Tickborne Diseases: Diagnosis and Management
Am Fam Physician. 2020 May 1;101(9):530-540.
Patient information: See related handout on protection from ticks, written by the authors of this article.
Author disclosure: No relevant financial affiliations.
Tickborne diseases that affect patients in the United States include Lyme disease, Rocky Mountain spotted fever (RMSF), ehrlichiosis, anaplasmosis, babesiosis, tularemia, Colorado tick fever, and tickborne relapsing fever. Tickborne diseases are increasing in incidence and should be suspected in patients presenting with flulike symptoms during the spring and summer months. Prompt diagnosis and treatment can prevent complications and death. Location of exposure, identification of the specific tick vector, and evaluation of rash, if present, help identify the specific disease. Lyme disease presents with an erythema migrans rash in 70% to 80% of patients, and treatment may be initiated based on this finding alone. RMSF presents with a macular rash starting on the wrists, forearms, and ankles that becomes petechial. RMSF has a higher rate of mortality than other tickborne diseases; therefore, empiric treatment with doxycycline is recommended for all patients, including pregnant women and children, when high clinical suspicion is present. Testing patient-retrieved ticks for infections is not recommended. Counseling patients on the use of protective clothing and tick repellents during outdoor activities can help minimize the risk of infection. Prophylactic treatment after tick exposure in patients without symptoms is generally not recommended but may be considered within 72 hours of tick removal in specific patients at high risk of Lyme disease.
The incidence of tickborne diseases is increasing in the United States.1–3 Diagnosis can be challenging because most patients do not recall being bitten by a tick, initial symptoms are similar and nonspecific, and ticks transmit multiple diseases in the same geographic area. Available diagnostic tests are limited by poor sensitivity early in the disease course, making clinical suspicion and familiarity with common laboratory findings important. Empiric treatment is recommended for tickborne diseases that fit the clinical presentation and geographic distribution. Early doxycycline administration improves morbidity and mortality. Table 11,2,4–18 and Table 21,2,4,5,7–9,13,15–24 summarize the epidemiology and clinical characteristics of tickborne diseases in the United States. Figure 1 highlights tickborne disease geographic distributions.25 Ixodes scapularis (Figure 2) and Dermacentor variabilis (Figure 3) are the ticks that commonly transmit disease in the United States.26
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
Diagnose Lyme disease clinically with classic erythema migrans rash.4 | C | Consensus guidelines from the Infectious Disease Society of America |
Prophylaxis after a tick bite in the absence of symptoms is generally not recommended.4 | C | Consensus guidelines |
A single dose of doxycycline may be used for prophylaxis against Lyme disease in patients at high risk within 72 hours of tick removal.4,36 | B | Infectious Disease Society of America guidelines, based on single randomized controlled trial showing decreased incidence of Lyme disease with treatment in patients at high risk of disease |
References
show all references1. Centers for Disease Control and Prevention. Lyme disease. Accessed March 31, 2019. https://www.cdc.gov/lyme/index.html...
2. Biggs HM, Behravesh CB, Bradley KK, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, erhlichioses, and anaplasmosis – United States. MMWR Recomm Rep. 2016;65(2):1–44.
3. Clark RP, Hu LT. Prevention of Lyme disease and other tick-borne infections. Infect Dis Clin North Am. 2008;22(3):381–396, vii.
4. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2007;45(7):941]. Clin Infect Dis. 2006;43(9):1089–1134.
5. Centers for Disease Control and Prevention. Rocky Mountain spotted fever. Accessed March 31, 2019. https://www.cdc.gov/rmsf/index.html
6. Regan JJ, Traeger MS, Humpherys D, et al. Risk factors for fatal outcome from Rocky Mountain spotted fever in a highly endemic area-Arizona, 2002–2011. Clin Infect Dis. 2015;60(11):1659–1666.
7. Centers for Disease Control and Prevention. Ehrlichiosis. Accessed March 31, 2019. https://www.cdc.gov/ehrlichiosis/index.html
8. Centers for Disease Control and Prevention. Anaplasmosis. Accessed March 31, 2019. https://www.cdc.gov/anaplasmosis/index.html
9. Centers for Disease Control and Prevention. Parasites - babesiosis. Accessed March 31, 2019. https://www.cdc.gov/parasites/babesiosis/index.html
10. Centers for Disease Control and Prevention (CDC). Babesiosis surveillance - 18 States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(27):505–509.
11. Stein E, Elbadawi LI, Kazmierczak J, et al. Babesiosis surveillance - Wisconsin, 2001–2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):687–691.
12. Apostolou A, Sorhage F, Tan C. Babesiosis surveillance, New Jersey, USA, 2006–2011. Emerg Infect Dis. 2014;20(8):1407–1409.
13. Centers for Disease Control and Prevention. Tularemia. Accessed April 13, 2019. https://www.cdc.gov/tularemia/index.html
14. Yendell SJ, Fischer M, Staples JE. Colorado tick fever in the United States, 2002–2012. Vector Borne Zoonotic Dis. 2015;15(5):311–316.
15. Centers for Disease Control and Prevention. Colorado tick fever. Accessed April 13, 2019. https://www.cdc.gov/coloradotickfever/index.html
16. Lambert AJ, Kosoy O, Velez JO, et al. Detection of Colorado tick fever viral RNA in acute human serum samples by a quantitative real-time RT-PCR assay. J Virol Methods. 2007;140(1–2):43–48.
17. Centers for Disease Control and Prevention. Relapsing fever. Accessed April 13, 2019. https://www.cdc.gov/relapsing-fever/index.html
18. Roscoe C, Epperly T. Tick-borne relapsing fever. Am Fam Physician. 2005;72(10):2039–2044. https://www.aafp.org/afp/2005/1115/p2039.html
19. Bratton RL, Corey R. Tick-borne disease. Am Fam Physician. 2005;71(12):2323–2330. https://www.aafp.org/afp/2005/0615/p2323.html
20. Nigrovic LE, Bennett JE, Balamuth F, et al.; Pedi Lyme Net. Accuracy of clinical suspicion of Lyme disease in the emergency department. Pediatrics. 2017;140(6):e20171975.
21. Chang C, Feemster KA, Coffin S, et al. Treatment-related complications in children hospitalized with disseminated Lyme disease. J Pediatric Infect Dis Soc. 2017;6(3):e152–e154.
22. Mukkada S, Buckingham SC. Recognition of and prompt treatment for tick-borne infections in children. Infect Dis Clin North Am. 2015;29(3):539–555.
23. Dhand A, Nadelman RB, Aguero-Rosenfeld M, et al. Human granulocytic anaplasmosis during pregnancy: case series and literature review. Clin Infect Dis. 2007;45(5):589–593.
24. Krause PJ, Lepore T, Sikand VK, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. 2000;343(20):1454–1458.
25. Centers for Disease Control and Prevention. Overview of tickborne diseases. Accessed September 1, 2019. https://www.cdc.gov/ticks/tickbornediseases/overview.html
26. U.S. Army Public Health Center. Accessed November 12, 2019. https://phc.amedd.army.mil
27. Depietropaolo DL, Powers JH, Gill JM. Diagnosis of Lyme disease. Am Fam Physician. 2005;72(2):297–304.
28. Waddell LA, Greig J, Mascarenhas M, et al. The accuracy of diagnostic tests for Lyme disease in humans, a systematic review and meta-analysis of North American research. PLoS One. 2016;11(12):e0168613.
29. Molins CR, Delorey MJ, Sexton C, et al. Lyme borreliosis serology: performance of several commonly used laboratory diagnostic tests and a large resource panel of well-characterized patient samples. J Clin Microbiol. 2016;54(11):2726–2734.
30. Mead P, Petersen J, Hinckley A. Updated CDC recommendation for serologic diagnosis of Lyme disease. MMWR Morb Mortal Wkly Rep. 2019;68(32):703.
31. Klempner MS, Hu LT, Evans J, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med. 2001;345(2):85–92.
32. Klempner MS, Baker PJ, Shapiro ED, et al. Treatment trials for post-Lyme disease symptoms revisited. Am J Med. 2013;126(8):665–669.
33. Berende A, ter Hofstede HJ, Vos FJ, et al. Randomized trial of longer-term therapy for symptoms attributed to Lyme disease. N Engl J Med. 2016;374(13):1209–1220.
34. Krupp LB, Hyman LG, Grimson R, et al. Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial. Neurology. 2003;60(12):1923–1930.
35. Fallon BA, Keilp JG, Corbera KM, et al. A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. Neurology. 2008;70(13):992–1003.
36. Nadelman RB, Nowakowski J, Fish D, et al.; Tick Bite Study Group. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345(2):79–84.
37. Drage LA. Life-threatening rashes: dermatologic signs of four infectious diseases. Mayo Clin Proc. 1999;74(1):68–72.
38. Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain spotted fever. J Pediatr. 2015;166(5):1246–1251.
39. Zientek J, Dahlgren FS, McQuiston JH, et al. Self-reported treatment practices by healthcare providers could lead to death from Rocky Mountain spotted fever. J Pediatr. 2014;164(2):416–418.
40. Cross R, Ling C, Day NP, et al. Revisiting doxycycline in pregnancy and early childhood—time to rebuild its reputation? Expert Opin Drug Saf. 2016;15(3):367–382.
41. Souza SS, Bishop HS, Sprinkle P, et al. Comparison of Babesia microti real-time polymerase chain reaction assays for confirmatory diagnosis of babesiosis. Am J Trop Med Hyg. 2016;95(6):1413–1416.
42. Dworkin MS, Schwan TG, Anderson DE Jr, et al. Tick-borne relapsing fever. Infect Dis Clin North Am. 2008;22(3):449–468, viii.
43. Centers for Disease Control and Prevention. Borrelia miyamotoi disease. Accessed August 5, 2019. https://www.cdc.gov/ticks/tickbornediseases/borrelia-miyamotoi.html
44. Krause PJ, Fish D, Narasimhan S, et al. Borrelia miyamotoi infection in nature and in humans. Clin Microbiol Infect. 2015;21(7):631–639.
45. Platonov AE, Karan LS, Kolyasnikova NM, et al. Humans infected with relapsing fever spirochete Borrelia miyamotoi, Russia. Emerg Infect Dis. 2011;17(10):1816–1823.
46. Centers for Disease Control and Prevention. Southern tick-associated rash illness. Accessed August 5, 2019. https://www.cdc.gov/stari/index.html
47. Masters EJ, Grigery CN, Masters RW. STARI, or Masters disease: Lone Star tick-vectored Lyme-like illness. Infect Dis Clin North Am. 2008;22(2):361–376, viii.
48. Commins SP, Jerath MR, Cox K, et al. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016;65(1):16–20.
49. Fischer J, Yazdi AS, Biedermann T. Clinical spectrum of α-Gal syndrome: from immediate-type to delayed immediate-type reactions to mammalian innards and meat. Allergo J Int. 2016;25:55–62.
50. Krow-Lucal ER, Lindsey NP, Fischer M, et al. Powassan virus disease in the United States, 2006–2016. Vector Borne Zoonotic Dis. 2018;18(6):286–290.
51. Piantadosi A, Rubin DB, McQuillen DP, et al. Emerging cases of Powassan virus encephalitis in New England: clinical presentation, imaging, and review of the literature. Clin Infect Dis. 2016;62(6):707–713.
52. Centers for Disease Control and Prevention. Powassan virus. Accessed August 1, 2019. https://www.cdc.gov/powassan/index.html
53. Edlow JA, McGillicuddy DC. Tick paralysis. Infect Dis Clin North Am. 2008;22(3):397–413, vii.
54. Centers for Disease Control and Prevention (CDC). Cluster of tick paralysis cases—Colorado, 2006. MMWR Morb Mortal Wkly Rep. 2006;55(34):933–935.
55. Morshed M, Li L, Lee MK, et al. A retrospective cohort study of tick paralysis in British Columbia. Vector Borne Zoonotic Dis. 2017;17(12):821–824.
56. Vázquez M, Muehlenbein C, Cartter M, et al. Effectiveness of personal protective measures to prevent Lyme disease. Emerg Infect Dis. 2008;14(2):210–216.
57. Richardson M, Khouja C, Sutcliffe K. Interventions to prevent Lyme disease in humans: a systematic review. Prev Med Rep. 2018;13:16–22.
58. Yates J. Advice for protection against mosquitoes and ticks. Am Fam Physician. 2015;91(11):754–755. Accessed February 3, 2020. https://www.aafp.org/afp/2015/0601/p754.html
59. Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes spp. - a literature review. Travel Med Infect Dis. 2013;11(6):374–411.
60. Gammons M, Salam G. Tick removal. Am Fam Physician. 2002;66(4):643–646. Accessed February 3, 2020. https://www.aafp.org/afp/2002/0815/p643.html
61. Gayle A, Ringdahl E. Tick-borne diseases. Am Fam Physician. 2001;64(3):461–467. Accessed February 3, 2020. https://www.aafp.org/afp/2001/0801/p461.html
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact
afpserv@aafp.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions
CME Quiz
More in AFP
Editor's Collections
Related Content
More in Pubmed
MOST RECENT ISSUE
Email Alerts
Don't miss a single issue. Sign up for the free AFP email table of contents.
