Linfadenopatía transmitida por garrapata. Un caso pediátrico de rickettsiosis en atención primaria / Lymphadenopathy transmitted by tick. A pediatric case of rickettsiosis in primary care

La entidad llamada tick-borne lymphadenopathy, también conocida como dermacentor-borne necrosis eritema lymphadenopathy, se incluye dentro del diagnóstico diferencial de enfermedades transmitidas por garrapatas, que han aumentado considerablemente en los últimos años debido a una mayor observación clínica-epidemiológica y mejoría diagnóstica. Es una zoonosis causada por Rickettsia slovaca y transmitida por la picadura de la garrapata Dermacentor marginatus. Los pacientes afectados tienen una escara necrótica rodeada de un halo eritematoso en el cuero cabelludo y adenopatías regionales dolorosas. Se presenta a un varón de siete años que mostró, tras la extracción de una garrapata, una escara necrótica en el cuero cabelludo, con adenopatías y febrícula. La reacción en cadena de la polimerasa y el cultivo de la lesión confirmaron la presencia de Rickettsia slovaca. El paciente recibió azitromicina oral con buena respuesta. En Atención Primaria, es importante el seguimiento de las picaduras de garrapatas para detectar posibles enfermedades transmitidas por estas.

The entity called tick-borne lymphadenopathy, also known as dermacentor-borne necrosis eritema lymphadenopathy, is included in the differential diagnosis of diseases transmitted by ticks, which have increased considerably in recent years due to greater clinical-epidemiological observation and diagnostic improvement. It is a zoonosis caused by Rickettsia slovaca and transmitted by the bite of the Dermacentor marginatus tick. Affected patients have a necrotic eschar surrounded by an erythematous halo in the scalp, as well as painful regional lymphadenopathy. Linfadenopatía transmitida por garrapata. Un caso pediátrico de rickettsiosis en atención primaria Lymphadenopathy transmitted by tick. A pediatric case of rickettsiosis in primary care We present a seven-year-old male who shows, after the extraction of a tick, a necrotic eschar on the scalp, accompanied by lymphadenopathy and low-grade fever. The study of polymerase chain reaction and culture of the lesion confirm the presence of Rickettsia slovaca. The patient received oral azithromycin with a good response. In Primary Care, it is important to monitor the tick bites, to detect possible diseases transmitted by them.

Tick killing in situ before removal to prevent allergic and anaphylactic reactions in humans: a cross-sectional study

BACKGROUND: Tick anaphylaxis is a potentially fatal outcome of improper tick removal and management. OBJECTIVE: To investigate whether killing ticks in-situ with ether-containing sprays or permethrin cream, before careful removal by the mouthparts could reduce this risk. METHODS: This was a prospective study at Mona Vale Hospital Emergency Department (ED) in Sydney, New South Wales, over a 6-month period during the peak tick season of 2016. Tick removal methods, allergic/anaphylactic reactions were recorded for patients presenting with ticks in situ or having already removed the ticks themselves. Primary endpoint was allergic/anaphylactic reaction after tick killing/removal. RESULTS: One hundred twenty-one patients met study inclusion criteria. Sixty-one patients (28 known tick-hypersensitive) had ticks killed with Wart-Off Freeze or Lyclear Scabies Cream (5% w/w permethrin) before removal with fine-tipped forceps or Tick Twister. Three patients (2 known tick-hypersensitive) had allergic reactions (5%), none anaphylactic. The 2 known hypersensitive patients suffered reactions during the killing process and the third patient had a particularly embedded tick meaning it could not be removed solely by mouthparts. Fifty patients presented to the ED posttick removal by various methods, none using either fine-tipped forceps or Tick Twister, of which 43 (86%) experienced allergic reactions – 2 anaphylactic. Five patients suffered allergic reactions before presentation despite no attempt at kill or removal, but ticks had likely been disturbed by some other method. Five patients had live ticks removed in ED – 3 refused killing and had no reaction despite 1 having known hypersensitivity; 2 had ticks on eyelids contraindicating killing, 1 with known hypersensitivity but both had allergic reactions post removal. CONCLUSION: Results support killing ticks in-situ before careful removal by mouthparts to reduce allergic/anaphylactic reactions although further research is still required.

Skin manifestations of tick bites in humans

Abstract: Ticks are blood-sucking arthropods that attach to human skin through oral devices causing diverse initial cutaneous manifestations, and may also transmit serious infectious diseases. In certain situations, the Health Teams (and especially dermatologists) may face difficulties in identifying the lesions and associating them to the parasites. To assist them in clinical diagnosis, we suggest a classification of the skin manifestations in primary lesions, which occur by the attachment the tick to the host (for toxicity and the anticoagulant substances in the saliva and/or marked inflammation by the penetration and permanence of the mouthparts) and secondary lesions that are manifestations of infections caused by rickettsia, bacteria, protozoa and fungi inoculated by the ticks.

A novel Australian tick Ixodes (Endopalpiger) australiensis inducing mammalian meat allergy after tick bite

Tick-induced mammalian meat allergy has become an emergent allergy world-wide after van Nunen et al. first described the association between tick bites and the development of mammalian meat allergy in 2007. Cases of mammalian meat allergy have now been reported on all 6 continents where humans are bitten by ticks, in 17 countries

A Case of Contrast Enhanced Cystic Mass of External Ear Canal Diagnosed as Engorged Hard Tick

A 58-year-old female complained earfullness and otalgia and came to the clinic. Dark gray colored cystic mass obstructing the left ear canal was observed during the endoscopic exam. Contrast enhanced CT image showed an oval shape soft tissue lesion in the mid part of the external auditory canal with a homogenous increased contrast uptake. The mass was removed under microscopic view at outpatient clinic. While dissecting the mass in the ear canal, a pod like structure was visualized. The external organism was densely adherent to the skin and turned out to be an engorged hard tick. Considering the final diagnosis, contrast uptake observed in the CT scan implicates the patient communication of blood between host and parasite. This unique image finding differs from a benign mass lesion in the ear canal was one of the differential diagnosis points for the lesion. This article is reporting the case of tick bite in the ear canal with a rare CT scan finding.

The Most Common Mite- and Tick-borne Infectious Diseases in Korea: Scrub Typhus and Severe Fever Thrombocytopenia Syndrome / 대한내과학회지

The incidence of mite- and tick-borne infectious disease is increasing with climate change and the development of diagnostic tools. Tick-borne infectious diseases include Lyme disease, anaplasmosis, ehrlichiosis, severe fever with thrombocytopenia syndrome (SFTS), and Japanese spotted fever. Rickettsial pox and scrub typhus are mite-borne infectious diseases. Scrub typhus and SFTS are the most common mite- and tick-borne infectious diseases in Korea, respectively. They are often difficult to diagnose at an early stage of disease. To make a definite diagnosis of mite- and tick-borne infectious disease, polymerase chain reaction (PCR) tests or serologic testing for antibodies during the acute and convalescent periods are necessary. If patients with nonspecific symptoms, such as fever, headache, nausea, and vomiting, have a history of outdoor activity or a tick bite, it is reasonable to consider the possibility of mite- or tick-borne infectious diseases clinically. There are no vaccinations against mite- and tick-borne infectious diseases. Therefore, preventing mite or tick bites is the best way to prevent the diseases.

An Uncommon Presentation of Human Otoacariasis by Haemaphysalis longicornis

Ticks are obligate parasites on animals and sometimes humans. They usually suck the blood of the hosts and can carry various infectious diseases as a vector. Otoacariasis is the presence of ticks and mites within the ear canal and relatively common in domestic and wild animals. However, tick infestations of human ear canals are rarely reported in the scientific literature and hardly occur in developed countries. Herein, we report a rare case of otoaracariasis involving Haemaphysalis longicornis . A 9-year-old girl living in a suburb presented with otalgia of left ear for 1 day. Otoscopic examination revealed a huge insect occluding the tympanic membrane. Tick removal and washing of external auditory canal was done successfully. The causative tick was identified as the H. longicornis. To our knowledge, this is the first reported case of human otoacariasis by a H. longicornis in Korea.

A Case of Engorged Female Hard Tick in the External Auditory Canal of an Infant

An oval-shaped mass with a smooth surface was found in the ear canal of a 22-month-old male infant. Although the mass appeared to be almost entirely blocking the ear canal, it was successfully removed under a surgical microscope without general anesthesia at the outpatient department. Under an optical microscope with hematoxylin and eosin staining, the specimen was observed to have a cuticle with a serrated surface and a pore canal, as well as parts of the capitulum, salivary glands, muscles, midgut, and the legs. The specimen was identified as a hard tick of the family Ixodidae, based on gross and histological findings. This paper is the first report in Korea on the diagnosis and treatment of a tick bite in the ear canal.

Present state and future of tick-borne infectious diseases in Korea

The incidence of vector-borne infectious diseases is increasing due to developments in diagnostic techniques, as well as due to economic, environmental, and ecological factors such as global warming, increased rainfall, globalization, and urbanization. Tick-borne infectious diseases occurring in Korea include severe fever with thrombocytopenia syndrome, Lyme disease, anaplasmosis, and Japanese spotted fever. Various skin lesions, such as erythema migrans, tick bite sites, rash, and eschar, are associated with tick-borne infectious diseases. It is necessary to remove ticks immediately to prevent transmission of these tick-borne infectious diseases. Especially for conditions such as Lyme disease, at least 24 to 48 hours of tick attachment to the host is required for transmission of the causative pathogens to the host. Tick-borne diseases are acquired after outdoor activities and have nonspecific symptoms such as fever, headache, and chills, which make them difficult to identify without a diagnostic test. Rapid diagnosis and early treatment can reduce the otherwise significant morbidity and mortality associated with these conditions; therefore, therapy should not be delayed until laboratory confirmation is received.

Tick Bite by Nymphal Amblyomma testudinarium

Ticks are parasites that usually suck the blood of wild or domestic animals; rarely, they ingest human blood and spread various febrile infectious diseases along with skin problems. Out of 40 cases of tick bite reported in Korea, only 3 were caused by nymphal ticks, and tick bites by nymphal Amblyomma testudinarium have not been reported previously. Herein, we report a rare case of tick bite by nymphal A. testudinarium. A 57-year-old woman presented with an asymptomatic solitary erythematous nodule on the left thigh that had been present for 6 days. The tick, which the patient removed from the lesion and brought to the hospital, was identified as a nymphal A. testudinarium. Doxycycline (200 mg) was used as treatment, and after seven days of use, the patient improved and no other lesions were detected.

Tick Bite by Male Amblyomma testudinarium in a Korean Woman / 대한피부과학회지

A 53-year-old woman presented with asymptomatic pedunculated mass on her buttock. She was attacked by the tick while climbing the Jungbyung mountain located in Changwon City, the southern coastal area of the Korean Peninsula. It was identified as male Amblyomma testudinarium according to its morphological characteristics. Histological examination showed dense inflammatory infiltration of neutrophils and eosinophils, and dilated vessels on the dermis beneath the biting site of the tick. There have been only few reports of the tick bite by A. testudinarium in the Korean literature. To the best of our knowledge, our patient is the second case of tick bite from this species and the first tick bite from the male tick recorded in Korea. Here, we report a case of tick bite by male A. testudinarium in a woman, including a review of relevant literature.

Tick-induced allergies: mammalian meat allergy, tick anaphylaxis and their significance

Serious tick-induced allergies comprise mammalian meat allergy following tick bites and tick anaphylaxis. Mammalian meat allergy is an emergent allergy, increasingly prevalent in tick-endemic areas of Australia and the United States, occurring worldwide where ticks are endemic. Sensitisation to galactose-α-1,3-galactose (α-Gal) has been shown to be the mechanism of allergic reaction in mammalian meat allergy following tick bite. Whilst other carbohydrate allergens have been identified, this allergen is unique amongst carbohydrate food allergens in provoking anaphylaxis. Treatment of mammalian meat anaphylaxis involves avoidance of mammalian meat and mammalian derived products in those who also react to gelatine and mammalian milks. Before initiating treatment with certain therapeutic agents (e.g., cetuximab, gelatine-containing substances), a careful assessment of the risk of anaphylaxis, including serological analysis for α-Gal specific-IgE, should be undertaken in any individual who works, lives, volunteers or recreates in a tick endemic area. Prevention of tick bites may ameliorate mammalian meat allergy. Tick anaphylaxis is rare in countries other than Australia. Tick anaphylaxis is secondarily preventable by prevention and appropriate management of tick bites. Analysis of tick removal techniques in tick anaphylaxis sufferers offers insights into primary prevention of both tick and mammalian meat anaphylaxis. Recognition of the association between mammalian meat allergy and tick bites has established a novel cause and effect relationship between an environmental exposure and subsequent development of a food allergy, directing us towards examining environmental exposures as provoking factors pivotal to the development of other food allergies and refocusing our attention upon causation of allergy in general.

Carbohydrates as food allergens

The literature supports the notion that carbohydrate epitopes, on their own, do not contribute significantly to the induction of allergic reactions. They bind weakly to IgE antibodies and have been termed as cross reactive carbohydrate determinants. These epitopes cause confusion in in vitro IgE testing through nonspecific cross-reactivity. Coincident with the rising trends in food allergy prevalence, there has recently been reports of anaphylaxis induced by carbohydrate epitopes. There are two distinct groups, each with unique characteristics and geographical distribution. Anaphylaxis and acute allergic reactions related to the carbohydrate galactose-α-1,3-galactose (α-Gal) epitope that are present in the monoclonal antibody, cetuximab and red meat have been described in the United States and Europe populations where tick bites have been found to be the primary sensitizer. Another carbohydrate inducing anaphylaxis is galacto-oligosaccharides in commercial milk formula which has been described in the several Asian populations including Singapore. The latter is unique in that the allergen is a pure carbohydrate. We summarize the current literature on carbohydrate-induced food allergy, and evaluate the two new groups of carbohydrate allergy that have defied previous findings on carbohydrates and their role.

Delayed Anaphylaxis to Red Meat Associated With Specific IgE Antibodies to Galactose

A novel delayed anaphylactic reaction to red meat, associated with tick bites and IgE antibodies against galactose-alpha-1, 3-galactose (alpha-gal), was reported in 2009 in the US, Australia and Europe. In this case, serum specific IgE to galactose-alpha-1, 3-galactose (>100 kU/L) and IgE to multiple non-primate mammalian proteins were positive. However, the pathogenesis of this disease remains unclear. We report the first case in Asia of delayed anaphylactic reaction to red meat, which was induced by bites from the hard tick, Hematophagous ixodidae. We confirmed the increased concentration of IgE reactive epitopes in non-primate mammalian organs, which may be rich in alpha-gal proteins in lymphatic and endothelial tissues. All confirmed ticks associated with this disorder in the literature and in our case belonged to the hard tick family. We hypothesize that hard tick saliva is enriched with blood-type substances, such as oligosaccharides, from the non-primate mammal victim's blood after days to weeks of blood sucking, which sensitizes humans through the injection route while blood sucking.

Four Cases of Severe Fever with Thrombocytopenia Syndrome Occurring in Jeju / 대한피부과학회지

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by a novel SFTS bunyavirus (SFTSV), a member of the genus Phlebovirus in the family Bunyaviridae. SFTSV is believed to be transmitted by Haemaphysalis longicornis. Common symptoms of SFTS include high fever, vomiting, diarrhea, thrombocytopenia, leukocytopenia, and multi-organ failure with an average case-fatality rate of 12~30%. In 2009, SFTS was firstly reported in China. In 2013, 27 cases of SFTS were documented in Korea, and 6 cases were confirmed on Jeju Island. Although the pathogenesis and transmission mode of SFTS remain unclear, SFTS is now considered endemic in East Asia. Accordingly, SFTS needs to be differentiated from scrub typhus, leptospirosis, and hemorrhagic fever with renal syndrome. We here report 4 cases of SFTS preceded by a tick bite, which were in need of a differential diagnosis of scrub typhus.

Perianal Tick-Bite Lesion Caused by a Fully Engorged Female Amblyomma testudinarium

A perianal tick and the surrounding skin were surgically excised from a 73-year-old man residing in a southwestern costal area of the Korean Peninsula. Microscopically a deep penetrating lesion was formed beneath the attachment site. Dense and mixed inflammatory cell infiltrations occurred in the dermis and subcutaneous tissues around the feeding lesion. Amorphous eosinophilic cement was abundant in the center of the lesion. The tick had Y-shaped anal groove, long mouthparts, ornate scutum, comma-shaped spiracular plate, distinct eyes, and fastoons. It was morphologically identified as a fully engorged female Amblyomma testudinarium. This is the third human case of Amblyomma tick infection in Korea.