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Tick-Borne Diseases, Lyme: Multimedia
Updated: Aug 26, 2009
Multimedia
 | Media file 1: This patient's erythema migrans rash demonstrates several key features of the rash, including size, location, and presence of a central punctum, which can be seen right at the lateral margin of the inferior gluteal fold. Note that the color is uniform; this pattern probably is more common than the classic pattern of central clearing. |
 | Media file 2: The thorax and torso are typical locations for erythema migrans. The lesion is slightly darker in the center, a common variation. In addition, this patient worked outdoors in a highly endemic area. Physical examination also revealed a right axillary lymph node. |
 | Media file 3: This patient recalled pulling a tick from the left side of his neck 7 days previously. His rash displays the vesicular variant. Roughly 18 hours after the first dose of doxycycline, he developed a typical Jarisch-Herxheimer reaction. |
 | Media file 4: The Ixodes scapularis tick is considerably smaller than the Dermacentor tick. The former is the vector for Lyme disease, granulocytic ehrlichiosis, and babesiosis. The latter is the vector for Rocky Mountain spotted fever. This photo displays an adult I scapularis tick (on the right) next to an adult Dermacentor variabilis; both are next to a common match displayed for scale. Photo by Darlyne Murawski; reproduced with permission. |
 | Media file 5: In general, Ixodes scapularis must be attached for 24-48 hours to transmit the spirochete to the host mammal. Prophylactic antibiotics are more likely to be helpful if feeding is longer. This photo shows 2 I scapularis nymphs. The one on the right is unfed; the other has been feeding for 48 hours. Note its larger size and the fact that the midgut diverticula (delicate brown linear areas on the body) are blurred. Photo by Darlyne Murawski; reproduced with permission. |
 | Media file 6: This is the classic target lesion of erythema migrans (EM). Although this morphology has been emphasized in the older literature, in North America, it represents only about 40% of all EM lesions. This morphology is more commonly found in Europe. Photo reproduced with permission; Lyme Disease Foundation, Hartford, CT. |
 | Media file 7: Lyme disease frequently affects children. Pictured below is a young girl with no known tick bite in the area. While vacationing with her family on Fire Island in August, this young girl developed the rash shown below. She was treated successfully with amoxicillin. Photo courtesy of Dr John Hanrahan. |
 | Media file 8: This is an ECG from a 21-year-old man with severe weakness and near syncope. Ten days earlier, while in upstate New York, he had a febrile illness without rash. No tick bite was known to occur, and the serologic result for Lyme disease was negative at the time. Seroconversion occurred when this ECG was obtained. He was admitted to a telemetry unit, had a temporary pacemaker inserted, and was given 2 g of intravenous ceftriaxone daily. He was well and did not need the pacemaker after 4 days. |
 | Media file 9: This patient from Nantucket presented in early July with this rash. When the rash started, he had been treated for 1 week with Lotrisone for a presumed tineal infection, but the initial lesion grew, and new ones developed. He worked outside as a carpenter but had no definite tick bite. |
 | Media file 10: This patient from a highly endemic area presented in July with a lesion on his ankle. It was mildly painful and had been present for 2-3 days. Mild tenderness was evident on physical examination. Both cellulitis and erythema migrans were possibilities; therefore, the patient was treated for both. Cefuroxime axetil or amoxicillin-clavulanate is useful in this situation because of their antimicrobial spectra. |
 | Media file 11: Ticks are the most common vectors for vector-borne diseases in the United States. In North America, tick bites can cause Lyme disease, human granulocytic and monocytic ehrlichiosis, babesiosis, relapsing fever, Rocky Mountain spotted fever, Colorado tick fever, tularemia, Q fever, and tick paralysis. Europe has a similar list of illnesses caused by ticks, but additional concerns include boutonneuse fever and tick-borne encephalitis. Lyme disease is one of the most prominent tick-borne diseases, and its main vector is the tick genus Ixodes, primarily Ixodes scapularis. Image courtesy of the US Centers of Disease Control and Prevention. |
 | Media file 12: This map demonstrates an approximate distribution of predicted Lyme disease risk in the United States. The true relative risk in any given country compared with other counties may differ from that shown here and may change from year to year. Information on risk distribution within states and counties is best obtained from state and local public health authorities. Map courtesy of the US Centers for Disease Control and Prevention. |
 | Media file 13: The bacterium Borrelia burgdorferi (darkfield microscopy technique, 400X; courtesy of the US Centers for Disease Control and Prevention). |
 | Media file 14: Approximate US distribution of Ixodes scapularis. Image courtesy of the US Centers for Disease Control and Prevention. |
 | Media file 15: Amblyomma americanum is the tick vector for monocytic ehrlichiosis and tularemia. An adult and a nymphal form are shown (common match shown for size comparison). Image by Darlyne Murawski; reproduced with permission. Ehrlichiosis is a tick-borne infection of the white blood cells caused by Ehrlichia species. Typical symptoms include fever, headache, malaise, and myalgia, and they occur 5-14 days after the tick bite. It is sometimes referred to as "spotless" Rocky Mountain spotted fever. The treatment of choice is doxycycline, 100 mg twice daily, either orally or intravenously for 10 days. This regimen will also treat Lyme disease and the often mistaken Rocky Mountain spotted fever. Rifampin, 200 mg twice daily for 7 days, is a second-line option because chloramphenicol does not treat Ehrlichia chaffeensis. Tularemia is a zoonosis caused by infection with Francisella tularensis. Typical symptoms include fever, lethargy, anorexia, and in some forms, extensive ulcerating lymphadenopathy. With early diagnosis and treatment, mortality is rare (1%). Antibiotic treatment with streptomycin, 1 g intramuscularly twice daily for 10 days, eradicates the bacteria. |
 | Media file 16: Approximate US distribution of A americanum. Image courtesy of the US Centers for Disease Control and Prevention. |
 | Media file 17: The soft-bodied tick of the genus Ornithodoros transmits various Borrelia species that cause relapsing fever. Photo courtesy of Julie Rawlings, MPH, Texas Department of Health. Relapsing fever is characterized by recurrent acute episodes of fever (usually >39°C). It is a vector-borne illness spread by lice and ticks. The spirochete species Borrelia is responsible. For tick-borne relapsing fever, treatment is with tetracycline, 500 mg orally every 6 hours, or doxycycline, 100 mg orally twice daily, for 10 days. The louse-borne illness usually only requires a single dose of tetracycline or erythromycin, 500 mg orally. |
 | Media file 18: Approximate US distribution of Dermacentor andersoni. Image courtesy of the US Centers for Disease Control and Prevention. |
 | Media file 19: Rhipicephalus ticks are vectors for babesiosis and rickettsial infections, among others. Image courtesy of Dirk M. Elston, MD. In typical practice, testing ticks for tick-borne infectious organisms is not generally recommended. However, healthcare practitioners should become familiar with the clinical manifestations of tick-borne diseases (eg, Lyme disease, especially those practicing in endemic areas) and maintain a high index of suspicion during warmer months. Ticks can be placed in a sealed container with alcohol if they need to be transported and identified. |
 | Media file 20: A rarely reported noninfectious complication for tick bites is alopecia. It can begin within a week of tick removal and typically occurs in a 3- to 4-cm circle around a tick bite on the scalp. A moth-eaten alopecia of the scalp caused by bites of Dermacentor variabilis (the American dog tick) has also been described. No particular species appears more likely to cause alopecia. Hair regrowth typically occurs within 1-3 months, although permanent alopecia has been observed. |
 | Media file 21:
To remove a tick, use fine-tipped forceps and
wear gloves. Grasp the tick as close to the skin surface as
possible, including the mouth parts, and pull upward with
steady, even traction. Do not twist or jerk the tick because
this may cause the mouth parts to break off and remain in the
skin; however, note that the mouth parts themselves are not
infectious. When removing, wear gloves to avoid possible
infection. Children, elderly persons, and immunocompromised
persons may be at greater risk for infection and should avoid
removing ticks if possible. A common misperception is that pressing a hot match to the tick or trying to smother it with petroleum jelly, gasoline, nail polish, or other noxious substances is beneficial. This only prolongs exposure time and may cause the tick to eject infectious organisms into the body. Additionally, using lidocaine (subcutaneously or topically) may actually irritate the tick and prompt it to regurgitate its stomach contents. Finally, do not squeeze, crush, or puncture the body of the tick because its fluids (saliva, hemolymph, gut contents) may contain infectious organisms. Once the tick is removed, wash the bite area with soap and water or with an antiseptic to destroy any contaminating microorganisms. Additionally, the person who removed the tick should wash his or her hands. |
 | Media file 22: Tick-borne disease prevention can be divided into environmental and personal measures. Patients exposed to tick-endemic areas should wear long-sleeved, light-colored clothing when outside. Lighter colors allow for easier identification of ticks. Chemical repellents with DEET (N,N-diethyl-3-methylbenzamide) and picaridin are available in numerous over-the-counter skin preparations as sprays or lotions. Permethrin is an acaricide that can be applied to clothing and is used in conjunction with chemical repellents. All individuals should perform regular skin checks. Ticks prefer warm, moist areas, such as the beltline, groin, and axilla, although in children, the hairline is a common site. Environmental prevention involves clearing underbrush and spraying acaricides in the spring around property sites. These measures prevent both mice and ticks from encroaching on properties. Studies involving the treatment of wild deer and mice have not been conclusive in reducing tick-borne diseases in humans. Currently, no Lyme disease vaccines are available in the United States. Lyme disease vaccine (Lymerix™) was discontinued in 2002, so some patients may still have residual protective antibodies. Image courtesy of the National Library of Medicine. |
 | Media file 23: Hematoxylin and eosin stained section from a biopsy performed at the periphery of an eruption. Note the perivascular lymphocytic infiltrate, a pattern that is not specific for, but is characteristic of, erythema migrans. |
 | Media file 24: Borrelial lymphocytoma of the earlobe, which shows a bluish red discoloration. The location is typical in children, as opposed to the nipple in adults. This manifestation of Lyme disease is uncommon and occurs only in Europe. Courtesy of Lyme Disease Foundation, Hartford, Conn. |
 | Media file 25: Acrodermatitis chronica atrophicans is found almost exclusively in European patients and comprises an early inflammatory phase and a later atrophic phase. As the term suggests, the lesion occurs acrally and ultimately results in skin described as being like cigarette paper. Courtesy of Lyme Disease Foundation, Hartford, Conn. |
 | Media file 26: Multiple lesions of erythema migrans occur in approximately 20% of patients. This patient, a carpenter from Nantucket who worked predominantly outside, had been treated with Lotrisone for 1 week prior to presenting to the emergency department with this rash. The patient had no fever and only mild systemic symptoms. He was treated with a 3-week course of oral antibiotics. |
 | Media file 27: Blood smear showing likely babesiosis. Babesiosis can be difficult to distinguish from malaria on a blood smear. |
 | Media file 28: Magnified ticks at various stages of development. |
 | Media file 29: Typical appearance of erythema migrans, the bull's-eye rash of Lyme disease |
 | Media file 30: Lyme rash. Courtesy of M. Fergione, B. Tucker, and L. Zernel; Pfizer Laboratories. |
 | Media file 31: Normal and engorged Ixodes ticks. |
 | Media file 32: Erythema migrans, the characteristic rash of early Lyme disease. |
More on Tick-Borne Diseases, Lyme |
| Overview: Tick-Borne Diseases, Lyme |
| Differential Diagnoses & Workup: Tick-Borne Diseases, Lyme |
| Treatment & Medication: Tick-Borne Diseases, Lyme |
| Follow-up: Tick-Borne Diseases, Lyme |
 Multimedia: Tick-Borne Diseases, Lyme |
| References |
| Further Reading |
| « Previous Page |
References
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[Guideline] Halperin JJ, Shapiro ED, Logigian E, Belman AL, Dotevall L, Wormser GP, et al. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Jul 3 2007;69(1):91-102. [Medline].
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Wormser GP, Ramanathan R, Nowakowski J, et al. Duration of antibiotic therapy for early Lyme disease. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. May 6 2003;138(9):697-704. [Medline].
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Further Reading
Clinical Guidelines
Practice parameter: treatment of nervous system Lyme disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. American Academy of Neurology - Medical Specialty Society. 2007 Jul. 12 pages. NGC:005671
Evidence-based guidelines for the management of Lyme disease. International Lyme and Associated Diseases Society - Disease Specific Society. 2004. 13 pages. NGC:003481
Infectious Diseases Society of America practice guidelines for clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis. Infectious Diseases Society of America - Medical Specialty Society. 2000 Jul (revised 2006 Jun). 150 pages. NGC:005085
Clinical Trials
Evaluation of Lyme Disease: Clinical, Microbiological, and Immunological Characteristics
Evaluation, Treatment, and Follow-up of Patients with Lyme Disease
Study and Treatment of Post Lyme Disease (STOP-LD)
A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial of the Safety and Efficacy of Ceftriaxone and Doxycycline in the Treatment of Patients With Seronegative Chronic Lyme Disease
A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial of the Safety and Efficacy of Ceftriaxone and Doxycycline in the Treatment of Patients With Seropositive Chronic Lyme Disease
Analysis of Lyme Disease Lesions
Keywords
tick-borne disease, Lyme disease, tick bite, Borrelia burgdorferi, Ixodes, vector-borne disease, juvenile arthritis, B burgdorferi, spirochete, tick-borne pathogens, myalgias, arthralgias, flulike illness, borrelial lymphocytoma
acrodermatitis chronicum atrophicans, lymphocytic meningitis, facial weakness, Bell palsy, borrelial facial palsy, lymphocytic pleocytosis, Bannwarth syndrome, chronic encephalopathy, syncope, heart block, complete heart block, lyme pericarditis, lyme myocarditis, lyme myopericarditis, myositis, tendonitis, bursitis, synovitis, conjunctivitis, keratitis, iritis, erythematous papule, erythematous macule, polycranial neuropathy
meningoradiculitis, lyme encephalopathy, peripheral axonal neuropathy, tamponade, congestive heart failure, monoarthritis, oligoarthritis, retinal hemorrhages, retinal exudates, papilledema, pseudotumor cerebral-like syndrome, splenomegaly, hepatomegaly, regional lymphadenopathy, , white matterencephalitis, HLA-DR4 antigen
