Tick-Borne Illness: A Diagnostic Approach for the Urgent Care Clinician (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Course

Tick-borne illnesses are increasingly common in the United States, with a growing geographic footprint. Urgent care clinicians should be familiar with the clinical signs and symptoms of the most prevalent tick-borne illnesses, as well as the key risk factors for tick exposure, in order to provide timely diagnosis and appropriate treatment. In this issue, you will learn:

The prevalence and geographic distribution of common tick-borne illnesses in the United States, including Lyme disease, Rocky Mountain spotted fever, STARI, ehrlichiosis, anaplasmosis, babesiosis, tularemia, and tick-borne relapsing fever

The history and physical examination findings that should raise clinical suspicion for tick-borne illness

The correct technique for tick removal

The indications for—and utility of—diagnostic testing and confirmatory studies in urgent care

The criteria for antibiotic prophylaxis after a tick bite

Evidence-based recommendations for antibiotic treatment regimens

CHARTING & CODING: Learn how to select the appropriate level of service for encounters with patients who present with suspected tick-borne illness.

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Lyme Disease
      1. Early Signs and Symptoms
      2. Late Signs and Symptoms
   2. Southern Tick-Associated Rash Illness
   3. Rocky Mountain Spotted Fever
   4. Rickettsia parkeri Rickettsiosis
   5. Ehrlichiosis
   6. Anaplasmosis
   7. Babesiosis
   8. Tick-Borne Relapsing Fever
   9. Tularemia
   10. Viral Tick-borne Illnesses
   11. Noninfectious Pathologies
   12. Significant Tick-borne Illnesses Outside the United States
6. Differential Diagnosis
   1. Rash at the Site of the Tick Bite
   2. Systemic Symptoms
7. Prevention
8. Urgent Care Evaluation
   1. History
   2. Physical Examination
      1. Attached Tick
9. Diagnostic Studies
   1. Tick Testing
   2. General Laboratory Testing
   3. Tick-Borne Illness–Specific Testing
   4. Testing for Lyme Disease
   5. Testing for Rocky Mountain Spotted Fever
   6. Testing for Ehrlichiosis, Anaplasmosis, Babesiosis, and Borrelia miyamotoi Infections
   7. Testing for Tularemia
   8. Peripheral Blood Smears
   9. Specialized Testing
10. Treatment
    1. Antibiotic Prophylaxis After a Tick Bite
    2. Lyme Disease Treatment
       1. Early Localized Disease
       2. Early Disseminated and Late Disease
    3. Rocky Mountain Spotted Fever Treatment
    4. Ehrlichiosis and Anaplasmosis Treatment
    5. Babesiosis Treatment
    6. Tularemia Treatment
11. Special Considerations
    1. Pregnancy and Breastfeeding
    2. Drug Allergies
12. Controversies and Cutting Edge
    1. Lyme Disease Vaccination
    2. Post-treatment Lyme Disease Syndrome
13. KidBits: Tick-borne Illnesses in Children
14. 5 Things That Will Change Your Practice
15. Risk Management Pitfalls for Tick-Borne Illness in Urgent Care
16. Disposition
    1. Required Disease Reporting
17. Summary
18. Time- and Cost-Effective Strategies
19. Critical Appraisal of the Literature
20. Case Conclusions
21. Charting & Coding: What You Need to Know
    1. Medical Decision Making
    2. Problems Addressed
    3. Complexity of Data
    4. Risk of Morbidity and Mortality
    5. Documentation
    6. Summary
22. Clinical Pathway for Urgent Care Management of Tick-Borne Illness
23. References

Abstract

Tick-borne illnesses, including Lyme disease and Rocky Mountain spotted fever, are becoming increasingly common in the United States. Presentations of various tick-borne illnesses are sometimes nonspecific, but timely and effective diagnosis are critical for optimal outcomes. Urgent care clinicians play an important role in identifying and treating tick-borne illnesses. This issue discusses the diagnosis of the tick-borne illnesses most commonly seen in urgent care settings in the United States, including the key clinical findings of the history and physical examination, and diagnostic testing options. Tick removal technique, indications for prophylactic treatment, and treatment recommendations for specific tick-borne illnesses are also reviewed.

Case Presentations

A 24-year-old man presents to urgent care for a rash...

• The patient reports an “unusual rash” on his right lower leg that started 3 days ago, but the rash has gradually enlarged each day. He does not report or recall a tick bite.
• He reports fatigue and malaise but is afebrile and otherwise asymptomatic.
• He notes that, until last week, he was working as a camp counselor at a summer camp in the Catskill Mountains in New York state.
• On examination, there is a well-demarcated erythematous patch in a “bull’s-eye” pattern measuring 8 cm in diameter on his right lower leg.
• You recognize his rash as erythema migrans, and consider whether Lyme disease testing is necessary in this patient…

A 54-year-old woman presents to an urgent care center for an embedded tick on her abdomen...

• The patient says she noticed a bump this morning while taking a shower 2 hours prior to arrival and, upon closer inspection, found an embedded tick.
• There is slight erythema around the bite site, but she is otherwise asymptomatic.
• In addition to prompt tick removal, you wonder if any testing or antibiotic therapy will be needed...

A 27-year-old woman presents to urgent care for follow-up care after an upper respiratory illness...

• The patient states that 2 weeks ago, she had a febrile upper respiratory illness. At another urgent care center, she was tested for Rocky Mountain spotted fever and given a prescription for doxycycline. She says she never started the medication because her symptoms quickly resolved.
• Yesterday she was notified by phone that her “tick test was positive” and that she should seek medical attention immediately.
• You consider whether this patient should start antibiotic treatment at this point, given that she is now asymptomatic, or if additional testing is needed...

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Clinical Pathway for Urgent Care Management of Tick-Borne Illness

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. Tick-Borne Disease Working Group, US Department of Health and Human Services. Tick-borne disease. 2018. Accessed May 10, 2023. (Expert recommendation)

11. * US Centers for Disease Control and Prevention. Ticks. Updated October 21, 2021. Accessed May 10, 2023. (Public health recommendations)

12. US Centers for Disease Control and Prevention. Tick surveillance. Updated November 8, 2022. Accessed May 10, 2023. (Public health surveillance data)

13. US Centers for Disease Control and Prevention. Lifecycle of blacklegged ticks. Updated November 11, 2011. Accessed May 10, 2023. (Expert recommendations)

18. Connecticut Department of Public Health. Summary of tick testing for 2021. Accessed May 10, 2023. (Analysis of surveillance data)

23. Centers for Disease Control and Prevention. Lyme disease data and surveillance. Updated August 29, 2022. Accessed May 10, 2023. (Expert recommendations)

31. National Institutes of Health, National Institute of Allergy and Infectious Diseases. History of Rocky Mountain Labs (RML). Updated March 31, 2022. Accessed May 10, 2023. (Online review)

46. US Centers for Disease Control and Prevention. Tularemia. Updated December 13, 2018. Accessed May 10, 2023.(Public health recommendations)

67. * Lantos PM, Rumbaugh J, Bockenstedt LK, 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. Arthritis Care Res (Hoboken). 2021;73(1):1-9. (Professional society recommendations) DOI: 10.1002/acr.24495

70. US Centers for Disease Control and Prevention. Preventing tick bites on people. Updated July 1, 2020.(Expert recommendation)

80. US Centers for Disease Control and Prevention. Lyme disease diagnosis and testing. Updated May 21, 2021. Access May 10, 2023. (Expert recommendations)

101. US Centers for Disease Control and Prevention. Lyme disease surveillance and available data, Updated November 15, 2022. Accessed May 10, 2023.(Public health surveillance data)

Subscribe to get the full list of 101 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: tick-borne illness, tick-borne disease, Lyme disease, Rocky Mountain spotted fever, RMSF, STARI, babesiosis, ehrlichiosis, anaplasmosis, tularemia, tick-borne relapsing fever, Powassan, rickettsiosis, alpha-gal syndrome, erythema migrans, Ixodes, blacklegged tick, deer tick, lone star tick, dog tick, doxycycline