Ticks survive by the hematophagy of mammals, birds, and reptiles. They act as vectors of diseases such as Crimean-Congo hemorrhagic fever, Lyme borreliosis, Q fever, and tularemia.[1,2] Ticks in periocular skin are often mistaken for dermatological lesions such as pigmented papules, infracting skin nodules, or foreign-body granuloma. Examination under high magnification is invaluable in such cases.[1,2] Complete removal of the tick is recommended to reduce the risk of both tick-borne diseases and tick-related local inflammatory reactions. We report the case of a 61-year-old male with left upper eyelid edema with erythema and live parasite on the lid margin.
A 61-year-old farmer presented to the outpatient department with complaints of watering, pain, and discharge in the left eye (LE) for 2 days. He had undergone cataract surgery in both eyes 6 months back. He worked on a cattle farm and gave no history of trauma to the eye.
On examination, visual acuity of the right eye (RE) was 6/9 and LE was 6/6. Intraocular pressure was 14 mm Hg in RE and 16 mm Hg in LE. The left upper lid was edematous with a parasite adherent on the middle third of the lid margin and lashes [Figure 1]. The anterior segment and the posterior segment examination of the eye were otherwise normal.
The patient was afebrile and systemic examination was found to be within normal limits.
The parasite was removed along with its pincers with plain nontoothed forceps under slit lamp visualization. Antimicrobial prophylaxis was not given to the patient immediately after the removal of the parasite. The patient was explained about ocular and systemic symptoms of tick bite-related disease and reviewed at 2 weeks. He was clinically asymptomatic at 2 weeks follow-up with the eyelid skin lesion healed.
The parasite was sent to Vector Control Research Centre, Puducherry, and identified as Rhipicephalushemophysaloides [Figure 2].
Ticks transmit pathogenic organisms such as viruses, rickettesiae, bacteria, spirochetes, and protozoans in humans and livestock. There are two classes of ticks causing disease in humans. Based on the exoskeleton, ticks may be hard ticks (Family Ixodidae) or soft ticks (Family Argasidae). Hard ticks are more likely to transmit disease to humans and difficult to remove compared to soft ticks.
Rhipicephalus hemophysaloides belongs to the family Ixodidae and has a typical three-host life cycle. All the developmental stages (larva, nymph, adult) require blood meal, and the host for all three stages is mammals. Moulting occurs off the host and the next stage may infect either the same host or a new host. The natural hosts of adult R. hemophysaloides include dogs, cattle, goats, pigs, and human beings are incidental hosts.
Ticks prefer a warm and moist environment and frequently localize to the eyelid margin and eyelashes. A tick at the margin habitually enroots the meibomian gland orifice and inserts its hypostome, a central piercing element that has hooks into the host’s skin. Ixodes ticks secrete anticoagulant, immunosuppressive, and anti-inflammatory substances into the area of their attachment. These substances help the tick to obtain a blood meal and also help any freeloading pathogens establish a foothold in the host. Diseases transmitted by Rhipicephalus hemaphysaloides are Kyasanur Forest Disease, and Babesiosis [Table 1].
All areas of the eye are susceptible to tick inoculation. The most common manifestations of globe involvement are conjunctivitis, uveitis, keratitis, and vasculitis. Tick bites on the eyelid have manifestations that range from transient pruritis to severe blepharitis. Periocular manifestation of tick presents as a mass mimicking the appearance of a hemangioma, nevus, or epidermal cyst and hence poses difficulty in diagnosis. Rarely the tick infestation may present with vitritis, uveitis, neuroretinitis, optic atrophy, or disc edema. They may also involve multiple cranial nerves and seventh nerve paresis can lead to neuroparalytic keratitis.
Removal of ticks completely from the affected tissues is most important in preventing tick-borne diseases. Based on human and animal studies, the risk of disease transmission and infection increases after the first 24 hours of tick infestation and is especially high after 48 hours. There are no clear guidelines regarding antimicrobial prophylaxis for tick-borne infections. Hence, ticks should be removed immediately and completely from affected tissue.
The options for tick removal on the eyelid are either en bloc excision or removal with forceps. Use of sharp forceps, and twisting off the head should be avoided, as this causes leakage of the tick’s potentially infectious body fluids and increase the risk for transmission of certain zoonoses, particularly Lyme disease.
Ticks are ectoparasites that have variable manifestations and may also cause a diagnostic dilemma. Tick removal should be immediate and complete. Patients should be followed up for the development of tick-borne diseases. Prevention of tick bites can be achieved by wearing appropriate long-sleeved clothing and the use of repellents in endemic regions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
Dr. D. Panneer MVSc, PhD. Veterinary Microbiologist in ICMR - VCRC, Puducherry.
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