Erythema migrans

This manuscript describes the typical presentation of erythema migrans caused by tick bite. The purposes of this article are (i) to encourage physicians to observe patients with tick bite carefully since it may cause fatal encephalitis, and (ii) to facilitate physicians, especially in endemic areas, to consider tick-borne encephalitis virus as one of the causes of encephalitis.

Repeated Amblyomma testudinarium tick bites are associated with increased galactose-α-1,3-galactose carbohydrate IgE antibody levels: A retrospective cohort study in a single institution

BACKGROUND

Alpha-gal syndrome is a hypersensitivity reaction to red meat mediated by IgE antibody specific to galactose-α-1,3-galactose carbohydrate (alpha-gal). Amblyomma tick bites are associated with this condition, but the pathophysiology is not understood.

OBJECTIVE

To clarify the mechanism of development of alpha-gal syndrome after tick bites.

METHODS

We compared alpha-gal antibody levels between patients with and without a history of tick bites and examined histologic stainings of tick bite lesions between patients with and without detectable alpha-gal IgE antibody.

RESULTS

Patients who had ≥2 tick bites had higher levels of alpha-gal IgE antibody compared with those with only 1 tick bite or healthy individuals. On histologic investigation, greater numbers of basophils and eosinophils, but not mast cells, were observed infiltrating lesions of patients with ≥2 tick bites compared with those with 1 tick bite. Type 2 cytokine-producing T-cell infiltration was predominantly observed in such patients.

LIMITATIONS

The study was conducted at a single institution in Japan.

CONCLUSION

In Amblyomma tick bite lesions, basophils; eosinophils; and type 2, cytokine-producing T cells infiltrate the skin and alpha-gal IgE antibodies are produced. These findings provide a potential mechanistic connection between Amblyomma bites and red meat hypersensitivity.

A Histopathologic Study of the Human Skin in the Early Stage After a Tick Bite: A Special Reference to Cutaneous Tissue Reaction to the Cement Substance of Tick Saliva

The Ixodidae family of hard ticks has cement-producing and non-cement-producing species. Involved skins of four patients bitten by cement-producing ticks and two by non-cement-producing ticks were histopathologically examined. Those of the latter two patients were also studied immunohistochemically to characterize the infiltrating inflammatory cells. In patients with cement-producing ticks, the cement substance was observed as external cement or outer zone of internal cement, respectively. Coagulative necrosis was present in the epidermis in one patient and from the epidermis to the dermis in another patient. Epidermal cells were damaged in the remaining two patients. Despite these severe tissue damages, the cutaneous inflammatory reaction in all four patients was very mild. In contrast, the patients bitten by non-cement-producing ticks had severe cutaneous inflammatory reaction. In addition to caseous necrosis-like change in the entrance site of the inserted mouthparts, extensive interstitial lymphohistiocytic infiltrate was present diffusely from the dermis to the subcutaneous tissue. In one of the patients coagulative necrosis was present from the dermis to the subcutaneous tissue. Immunohistochemically, the infiltrating lymphocytes were T-cell dominant and mixed moderately with B-cells. Pathogenetically, the cutaneous inflammatory reaction is only mild in the skins involved by the cement-producing ticks, perhaps because inflammatory reaction in the host skin is suppressed by antiinflammatory and immunosuppressive substances contained in tick's saliva in order to prevent position of their mouthparts fixed to the host skin from rejection of the host until finishing their engorgement. In contrast, the cutaneous inflammatory reaction induced by the non-cement-producing ticks is severe, possibly because these ticks have no antiinflammatory and immunosuppressive substances in their saliva, and because their saliva is much more injurious than that of the cement-producing ticks.

TICK INFESTATION: A 200-PATIENTS' SERIES

Background:

A great number of zoonotic diseases with high mortality rate are transmitted by ticks. We performed this study in order to investigate patients admitted to emergency department following a tick bite. We examined the patients and get knowledge about the infestation and we followed up them for possible tick-conducted disease symptoms and laboratory findings both clinically and serologically.

Materials and Methods:

The study presented was hold for one year, between 01.01.2012 and 31.12.2012. 200 tick infested cases, admitted to Emergency Department of Haydarpasa Numune Training and Research Hospital, were subjected in the study. Demographic patterns of the patients and the region they come from, infested area on body, admission time and blood analyzing results were detected.

Results:

Rate of adult patients to pediatric was 2:1; gender distribution was similar to each other. The most common body areas that ticks were removed from were lower extremity. The highest tick bite incidence was in summer and on weekends. No tick bite incident of Istanbul surrounding from the year 2012 progressed to a zoonotic disease.

Conclusions:

Although non-of the patients of our study has been diagnosed with Crimean-Congo hemorrhagic fever we informed all of them for the incubation period and call for observation during the time. Tick borne infections may present with vary of symptoms, the most sever of which is hemorrhagic diathesis and patients should be informed for the risks. Knowledge of local area fauna risks may guide physicians so studies on this topic are essential.

Tularemia presenting as suspected necrotic arachnidism

The true danger of the spider bite stems from misdiagnosis and resultant delay in proper treatment of entities that, unlike spider bites, are not self-limited. Obtaining a complete exposure and travel history is central to the development of an accurate and appropriate differential diagnosis.

Characterization of the early local immune response to Ixodes ricinus tick bites in human skin

Little is known about the immunomodulation by tick saliva during a natural tick bite in human skin, the site of the tick-host interaction. We examined the expression of chemokines, cytokines and leucocyte markers on the mRNA levels and histopathologic changes in human skin biopsies of tick bites (n=37) compared to unaffected skin (n=9). Early tick-bite skin lesions (<24 hours of tick attachment) were characterized by a predominance of macrophages and dendritic cells, elevated mRNA levels of macrophage chemoattractants (CCL2, CCL3, CCL4) and neutrophil chemoattractants (CXCL1, CXCL8), of the pro-inflammatory cytokine, IL-1β, and the anti-inflammatory cytokine, IL-5. In contrast, the numbers of lymphocytes and mRNA levels of lymphocyte cell markers (CD4, CD8, CD19), lymphocyte chemoattractants (CXCL9, CXCL10, CXCL11, CXCL13, CCL1, CCL22), dendritic cell chemoattractants (CCL20), and other pro- (IL-6, IL-12p40, IFN-γ, TNF-α) and anti-inflammatory cytokines (IL-4, IL-10, TGF-β) did not differ from normal skin. With longer tick attachment (>24 hours), the numbers of innate immune cells and mediators (not significantly) declined, whereas the numbers of lymphocytes (not significantly) increased. Natural tick bites by Ixodes ricinus ticks initially elicit a strong local innate immune response in human skin. Beyond 24 hours of tick attachment, this response usually becomes less, perhaps because of immunomodulation by tick saliva.

Socio-Economic Characteristics in Notified Erythema Migrans Patients

Background

Lyme borreliosis disease results from infection by members of the Borrelia burgdorferi sensu lato complex. The most common clinical presentation of Lyme borreliosis is erythema migrans (EM). To gain knowledge of the epidemiological parameters and the risk factors of EM in Slovenia, a survey has been carried out in 2010.

Methods

A short anonymous and self-administrated questionnaire was sent to 4917 notified EM patients in 2010, aiming to collect epidemiological data and assess socio-economic determinants in patients with EM.

Results

Three thousand and five (61%) patients with EM returned completed questionnaires. One thousand and nine hundred twenty-nine (74%) patients noted the tick where the EM developed. The tick bite was most often located on the legs in adults and in the head/neck area in children. The time that elapsed before the tick has been removed increased significantly with age. The attached tick was most frequently overlooked in preschool children. Nearly 70% of patients believed that they contracted the infection with borrelia near home. Infection away from their permanent residence was more often the case in those with a higher level of education and in 15–49 age groups. Compared to the Slovenian general population over 14 years of age, those with a higher level of education, the unemployed and farmers were overrepresented among the EM patients.

Conclusions

The risk of Lyme borreliosis is widespread in Slovenia, with some areas more affected then others. Determinants of exposure to infected ticks are different, and depend on the socio-economic status and demographic characteristics.

[Why is my foot swollen and red?]

We present the case of a 26 year old man reporting to the family doctor due to swelling and redness of the foot. After thrombosis and a tumorous mass could be excluded, the suspicion fell on an acrodermatitis chronica atrophican which could be confirmed by laboratory tests. During therapy there was a significant regression of the cutaneous lesion. The treatment of the Lyme disease was taken over by the casualty insurer.

Tick Bite Prophylaxis: Results From a 2012 Survey of Healthcare Providers

In a recent national survey, over 30% of healthcare providers (HCPs) reported prescribing tick bite prophylaxis in the previous year. To clarify provider practices, we surveyed HCPs to determine how frequently and for what reasons they prescribed tick bite prophylaxis. We included four questions regarding tick bite prophylaxis in the DocStyles 2012 survey, a computer-administered questionnaire of 2205 US primary care physicians, paediatricians and nurse practitioners. Responses in 14 states with high Lyme disease incidence (high LDI) were compared with responses from other states (low LDI). Overall, 56.4% of 1485 providers reported prescribing tick bite prophylaxis at least once in the previous year, including 73.9% of HCPs in high LDI and 48.2% in low LDI states. The reasons given were 'to prevent Lyme disease' (76.9%), 'patients request it' (40.4%) and 'to prevent other tickborne diseases' (29.4%). Among HCPs who provided prophylaxis, 45.2% did so despite feeling that it was not indicated. Given a hypothetical scenario involving a patient with an attached tick, 38.1% of HCPs from high LDI states and 15.1% from low LDI states would prescribe a single dose of doxycycline; 19.0% from high LDI states and 27.5% from low LDI states would prescribe a full course of doxycycline. HCPs prescribe tick bite prophylaxis frequently in areas where Lyme disease is rare and for tickborne diseases for which it has not been shown effective. HCPs may be unaware of current tick bite prophylaxis guidelines or find them difficult to implement. More information is needed regarding the efficacy of tick bite prophylaxis for diseases other than Lyme disease.

A case of Amblyomma testudinarium tick bite in a Korean woman

A case of tick bite was found in the inguinal region of a 74-year-old Korean woman. She was attacked by the tick while working in her vegetable garden in the vicinity of mountain located in Suncheon City, the southern coastal area of the Korean Peninsula. On admission she complained of mild discomfort and itching around the bite area. The causative tick was 23 mm long and had slender pedipalps. The scutum was quite ornate and had eyes at the edge. The genital aperture was located anterior to the level of the coxa II. The spiracular plate was comma-shaped and the anus was surrounded posteriorly by the anal groove. The coxa I had subequal 2 spurs; the external one slightly larger. The spur of coxa IV was slightly longer than those of coxae II and III. The tarsus IV had 2 distinct subapical ventral spurs. It was identified as the fully engorged adult female of Amblyomma testudinarium. This is the first human case of Amblyomma bite in Korea.

Typhus and other rickettsioses: emerging infections in Germany

BACKGROUND

Rickettsioses are diseases caused by rickettsiae, obligate intracellular bacteria that are transmitted by arthropods to humans. They cause various types of spotted fever and typhus.

METHODS

A review of the literature is presented along with the authors' own findings.

RESULTS

Six indigenous species of rickettsiae have been found in Germany to date, five of which have been described as human pathogens in other countries. Rickettsia slovaca causes tick-borne lymphadenitis (TIBOLA). Rickettsia helvetica is a known pathogen of nonspecific fever; its role in endocarditis is still under investigation. Rickettsia felis causes so-called flea-borne spotted fever. Rickettsia monacensis and Rickettsia massiliae were recently shown to cause the classical form of tick-borne spotted fever. The sixth indigenous species in Germany, Rickettsia sp. RpA4, has not yet been associated with any human disease. The most important rickettsioses imported to Germany by travelers are African tick bite fever and Mediterranean spotted fever.

CONCLUSIONS

Modern molecular biological techniques have enabled the detection of a number of rickettsial species in Germany. The medical importance of these illnesses in Germany remains to be determined. In travel medicine, imported rickettsioses play a role that should not be underestimated.

Lyme disease--current state of knowledge

BACKGROUND

Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease.

METHOD

The authors conducted a selective review of the literature, including various national and international guidelines.

RESULTS

The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins.

CONCLUSIONS

After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.

Two human cases of tick bite caused by Ixodes nipponensis

We report two human cases of tick bite. A 63-year-old male had a pruritic pea-sized brownish nodule on the left popliteal area. Another 41-year-old male had an asymptomatic bean-sized black nodule in the pubic area. The ticks were identified as Ixodes nipponensis, which are the 18th and the 19th cases in Korea.