With spring in the area, the temperature is warming up and maybe that bambi remake announcement was the final push needed to get people out on the trails and hiking through the hills again. With the increased traffic through the woods comes the inevitable presence of those freeloaders that hop on for a lift and bite. That’s right, it’s tick season. Late Spring to early summer is when tick nymphs are in the limelight, or lymelight, if you will. 

Now in the Southern Tier of New York the biggest tick borne illness that we see is Lyme disease. This Spirochetalinfection is caused by none other than the Borrelia burgdorferi. You wilderness medicine folks, with a propensity for traveling, may also be aware of other Borrelia ticks in Europe and Asia, but none of this really matters. This spirochete is not what we will be identifying. We need to know if the tick is of the Ixodesspecies. The tick has three forms, Larva Nymph and Adult, and like Sephiroth, it is mainly the second form that give us any problems.  The Adult form is active later in the year (later summer and fall) and can still transmit lyme, but because of the size of the adult it is easily noticeable and therefore less frequently an issue.    

So, a patient comes in to your ED just after July 4th weekend and says he has a tick. First we need to identify and remove the tick. It is good practice to examine the tick prior to removal as you may damage it during the removal process which will make identification much more difficult.  It is important to determine if the tick is of the Ixodes species (deer tick) or that of the Dermacentor variabili (dog tick). The Dog tick is not associated with transmission of Lyme’s. 

Figure 1: Top Left to right: Ixodes scapularis nymph (immature), adult male, adult female, engorged adult female. (Bottom row) The American dog tick. Left to right: adult male, adult female, engorged adult female. 

In an effort to save you the torture of those Highlights magazines from the dentist office, allow me to point out the white markings on the back of the dog tick. The male has it more diffusely and the female is more concentrated around the head and not on the abdomen.  It is understandable how someone could easily confuse the female of the two.  The deer tick being the more plain looking of the two comes with a higher concern for medical intervention.  So lets get this sucker off! 

Removal techniques are numerous, but data around each of their efficacy is lacking. But there is a study ongoing currently at AOMC evaluating the KOCO method vs the standard tweezer method.  The KOCO method involves using a cotton swab with a drop of dish soap and rubbing the tick counterclockwise which should release the tick from the patient in less than 1 minute and onto the cotton swab. More data on this will be released when the study sample size is large enough. Unfortunately, many of the patients will have already attempted to get the tick off prior to coming to the ED, which may inhibit your ability to do any identification. If all else fails, fine tweezers pulling gently and firmly while trying to avoid squeezing the body of the tick is recommended. If pieces of the ticks mouth remain in the skin there is no need to fish them out. 

With the tick now gone we need to discuss treatment. Lyme disease is a serious bacterial infection with significant sequalla that we are not going to go into here.  The spirochete is unlikely to have been transmitted in under 36 hours from time of tick attachment.  This is in contrast to other tick borne illness which can be transmitted much sooner.  If the tick has been attached for greater than 36 hours, the tick is identified as an Ixodes, and the patient is in an endemic (>20% tick carrier rate) area we will prophylaxis the patient. Prophylaxis consists of 200 mg of Doxycycline once.  If the patient has any contraindication of Doxycycline (under 8 years old, pregnant, or lactating) then no prophylaxis is indicated. Coordinate follow up with their PCP and have them report any development of Erythema Migrans, the bullseye rash. No testing of serum Lyme or tick testing is indicated at this time.

Wrap Up:

As a quick recap, your spring to fall months are prime time for ticks carrying Lyme disease to grab a bite. Identify the tick using it’s size and lack of markings. Nail down that history to get a maximum time that the tick could have been attached. Grab a cotton swab and some soap with tweezers as your back up.  Prophylax with Doxy 200 mg if you meet all the criteria and set them up for some follow up and instruction regarding development of a bullseye rash. 

Enough of the reading, go for a hike, we’ve got nothing to worry about any more! 

Authors:
Dan Loughran, MD
Peer reviewed and edited by: Kevin O’Connor, MD