Tickborne Diseases: Diagnosis and Management

Emma J. Pace; Matthew O'Reilly

May 1, 2020 Issue

Tickborne Diseases: Diagnosis and Management

EMMA J. PACE, MD, and MATTHEW O'REILLY, DO, Naval Hospital Camp Pendleton Family Medicine Residency Program, Camp Pendleton, California

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

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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
Initiate treatment in patients with suspected rickettsial infection (Rocky Mountain spotted fever, ehrlichiosis, and anaplasmosis) before confirming diagnosis to minimize morbidity and mortality.^2,4,6,23,38	C	Centers for Disease Control and Prevention guidelines, based on observations of improved outcomes with early treatment
Doxycycline is the preferred treatment for all patients with suspected rickettsial infections.^{2,5,23,38–40}	C	Centers for Disease Control and Prevention guidelines based on cohort studies showing low risk of adverse effects including children and pregnant women
Use protective clothing and tick repellents to prevent acquisition of tickborne diseases.^4,56,57	B	Systematic reviews of literature

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
Initiate treatment in patients with suspected rickettsial infection (Rocky Mountain spotted fever, ehrli

The Authors

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EMMA J. PACE, MD, is a faculty member in the Family Medicine Residency Program at Naval Hospital Camp Pendleton, Calif....

MATTHEW O'REILLY, DO, is a resident in the Family Medicine Residency Program at Naval Hospital Camp Pendleton.

Address correspondence to Emma J. Pace, MD, 200 Mercy Circle, Camp Pendleton, CA 92055 (email: emma.j.pace2.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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