Lyme disease is a tick-borne disorder caused by the spirochete Borrelia burgdorferi, Borrelia afzelii, and Borellia garinii. It is a multisystem disorder that is transmitted by the bite of the ticks. Borrelia burgdorferi is normally carried by mice, squirrels, birds, and other small animals. The slow feeding habit of Ixodes ticks and their attachment with hosts for relatively longer periods allow sufficient time for pathogen acquisition and transmission.
Skin lesions are often the first clinical manifestation of the disease; early identification of such lesions is important for prompt diagnosis and treatment, which can prevent systemic complications. Although the disease was previously reported only from endemic areas like the United States, Europe, the Middle East, and Southeast Asia, its incidence has steadily increased due to increasing migration. Only a few cases have been reported in the literature from India, with none of them discovering a live tick on the body of the patient.
We report a case of a 68-year-old gentleman who presented with an unexplained fever of seven days, where a live dog tick, Rhipicephalus, was found on the anterior aspect of his right thigh on day 3 of his treatment. The purpose of this report is to emphasize the importance of history taking and meticulous examination, which helped us in finding the live tick with its possible source, and in identifying the pathognomonic cutaneous manifestation of Lyme’s disease.
A 68-year-old male, known hypertensive and diabetic with a history of coronary artery disease (post transcutaneous coronary angioplasty with stent placement), presented with complaints of high-grade fever with chills for the last seven days, associated with body ache, malaise, fatigue, and decreased appetite. Upon presentation, he was febrile (temperature 102°F) with a heart rate of 94/minutes and a blood pressure of 120/70 mmHg in the right arm supine position (while being on medication). There were no localizing symptoms, and systemic examination was essentially normal. The patient had travelled to and back from Nainital over the last three weeks, and his fever began four days following his return. He did not give a history of any rash or insect bites during the trip.
Investigations revealed mild anaemia (Hb 10.1 gm/dl), leukopenia (TLC - 3.25 ´ 109/L), transaminitis (SGOT – 107 U/L, SGPT – 139 U/L), and a creatinine of 1.3 mg/dl; widal test was negative. He was empirically initiated on a broad-spectrum antibiotic (IV ceftriaxone). Blood and urine cultures were also sterile. Chest X-ray PA view revealed no abnormality, and USG of the whole abdomen showed liver hemangioma and raised bilateral renal echogenicity.
As the patient continued to have a fever with chills and preliminary investigations were normal, Doxycycline was added due to high clinical suspicion of tick-borne fever. The patient was examined in detail, and a painless 4.3 cm ´ 3.5 cm targetoid lesion was found just below his right knee, which had an erythematous margin with central darkness along with a small crusted lesion on the right shin [Figure 1]. A live hard tick was found on the anterior aspect of his right thigh [Figure 2]. It was carefully and completely removed using toothed forceps by the dermatologist; and then preserved and identified to be of the Rhipicephalus species (Dog tick) by National Center for Disease Control (NCDC) along with positive Rickettsial serology. On revisiting the history of animal exposure, he informed us about a pet dog at home who could be a possible source of the tick. Erythematous rash spreading centrifugally appearing like a bullseye was also noted all over the lower limbs and was identified as erythema chronicum migrans (ECM).
He was discharged on day 6 of admission with complete remission of fever, and Doxycycline was continued for a total of three weeks. On follow-up, the patient had completely recovered with clearance of the ECM.
Lyme disease is a tick-borne disease, causing multisystem inflammatory disorder. Various species of tick of Ixodes family transmit the disease. The distribution of the disease also corresponds with the global distribution of Ixodes tick. No cases have been previously reported with Rhipicephalus spp., a dog tick, acting as the vector of Lyme disease, as per our literature search. Borrelia is the causative organism that includes three pathogenic species: B. burgdorferi, reported from America, whereas B. afzelii and B. garinii, reported from Asia.
Lyme disease is divided into three stages as per clinical manifestations: early localized disease, early disseminated disease, and chronic disease. Skin is the most commonly involved organ in early localized disease. Pathognomonic lesion occurring at the site of inoculation after 7–15 days of tick detachment, that is, the ECM, is seen in early localized disease and appears as various hues of erythema, spreading centrifugally with central clearing, giving the appearance of a bullseye. It is the best clinical marker of the disease occurring in 60-80% of patients. Musculoskeletal, cardiovascular, and neurological systems are involved in disseminated disease. Joint swelling and arthritis are common musculoskeletal manifestations, whereas lymphocytic meningitis, cranial neuritis, facial palsy, radiculoneuropathy are common neurological manifestations. Cardiological manifestations include acute onset, high grade (2nd or 3rd degree) atrioventricular conduction defect occasionally associated with myocarditis.
Diagnosis of Lyme disease is based on the clinical manifestation of ECM, which is sufficient to make diagnosis even in the absence of corroboratory laboratory tests. Serology test, the commonly used modality, follows a two-step approach involving initial ELISA followed by western blot in case of reactive or equivocal cases. The clinical manifestation of ECM, positive serology, and clinical improvement with Doxycycline established our diagnosis.
All patients with ECM, a primary manifestation of early localized disease, should be treated with Doxycycline or Amoxicillin or Cefuroxime, to prevent progression of the disease along with shortening the duration of signs and symptoms. Early disseminated disease i.e., patients having multiple erythema migrans lesion, carditis manifested by a heart block, neurologic abnormalities, or acute large joint arthritis, should also be treated with oral Doxycycline or IV Ceftriaxone or Cefotaxime, in case of hospitalization.
Only a few cases of Lyme disease have been reported from India in the past, with no previously reported case with Rhipicephalus, a dog tick acting as a vector of the disease. The purpose of this case is to create awareness among the physicians regarding the cutaneous manifestations presenting in early localized disease, leading to early diagnosis and prompt initiation of treatment which shortens the duration of signs and symptoms with stopping the progression of the disease.
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1. Steere AC Lyme disease N Engl J Med 1989 321 586 96
2. Sharma A, Guleria S, Sharma R, Sharma A Lyme disease: A case report with typical and atypical lesions Indian Dermatol Online J 2017 8 124 7
3. Ghosh S, Nagar G Problem of ticks and tick-borne diseases in India with special emphasis on progress in tick control research: A review J Vector Borne Dis 2014 51 259 70
4. Rizzoli A, Hauffe H, Carpi G, Vourc H G, Neteler M, Rosa R Lyme borreliosis in Europe Euro Surveill 2011 16 19906
5. Grubhoffer L, Golovchenko M, Vancová M, Zacharovová-Slavícková K, Rudenko N, Oliver JH Jr Lyme borreliosis: Insights into tick-/host-borrelia relations Folia Parasitol (Praha) 2005 52 279 94
6. Vasudevan B, Chatterjee M Lyme borreliosis and skin Indian J Dermatol 2013 58 167 74
7. Espana A Figurate erythema Jorizzo JL, Rapini RP Bolognia Textbook of Dermatology. Dermatology 2008 2nd ed 1 British Library Cataloguing in Publication Data 1717 20
8. Pachner AR Early Disseminated Lyme disease: Lyme meningitis Am J Med 1995 98 30S 43S
9. Hay RJ, Adriaans BM Bacterial infections Burns T, Breathnach S, Cox N, Griffiths C Rook's Textbook of Dermatology 2010 8th ed West Sussex, United Kingdom Wilet-Blackwell 30 64
10. Kaiser R Neuroborreliosis J Neurol 1998 245 247 55
11. Stanek G, Fingerle V, Hunfeld KP, Jaulhae B, Kaiser R, Krause A, et al. Lyme borreliosis: Clinical case definitions for diagnosis and management in Europe Clin Microbiol Infect 2011 17 69 79
12. Nadelman RB, Luger SW, Frank E, Wisniewski M, Collins JJ, Wormser GP Comparison of cefuroxime axetil and doxycycline in the treatment of early Lyme disease Ann Intern Med 1992 117 273 80
13. Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, et al. Clinical practice guidelines by the infectious diseases society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis and treatment of Lyme disease Clin Infect Dis 2021 72 1 48
14. Kortela E, Kanerva MJ, Puustinen J, Hurme S, Airas L, Lauhio A, et al. Oral doxycycline compared to intravenous ceftriaxone in the treatment of Lyme neuroborreliosis: A multicenter, equivalence, randomized, open-label trial Clin Infect Dis 2021 72 1323 31