Southern Tick-associated Rash Illness Research Articles

Surveillance of ticks (Acari: Ixodidae) and tick-borne pathogens in Eastern Central Alabama.

Similar to other states in the southeastern United States, human cases of tick-borne diseases in Alabama have risen steadily over the last 2 decades. Nevertheless, limited data have been published on ticks or tick-borne pathogen (TBP) distributions since the 1990s. To better understand the risk of tick and TBP exposure in eastern central Alabama, ticks were sampled repeatedly across 8 sites associated with recreational use during May and June of 2015 to characterize tick density and diversity. Although habitats were similar across sites, tick density varied among locations. Seven species were collected, but 97.7% of 1,310 samples were the lone star tick, Amblyomma americanum (L.), the primary vector of ehrlichial agents and the tick species most commonly linked to alpha-gal syndrome and southern tick-associated rash illness. To investigate pathogen prevalence among sites, we tested A. americanum by a multiplex qPCR assay for 5 bacterial species, including 3 Ehrlichia spp. and 2 Rickettsia spp. None of the specimens tested positive for Panola Mountain Ehrlichia or Rickettsia parkeri. However, causative agents of human ehrlichiosis, Ehrlichia chaffeensis and Ehrlichia ewingii, occurred at half of the locations with, respectively, 0.27% and 0.45% of A. americanum infected on average. In contrast, Rickettsia amblyommatis, a tick endosymbiont suspected to be nonpathogenic, was found in 54.5% of the 1119 A. americanum tested. Despite low infection rates of Ehrlichia spp. in A. americanum, high encounter rates with this species in recreational deciduous woodlands suggest a moderate risk of tick bite and a low-to-moderate risk of TBP exposure in late spring.

Lone Star Ticks (Amblyomma americanum):: An Emerging Threat in Delaware.

Public health messaging in the eastern United States has historically underemphasized the risks posed by lone star ticks (Amblyomma americanum), focusing instead on blacklegged ticks (Ixodes scapularis). This gap persists despite mounting evidence that lone star ticks also play an important role in disease ecology as confirmed vectors for a wide variety of tick-borne pathogens. These pathogens include several distinct bacterial agents that cause ehrlichiosis and tularensis in humans and dogs, a protozoal agent that causes cytauxzoonosis in cats, and emerging viruses such as Heartland, Bourbon, and Tacaribe. Lone star ticks are additionally linked to Rocky Mountain spotted fever, southern tick-associated rash illness, and alpha-gal syndrome, a condition marked by immune reactions to ingestion of mammalian meat. Moreover, their distribution in North America is expanding due to changing climatic factors and land use patterns. Lone star ticks are the most commonly encountered tick in Delaware, especially in Sussex and Kent Counties, and make up the vast majority of ticks collected in the first two years of the state’s tick surveillance program. Given the magnitude of lone star ticks’ medical and veterinary import, it is vital for healthcare professionals and health educators to devote more attention to this emerging threat.

Committee Opinion No. 399: Management of Tick Bites and Lyme Disease During Pregnancy.

Lyme disease is an emerging infection in Canada caused by the bacterium belonging to the Borrelia burgdorferi sensu lato species complex, which is transmitted via the bite of an infected blacklegged tick. Populations of blacklegged ticks continue to expand and are now established in different regions in Canada. It usually takes more than 24 hours of tick attachment to transfer B. burgdorferi to a human. The diagnosis of early localized Lyme disease is made by clinical assessment, as laboratory tests are not reliable at this stage. Most patients with early localized Lyme disease will present with a skin lesion (i.e., erythema migrans) expanding from the tick bite site and/or non-specific "influenza-like" symptoms (e.g., arthralgia, myalgia, and fever). Signs and symptoms may occur from between 3 and 30 days following the tick bite. The care of pregnant patients with a tick bite or suspected Lyme disease should be managed similarly to non-pregnant adults, including the consideration of antibiotics for prophylaxis and treatment. The primary objective of this committee opinion is to inform practitioners about Lyme disease and provide an approach to managing the care of pregnant women who may have been infected via a blacklegged tick bite. Health care providers who care for pregnant women or women of reproductive age. Women of reproductive age. In November 2018, Medline, EMBASE, PubMed, and CENTRAL databases were searched for 2 main categories: (1) Lyme disease and (2) other tick-borne diseases. Because the main focus was Lyme disease, and considering the limited number of the articles, no further filters were applied for publication time or type of study. For other tick-borne diseases, the results were restricted to a publication date within the last 10 years (2008-2018). The search terms were developed using MeSH terms and keywords including Lyme Disease, Pregnancy, Pregnant Women, Pregnancy Complications, Ehrlichiosis, Anaplasmosis, Rocky Mountain Spotted Fever, Babesiosis, Tularemia, Powassan Virus, Encephalitis Viruses, Tick-Borne, Tick-Borne Diseases, Colorado Tick Fever, Q Fever, Relapsing Fever, and Southern Tick-Associated Rash Illness. All articles on Lyme disease and other tick-borne diseases with a target population of pregnant women were included; other groups and populations were excluded. The content and recommendations of this committee opinion were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication.

Report of Non-Lyme, Erythema Migrans Rashes from New Jersey with a Review of Possible Role of Tick Salivary Toxins.

Erythema migrans (EM) rashes once considered pathognomonic of Lyme disease (LD) have been reported following bites of arthropods that do not transmit LD and in areas with no LD. Also, EM rashes have been reported in association with organisms other than members of Borrelia burgdorferi sensu lato complex. Arthropod saliva has chemicals that have effects on the host and pathogen transmission. Tick saliva has protein families similar to spiders and scorpions and even substances homologous to those found in snakes and other venomous animals. Ticks "invertebrate pharmacologists" have a sophisticated arsenal of chemicals that assist in blood feeding, pathogen transmission, and suppressing host defenses. No organisms have been isolated from many EM rashes. We propose that tick salivary toxins may play a role in the causation of rashes and laboratory abnormalities in tick-borne diseases. The role of tick salivary toxins needs further exploration. Cases of Lyme-like EM rashes referred to as STARI (Southern Tick-Associated Rash Illness) following bites of the lone star tick, Amblyomma americanum, in the United States have been reported predominantly in Southeastern Missouri and a few in South Carolina, North Carolina, Georgia, and one case each in Mississippi and Long Island, New York. Although there is one report of Borrelia lonestari in a patient with a rash, biopsies of 31 cases of STARI, with cultures and PCR, failed to show a relationship. Distribution of A. americanum, whose bites are associated with STARI, now extends along the East Coast of the United States, including New Jersey, up to the Canadian border. As far as we are aware, there have been no prior reports of Lyme-like rashes in New Jersey. In this study, we present case examples of 2 Lyme-like rashes, variations of EM rashes, and a brief review of studies that suggest a role of tick salivary toxins in tick-borne diseases.

Alpha Gal-Induced Anaphylaxis to Herpes Zoster Vaccination

SESSION TITLE: Airway SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Reported incidence of tick borne illness has progressively risen over the last decade. Galactose-alpha-1,3-galactose (alpha gal) allergy is a novel presentation of a tick borne illness induced by the Lone Star Tick, which is a well known vector for ehrlichiosis, tularemia, and Southern Tick-associated Rash Illness (STARI). Individuals with tick borne illnesses in the Lone Star Tick distribution of southern, midwestern and northeastern states are at greater risk for developing this condition. Three major hypotheses exist to describe how ticks might induce an IgE response through transmission of alpha gal: 1) alpha gal may be a component of tick saliva, 2) alpha gal may be residual from prior blood meal, and 3) alpha gal may be transmitted through commensal organism transmission. Clinical presentation of alpha gal allergy includes gastrointestinal symptoms, itching and urticaria, and delayed anaphylaxis. There has been one prior report of alpha gal induced anaphylaxis after administration of herpes zoster vaccination in the literature. We describe a second, unique presentation of this allergic condition observed at our institution. CASE PRESENTATION: A 73 year old female with a past medical history of hypertension, chronic hepatitis C, and alpha gal allergy presented to our Emergency Department for near syncope after epinephrine administration for upper lip, mouth and tongue swelling experienced 45 minutes after obtaining her herpes zoster vaccination. Review of the vaccination contents revealed use of porcine gelatin - a meat product felt to have induced an IgE response in the setting of alpha gal allergy. The patient was admitted, managed with intravenous fluids, and discharged the following morning. DISCUSSION: To increase physician awareness of alpha gal allergy and increased incidence in populations exposed to tick-borne diseases. We suggest avoiding administering the herpes zoster vaccine in patients with a history of a tick borne illness. CONCLUSIONS: Alpha gal allergy is a relatively novel presentation of tick borne illness induced by the Lone Star Tick - commonly found in the southern, midwest and northeastern United States. We report an unusual case of alpha gal allergy with anaphylaxis induced by herpes zoster vaccination due to use of porcine gelatin. Reference #1: Steinke, John W., Thomas AE Platts-Mills, and Scott P. Commins. “The alpha-gal story: lessons learned from connecting the dots.” Journal of Allergy and Clinical Immunology 135.3 (2015): 589-596. Reference #2: Centers for Disease Control and Prevention. Tick-Borne Diseases. 2012; https://www.cdc.gov/niosh/topics/tick-borne/. Accessed February 4, 2017. Reference #3: Commins, Scott P., et al. “The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1, 3-galactose.” Journal of Allergy and Clinical Immunology 127.5 (2011): 1286-1293. DISCLOSURE: The following authors have nothing to disclose: Krishna Akella, Hemal Patel, James Wai, Heidi Roppelt, David Capone No Product/Research Disclosure Information

Tick-Borne Diseases: Identification, Management and Prevention

Tick borne diseases have become a public health crisis in endemic areas of the world. It is important for health care professionals to be aware of the clinical manifestations of tick borne diseases, and recommended practices for their diagnosis and treatment. It is also important to educate the public on signs of disease and how to mitigate exposure. An understanding about the life cycle of ticks and the interplay of the environment is also crucial to reduce morbidity and mortality. This article presents the most common tick borne diseases of hard bodied ticks in the United States which are transmitted by: deer tick: Ixodes scapularis and pacificus, dog tick: Amblyomma americium and lone star tick: Dermacentor variabilis. Diseases from infected ticks (bacterial, parasitic and viral) include Lyme disease, babesiosis, anaplasmosis, ehrlichiosis, tularemia, Powassan virus (POW virus) and Southern Tick Associated Rash Illness (STARI). There is increasing concern with new and emerging strains of other tick borne diseases such as Borrelia miyamotoi.

Metabolic differentiation of early Lyme disease from southern tick-associated rash illness (STARI).

Lyme disease, the most commonly reported vector-borne disease in the United States, results from infection with Borrelia burgdorferi. Early clinical diagnosis of this disease is largely based on the presence of an erythematous skin lesion for individuals in high-risk regions. This, however, can be confused with other illnesses including southern tick-associated rash illness (STARI), an illness that lacks a defined etiological agent or laboratory diagnostic test, and is coprevalent with Lyme disease in portions of the eastern United States. By applying an unbiased metabolomics approach with sera retrospectively obtained from well-characterized patients, we defined biochemical and diagnostic differences between early Lyme disease and STARI. Specifically, a metabolic biosignature consisting of 261 molecular features (MFs) revealed that altered N-acyl ethanolamine and primary fatty acid amide metabolism discriminated early Lyme disease from STARI. Development of classification models with the 261-MF biosignature and testing against validation samples differentiated early Lyme disease from STARI with an accuracy of 85 to 98%. These findings revealed metabolic dissimilarity between early Lyme disease and STARI, and provide a powerful and new approach to inform patient management by objectively distinguishing early Lyme disease from an illness with nearly identical symptoms.

Facts about Wildlife Diseases: South Tick Associated Rash Illness or "STARI"

Southern tick-associated rash illness (STARI) is a human tick-borne disease that occurs following the bite of Amblyomma americanum, the lone star tick, which is the most common and aggressive human-biting tick in the South, accounting for over 90% of human tick bites in the region. STARI is often described as a “Lyme-like illness” because it causes a rash like the “bulls eye” rash associated with Lyme. Other symptoms of STARI that are similar to symptoms of Lyme disease include headache, fatigue, and muscle and joint pain. Scientists know the tick vector and that some wildlife species play a role in maintaining the disease in nature, but very little else is understood about this mysterious illness. This 4-page fact sheet provides the basic facts we do know, the differences between STARI and Lyme disease, plus advice for tick-bite sufferers and strategies to avoid tick bites. Written by Katherine Sayler, Carisa Boyce, and Samantha Wisely, and published by the Department of Wildlife Ecology and Conservation, August 2016.

Not All Erythema Migrans Lesions Are Lyme Disease

BackgroundLyme disease is the number one arthropod-transmitted disease in the US, and one of the diagnostic criteria for the illness is development of an erythematous bull's-eye rash around a tick bite that may expand over time, hence the term erythema migrans. However, there are other erythema migrans-like rashes, such as those from a condition known as southern tick-associated rash illness. This article describes a patient with an erythema migrans-like lesion similar to that associated with Lyme disease, resulting from a bite by a nymphal-stage lone star tick, Amblyomma americanum. MethodsA tick removed from the center of an erythema migrans-like lesion in a patient was identified to species and then submitted to the Centers for Disease Control and Prevention for testing for the agent of Lyme disease, Borrelia burgdorferi. The patient was evaluated by an internist 7 weeks later. After another 3 weeks, the patient's blood was tested serologically for Lyme disease by American Esoteric Laboratories, Memphis, Tenn. ResultsBoth the tick and human blood sample from this patient were negative for evidence of Lyme disease. Clinically, other than the erythema migrans-like lesion, the patient displayed no signs or symptoms consistent with Lyme disease. ConclusionsThis case presents clinical, serological, and molecular evidence that erythema migrans lesions may occur after tick bites in patients and that these lesions may not be due to infection with the agent of Lyme disease.

Arthropod-Borne Diseases: The Camper's Uninvited Guests.

Arthropod-borne diseases are a major problem whenever outdoor activities bring arthropods and people into contact. The arthropods discussed here include arachnids (ticks) and insects. Most arthropod bites and stings are minor, with the notable exception being bee-sting anaphylaxis. Ticks cause the most disease transmission. Key hard tick vectors include black-legged (Ixodes), dog (Dermacentor), and lone star (Amblyomma) ticks, which transmit Lyme and various rickettsial diseases. Insect repellents, permethrin sprays, and proper tick inspection reduce this risk significantly. Lyme disease and the milder southern-tick-associated rash illness (STARI) are characterized by the erythema migrans rash followed, in the case of Lyme disease, by early, disseminated, and late systemic symptoms. Treatment is with doxycycline or ceftriaxone. Indefinite treatment of "chronic Lyme disease" based on subjective symptoms is not beneficial. Rickettsial diseases include ehrlichiosis, anaplasmosis, and Rocky Mountain spotted fever, which are characterized by fever, headache, and possible rash and should be empirically treated with doxycycline while awaiting laboratory confirmation. Tularemia is a bacterial disease (Francisella) spread by ticks and rabbits and characterized by fever and adenopathy. Treatment is with gentamicin or streptomycin. Babesiosis is a protozoal disease, mimicking malaria, that causes a self-limited flu-like disease in healthy hosts but can be life threatening with immune compromise. Treatment is with atovaquone and azithromycin. Other tick-related conditions include viral diseases (Powassan, Colorado tick fever, heartland virus), tick-borne relapsing fever (Borrelia), and tick paralysis (toxin). Mosquitoes, lice, fleas, and mites are notable for their annoying bites but are increasingly significant disease vectors even in the United States.

A Coxiella-like endosymbiont is a potential vitamin source for the Lone Star tick.

Amblyomma americanum (Lone star tick) is an important disease vector in the United States. It transmits several human pathogens, including the agents of human monocytic ehrlichiosis, tularemia, and southern tick-associated rash illness. Blood-feeding insects (Class Insecta) depend on bacterial endosymbionts to provide vitamins and cofactors that are scarce in blood. It is unclear how this deficiency is compensated in ticks (Class Arachnida) that feed exclusively on mammalian blood. A bacterium related to Coxiella burnetii, the agent of human Q fever, has been observed previously within cells of A. americanum. Eliminating this bacterium (CLEAA, Coxiella-like endosymbiont of A. americanum) with antibiotics reduced tick fecundity, indicating that it is an essential endosymbiont. In an effort to determine its role within this symbiosis, we sequenced the CLEAA genome. While highly reduced (656,901 bp) compared with C. burnetii (1,995,281 bp), the CLEAA genome encodes most major vitamin and cofactor biosynthesis pathways, implicating CLEAA as a vitamin provisioning endosymbiont. In contrast, CLEAA lacks any recognizable virulence genes, indicating that it is not a pathogen despite its presence in tick salivary glands. As both C. burnetii and numerous “Coxiella-like bacteria” have been reported from several species of ticks, we determined the evolutionary relationship between the two bacteria. Phylogeny estimation revealed that CLEAA is a close relative of C. burnetii, but was not derived from it. Our results are important for strategies geared toward controlling A. americanum and the pathogens it vectors, and also contribute novel information regarding the metabolic interdependencies of ticks and their nutrient-provisioning endosymbionts.

Commentary

Commentary

Assembly behaviour by the lone star tick, Amblyomma americanum (Acari: Ixodidae), to tick excreta is not species-specific and influenced by relative humidity

This study tested the lone star tick, Amblyomma americanum, vector of ehrlichiosis, tularemia, Southern tick-associated rash illness borreliosis, for arrestment to excreta from different tick species. The purpose was to explore off-host clustering along with spread and establishment into habitats occupied previously by other ticks. This response was analysed in relation to relative humidity since this is environmental. Females had the greatest responses towards natural excreta, and excreta components guanine and uric, and nymphs behaved like adults but with lower response levels. Response was poor by larvae, by showing inconsistent, or no response to excreta exposure. Clustering occurred on excreta from Amblyomma maculatum, Dermacentor variabilis, Ixodes scapularis, and Rhipicephalus sanguineus. This indicates there is unlikely a species-specific assembly component in excreta of A. americanum. In fact, highest level of assembly by A. americanum was to I. scapularis excreta. Greater speed and intensity for assembly occurred at 33% RH, with more ticks engaged in clustering on excreta-coated surfaces, than at 93% RH. No avoidance reaction was observed when exposed to other tick species excreta, suggesting that excreta from heterospecifics do not repel A. americanum. We conclude that dehydrating conditions cause lone star ticks to more actively pursue optimal moisture-rich, favourable habitats signalled by tick excreta. This behaviour is more important for females and nymphs than larvae, and there is capacity to recognize excreta of overlapping tick species. This co-recognition could facilitate occurrence of A. americanum with other ticks such as I. scapularis that are frequently sympatric with A. americanum through much of their geographic distribution.

Lyme borreliosis in human patients in Florida and Georgia, USA.

The aim of this study was to determine the cause of illness in several human patients residing in Florida and Georgia, USA, with suspected Lyme disease based upon EM-like skin lesions and/or symptoms consistent with early localized or late disseminated Lyme borreliosis. Using polymerase chain reaction (PCR) assays developed specifically for Lyme group Borrelia spp., followed by DNA sequencing for confirmation, we identified Borrelia burgdorferi sensu lato DNA in samples of blood and skin and also in lone star ticks (Amblyomma americanum) removed from several patients who either live in or were exposed to ticks in Florida or Georgia. This is the first report to present combined PCR and DNA sequence evidence of infection with Lyme Borrelia spp. in human patients in the southern U.S., and to demonstrate that several B. burgdorferi sensu lato species may be associated with Lyme disease-like signs and symptoms in southern states. Based on the findings of this study, we suggest that human Lyme borreliosis occurs in Florida and Georgia, and that some cases of Lyme-like illness referred to as southern tick associated rash illness (STARI) in the southern U.S. may be attributable to previously undetected B. burgdorferi sensu lato infections.

Southern Tick-Associated Rash Illness: Further Considerations

Southern Tick-Associated Rash Illness: Further Considerations

Southern Tick-Associated Rash Illness (STARI) in the North: STARI Following a Tick Bite in Long Island, New York

The most common clinical manifestation of Lyme disease is the characteristic rash, erythema migrans (EM). In the 1980s EM-like eruptions were reported in Missouri and other southeastern states. The EM-like eruptions, which were of unknown etiology, often followed the bite of the Lone Star tick (Amblyomma americanum) and the rash is called STARI (southern tick-associated rash illness). Although the Lone Star tick is found in the Lyme disease-endemic areas of New England and Mid-Atlantic regions of the United States, STARI has been reported only once from the Northeast and Mid-Atlantic regions. We report a child from Connecticut who visited Long Island, New York, and developed a rash that was thought to be EM. Because the patient failed to respond to antibiotics used to treat Lyme disease, an investigation ensued, and the diagnosis of STARI was established.

Practice-Based Research Network Partnership with CDC to Acquire Clinical Specimens to Study the Etiology of Southern Tick-Associated Rash Illness (STARI)

Erythema migrans (EM) is an annular, erythematous, expanding rash that is characteristic of early Lyme disease. In the southern United States, however, many cases of EM seem to have an etiology different from that of Lyme disease. This little-understood condition is called Southern tick-associated rash illness. With the goal of obtaining biological specimens and clinical histories from 12 to 20 STARI patients for use in etiologic research, microbiologists from the Centers for Disease Control and Prevention contacted the North Carolina Network Consortium, a statewide consortium of practice-based research networks. This article describes the methods by which the North Carolina Network Consortium successfully identified and enrolled Southern tick-associated rash illness patients into a primary care-based research protocol. A total of 23 patients were enrolled, with 100% attainment of the desired specimens. After an initial lack of success, the revised protocol identified and trained physicians practicing in endemic areas for the illness, used a coordinator with 24-hour availability, recruited participants using newspaper notices and medical providers, and provided regular reminders and progress updates. A practice-based research network can help basic scientists identify patients and collect specimens for clinically relevant research.

Erythema Migrans–like Illness among Caribbean Islanders

Erythema migrans is the skin manifestation of Lyme disease and southern tick-associated rash illness. Neither disease is found in the Caribbean. We report 4 cases of erythema migrans of a possible emerging clinical entity, Caribbean erythma migrans–like illness.

Emerging Zoonoses in the Southern United States: Toxocariasis, Bovine Tuberculosis and Southern Tick-Associated Rash Illness

The majority of emerging diseases in humans have been linked to zoonotic pathogens originating in domestic animals or wildlife. This is a public health concern because zoonotic infections affect several aspects of the society. The complex interactions among pathogen, host and environment also pose challenges in estimating the true burden of those infections. However, the recent development of new molecular diagnostic tools has allowed for better diagnosis of zoonotic infections. This review focuses on 3 emerging zoonoses, namely toxocariasis, bovine tuberculosis and southern tick-associated rash illness, and demonstrates that these infections may be more prevalent in the southern United States than previously recognized. This review places special emphasis on the recent epidemiologic trends, intra/interspecies transmission and clinical features of each of these zoonoses. In addition, treatment and prevention for each zoonotic pathogen are discussed. Clinicians working in the southern United States should be aware of the presence of those zoonotic infections.

Tick Burdens onPeromyscus leucopusRafinesque and Infection of Ticks byBorreliaspp. in Virginia

The emergence of Southern Tick-Associated Rash Illness (STARI) questions the validity of reported Lyme disease (LD) cases throughout the southern United States. Acute symptoms are identical, and an efficient method of diagnosis is currently unavailable, with the cause(s) in question. The etiologic agent of LD, Borrelia burgdorferi, is transmitted by Ixodes scapularis (Black-legged Tick), while Amblyomma americanum (Lone Star Tick) is known to carry B. lonestari, the bacterium associated with cases of STARI. Peromyscus leucopus (White-footed Mouse) is a very efficient reservoir for these bacteria and tolerant of their vectors. We sampled small (<3 ha) and large (>3 ha) forest patches in Virginia for tick densities, burdens, and infestation rates by collecting ticks by drag sampling and from mice. We also tested ticks for infection by Borrelia. Although mouse density was greater in small patches, tick densities, burdens, and infestation rates did not differ with patch size. B. burgdorferi was not detected in any tick species, but 3.4% of nymphal and 5.9% of adult Lone Star Ticks removed from vegetation were infected with B. lonestari.