Case for Diagnosis
Complication of a Tick Bite
Garrapata complicada
L. Fernández de la Fuente
, S. Herrero Ruiz, B. Echeverría
Corresponding author
Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Madrid, Spain
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"apellidos" => "Fernández de la Fuente" "email" => array:1 [ 0 => "lfdelafuente@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Herrero Ruiz" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Echeverría" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Garrapata complicada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 350 "Ancho" => 521 "Tamanyo" => 67480 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 56-year-old woman, with no relevant past medical history, who presented to the ER last October after finding a tick attached to her scalp (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>). In the 15 days prior, she had been in a rural area. The tick was removed intact, including the hypostome, by gently pulling it out with blunt forceps. Forty-eight hours later, she developed an indurated lesion at the tick bite site, along with low-grade fever spikes (37.8<span class="elsevierStyleHsp" style=""></span>°C), which were noted at the ER.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Upon examination, the patient exhibited a necrotic eschar covered by a honey-colored crust at the tick bite site (<a class="elsevierStyleCrossRef" href="#fig0010">fig. 2</a>), with no perilesional erythema. The patient also exhibited an ill-defined erythematous and edematous plaque extending from the tick bite site towards the lip region, covering the entire forehead and periorbital region (<a class="elsevierStyleCrossRef" href="#fig0015">fig. 3</a>). The patient also exhibited very painful, palpable, bilateral, and cervical lymphadenopathies of anteroposterior location.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Supplementary tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Basic blood tests were performed, including a complete blood count and comprehensive profiling of blood coagulation, which failed to reveal any abnormalities. The liver enzyme levels, however, were elevated: AST (43 IU/L) and ALT (53 IU/L), as well as the C-reactive protein (CRP) (5.37<span class="elsevierStyleHsp" style=""></span>mg/L). Serology for <span class="elsevierStyleItalic">Rickettsia conorii</span> and <span class="elsevierStyleItalic">Borrelia burgdorferi</span> turned out negative. The removed tick was identified as a female <span class="elsevierStyleItalic">Dermacentor marginatus</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Necrotic eschar and tick-borne lymphadenopathy, also known as TIBOLA.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Course of the disease and treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">After the application of a 15-day daily course of doxycycline 200<span class="elsevierStyleHsp" style=""></span>mg and fusidic acid cream on the honey-colored crust, the symptoms disappeared, the necrotic eschar fell off, and the previously altered PCR and liver enzyme levels went back to normal.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tick bites are a relatively common reason for consultation in Spain, especially in the summertime.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> There are over 800 species of ticks which feed by latching onto the skin, with a preference for folds and the scalp.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In a small percentage of tick bites, complications known as “tick-borne diseases” (TBDs) can occur. There is a certain specificity between each TBD and each tick species. In our setting, the most common TBDs are Lyme disease, transmitted by <span class="elsevierStyleItalic">Ixodes</span><span class="elsevierStyleItalic">ricinus</span>, Mediterranean spotted fever, transmitted by <span class="elsevierStyleItalic">Rhipicephalus sanguineus</span>, and necrotic eschar and tick-borne lymphadenopathy transmitted by <span class="elsevierStyleItalic">Dermacentor marginatus</span>. Less common diseases include human anaplasmosis and babesiosis. Additionally, sporadic cases of tularemia and Crimean-Congo fever have been reported.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Tick-borne lymphadenopathy has been described under various nomenclatures in the scientific medical literature, such as TIBOLA, DEBONEL (dermacentor-borne necrosis erythema lymphadenopathy), or SENLAT (scalp eschar and neck lymphadenopathy). The main causative agents of this disease are <span class="elsevierStyleItalic">Rickettsia slovaca</span>, <span class="elsevierStyleItalic">Rickettsia raoultii</span>, or <span class="elsevierStyleItalic">Rickettsia rioja</span>, being the transmission vector ticks of the <span class="elsevierStyleItalic">Dermacentor</span> genus, which are endemic to Spain.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Unlike most tick bites, these tend to occur during the autumn and winter months.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This clinical picture should be suspected when a patient has a history of tick bites, a necrotic eschar at the bite site, painful lateral cervical and posterior lymphadenopathies, and low-grade fever or febricula. The diagnosis is primarily clinical.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Blood tests may show slightly elevated transaminase levels. Some centers have tick identification methods, specific serology, and PCR assay detection of <span class="elsevierStyleItalic">Rickettsia slovaca</span> in the eschar itself.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment should be started right away on clinical suspicion. Waiting for diagnostic confirmation is ill-advised. The treatment of choice is a 5-to-15-day course of doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>hours.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical history" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Supplementary tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Course of the disease and treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 350 "Ancho" => 521 "Tamanyo" => 67480 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 400 "Ancho" => 544 "Tamanyo" => 76880 ] ] ] 2 => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 400 "Ancho" => 437 "Tamanyo" => 31256 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TIBOLA: enfermedad emergente producida por picadura de garrapata" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Sanantonio Valdearcos" 1 => "M.C. Otero Reigada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Aten Primaria" "fecha" => "2015" "volumen" => "17" "paginaInicial" => "e193" "paginaFinal" => "e195" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rickettsiosis, un caso de TIBOLA" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Martínez-Castillón" 1 => "D.I. Doste-Larrull" 2 => "A. Sanz-Cardiel" 3 => "J. 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