Conjunctival attachment of a live tick (Ixodes species) in an infant: a rare case report with literature review : IJS Short Reports

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Case Report

Conjunctival attachment of a live tick (Ixodes species) in an infant: a rare case report with literature review

Mohammed, Rawand F. MDa; Abdulla, Berun A. BScb,c; Mohammed, Shvan H. BScc; Salih, Rawezh Q. BScb,c; Abdullah, Hiwa O. BScb,c; Salih, Abdulwahid M. MDb,d; Kakamad, Fahmi H. MD, PhDb,c,d,*; Noori, Savo Sh. MDe

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IJS: Short Reports 7(4):p e61, October/December 2022. | DOI: 10.1097/SR9.0000000000000061
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Abstract

Tick was one of the first recognized arthropods to transmit disease and pathogens as a vector. Nowadays, alongside mosquitoes, they are regarded as one of the main causes of infectious disease transmission to humans and domestic animals. The diseases they transmit include Crimean-Congo hemorrhagic fever, Lyme disease, Tularemia, and some others. Ticks are blood-sucking ectoparasites that gain their nutrition from the host animals1,2. Taxonomically, ticks can be classified into 2 families. The Ixodidae family consists of the hard ticks which are characterized by having a rigid and sclerotized dorsal plate. The second family (Argasidae), known as the soft ticks, does not have rigid and sclerotized dorsal plates.

The life cycle of ticks includes the egg, larvae, nymph, and adult stages. Each generation may live for 1–6 years3. Ticks have a specialized mouthpart containing sharpened chelicerae that can penetrate the skin. During the feeding process, following the penetration of the dermis of the host a blood pond is formed from which the tick feeds. For optimizing the feeding process, the vector secretes saliva that contains several anti-coagulants and anti-inflammatory proteins. Due to this reason, the pathogens in the saliva can be transmitted to the host3. Several other clinical issues can emerge due to tick infestation, including skin granuloma, erythema chronicum-like lesions, and the formation of skin abscesses4. The tick’s geographical distribution changes because of deforestation, urbanization, and climate change factors5. Although ticks are a recognized vector for disease spread through the penetration of the skin, their attachment to the conjunctiva is a rather infrequent entity with little mention in the literature. Only several cases of conjunctival tick bites have been reported in the literature2,4,6.

This study aims to report a rare case of conjunctival tick attachment in a 10-month-old male infant. This paper has been written based on the SCARE 2020 guidelines7.

Case presentation

Patient information

A 10-month-old infant presented to the emergency department brought in by his parents with right eye redness for the past 8 hours owing to the attachment of an unknown foreign body to the conjunctiva. The mother noticed the redness seeing the infant crying and rubbing his right eye. The family lived in a rural area and owned several domestic animals like sheep, goats, and dogs. The baby had a normal appetite with no allergy to any medication. There was no associated fever with no past medical history of note.

Clinical findings

General clinical examination revealed that the child was conscious and alert; redness of the right eye was visible (Fig. 1). Under an ophthalmic microscope, the foreign body was found to be a tick. The left eye was normal and systemic examination was unremarkable.

F1
Figure 1:
A 10-month-old boy with right eye redness and inflammation. A foreign body is attached to the inferotemporal part of the conjunctiva.

Diagnostic assessment

No diagnostic assessment was applied.

Therapeutic intervention

After taking consent from the parents, Tetracaine 0.5% eye drop was instilled into the right eye of the infant. The infant was put under an ophthalmic microscope and the tick was gently removed with a sterilized blunt forceps. After careful examination of the foreign body under the microscope, then under the slit-lamp biomicroscopy, the foreign body was recognized as an animal tick (Ixodes species), and all parts of the tick appeared to be intact (Fig. 2).

F2
Figure 2:
The tick after cleaning under slit-lamp biomicroscopy.

Follow up

A 7 days follow-up with the administration of Ofloxacin 0.3% eye drop and Erythromycin 0.5% eye ointment revealed no ophthalmic or systemic complications. The infant’s condition was restored to normal.

Discussion

Ticks are classified as nonpermanent, obligate blood-sucking ectoparasites that can be found on mammals, amphibians, birds, and reptiles. Their bites are strong enough to penetrate the skin of animals and humans which may transmit many infectious agents like viruses, bacteria, and protozoa. In addition, there are a few species that are associated with the direct spread of pathogens to humans: Argasidae and Ixodidae, which are known as soft ticks and hard ticks, respectively. The pathogens can be transmitted to the host more quickly through the soft ticks in comparison to the hard ticks. while hard ticks are more common and have a greater ability to spread disease—even their removal is a much more difficult procedure8. The factors that play roles in the development and distribution of ticks can be natural or artificial. The factors inducing a suitable environment for the reproduction and increase of the tick populations include regions with various climates and high humidity, the presence of livestock, and using chemical agents (pesticides) in an unplanned and irregular manner9.

In the present study, the tick belonged to the family Ixodidae, from the genus Ixodes. The family lived in a rural area and owned several domestic animals like sheep, goats, and dogs. In our study, the patient was an infant and didn’t have any direct contact with domestic animals so the tick could have been transported to the infant from his parents.

The infestation of ticks to the ocular tissues is considered a very rare entity in the literature, and the major manifestations are vasculitis, uveitis, keratitis, and conjunctivitis.

In addition, the infestation may appear as an eyelid margin tumor when the tick embeds in the meibomian gland orifice2. Following the tick bite, several side effects, including allergic dermatitis or anaphylaxis, local or secondary infection, ascending paralysis, and foreign body granuloma may emerge as the consequences. The skin reaction to the bite after several days can appear as a small erythematous macule or papule. Foreign body granulomas mainly occur due to the remaining of the tick’s mouthpart in the skin of the host after the removal procedure. The saliva of the tick may cause secondary infection by transmitting pathogens like Staphylococcus aureus and streptococcus species and results in ecthyma, cellulitis, headache, vomiting, fever, and many other difficulties3.

In this case, the tick was attached to the conjunctiva of the patient causing eye redness and itching for about 8 hours. The condition was brought to light when the mother of the infant noticed that her baby was crying and rubbing his right eye. The infant had a normal appetite. There was no associated fever or any other symptoms.

One of the dangerous phenomena possible to develop following the tick bite is tick paralysis. It is mostly associated with severe and ascending paralysis. Ixodid ticks are more likely to lead to tick paralysis than argasid ticks. It has been reported that tick paralysis is because of a specific protein injected into the host’s blood during the blood-sucking process. For instance, Ixodes holocyclus secrets a toxin known as holocyclotoxin that induces hypertension. Some other species release neurotoxins which decrease the action potential of the motor neuron or neurotransmitter acetylcholine activity10,11. The major symptoms of tick paralysis are similar to those of Guillain-Barre syndrome, including weakness with difficulty in movement, ophthalmoplegia, lack of deep tendon reflexes, dysarthria, and decreasing muscle action potential3. Tick paralysis is life-threatening and may lead to death in cases of respiratory paralysis owing to inappropriate tick removal. After removal of the tick, some cases may need supportive treatment or even intensive care unit admission12. The patient in this study recovered safely without any ophthalmic or systemic complications.

Because there is a high risk of disease transmission after 24 hours of tick attachment, it is essential to remove the tick as soon as possible2,13. With regards to the treatment modality, several chemical substances like ether, lindane shampoo, iodine, and deodorized kerosene have been proposed and used in the past to help detach the tick. But it has been revealed that chemical substances may cause irritation and encourage the tick to release infectious saliva as a reaction. The most effective technique is the mechanical intervention by using a blunt, medium-tip angled forceps, which is a quick, simple, and safe treatment modality, especially for conjunctival tick attachment2,6,14. If the tick attaches deeply into the host tissue, conjunctival excision is the best treatment modality.

It is important to ensure the complete removal of the tick with no retained mouthpart to prevent later complications13,15. Medication is not recommended.

In addition, using doxycycline to prevent Lyme disease has not been recommended until the following criteria have been confirmed: precise identification of adult or nymph of Ixodes scapularis, more than 36 hours of attachment, the possibility of prophylaxis during 72 hours of tick removal, no drug contraindications, and the incidence of at least 20% local rate of Borrelia burgdorferi16.

In the present study, the tick was gently removed using a blunt forceps. After careful examination of the foreign body under the microscope, then under the slit lamp biomicroscopy, the foreign body was recognized as an animal tick (Ixodes species).

In conclusion, conjunctival tick attachment presenting with the symptoms of eye redness and itching is a very uncommon entity. The proper management is the complete removal of the tick using a blunt, medium-tip, angled forceps.

Ethical approval

None.

Sources of funding

None.

Authors’ contribution

R.F.M., B.A.A., F.H.K., and H.O.A.: writing the manuscript, final approval of the manuscript. S.H.M., R.Q.S., A.M.S., and S.S.N.: literature review, final approval of the manscript.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

Fahmi Hussein Kakamad.

References

1. Dantas-Torres F, Chomel BB, Otranto D. Ticks and tick-borne diseases: a One Health perspective. Trends Parasitolo 2012;28:437–46.
2. Celik E, Türkoğlu EB, Boz AA, et al. Conjunctival attachment of a tick: case report. Semin Ophthalmol 2014;29:186–8.
3. Dana AN. Diagnosis and treatment of tick infestation and tick‐borne diseases with cutaneous manifestations. Dermatol Therapy 2009;22:293–326.
4. Bode D, Speicher P, Harlan H. A seed tick infestation of the conjunctiva: Amblyomma americanum larva. Ann Ophthalmol 1987;19:63–4.
5. Sathiamoorthi S, Smith WM. The eye and tick-borne disease in the United States. Curr Opin Ophthalmol 2016;27:530–7.
6. Teong JM, Adler PA, Doggett SL, et al. Conjunctival attachment of a live paralysis tick, Ixodes holocyclus, in a child: a case report. Case Rep Ophthalmol 2015;6:120–6.
7. Agha RA, Franchi T, Sohrabi C, et al. The SCARE 2020 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg 2020;84:226–30.
8. Anderson JF, Magnarelli LA. Biology of ticks. Infect Dis Clin North Am 2008;22:195–215.
9. Aydin L, Bakirci S. Geographical distribution of ticks in Turkey. Parasitol Res 2007;101:163–6.
10. Edlow JA, McGillicuddy DC. Tick paralysis. Infect Dis Clin N Am 2008;22:397–413.
11. Spach DH, Liles WC, Campbell GL, et al. Tick-borne diseases in the United States. N Engl J Med 1993;329:936–47.
12. Brown AF, Hamilton DL. Tick bite anaphylaxis in Australia. Emerg Med J 1998;15:111–3.
13. Gammons M, Salam GA. Tick removal. Am Fam Physician 2002;66:643.
14. Love MC, Platt L, Westfall CT. Lone-star tick bite of the conjunctiva. Arch Ophthalmol 2001;119:1854–5.
15. Price KM, Woodward JA. Management of tick infestation of the eyelid. Ophthalmic Plast Reconstr Surg 2009;25:328–30.
16. Rai R, Yoon MK, Stacy RC. Tick infestation of the eyelid with histopathologic characterization. Ophthalmic Plast Reconstr Surg 2016;32:e55–8.
Keywords:

Infestation; Ocular; Vector-borne diseases

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.