Boy in Texas presents with erythema after tenting

Determine 2. Erythema migrans on account of Lyme illness. Supply: Mike Cater, MD.

What’s your analysis?

A. Borrelia burgdorferi

B. Rickettsia rickettsia

C. Rhus dermatitis

D. Southern tick-associated rash sickness, or STARI

Reply and dialogue:

The reply is STARI (selection D). As summer season is right here, and ticks are energetic, this looks as if time to overview this subject. STARI is a rash-producing infection of unknown etiology that’s unfold by the lone star tick (Amblyomma americanum), which can be in any other case asymptomatic, or accompanied by some flu-like signs. It ends in an increasing, annular rash lesion similar to the erythema migrans of Lyme illness. In reality, I used this similar case within the June 2007 concern of IDC, considering it was Lyme illness. Shortly thereafter, I used to be corrected by the main professional of Lyme illness and different tick-born infections, Eugene Shapiro, MD, of Yale College, who said that we don’t see endemic Lyme illness in Texas as a result of we would not have the correct vector. So, for the primary time, I needed to publish a correction. Dr. Shapiro and I touched base once more lately, and we each agree that the one Lyme illness seen in Texas is predominantly imported by vacationers or mistaken for STARI or one thing else with a false-positive Lyme titer. Due to this fact, the circumstances which are reported to the native well being departments in Texas (which apparently would not have to be documented by serology) and in the end to the state and CDC are probably STARI circumstances however get reported as Lyme. Even when there have been circumstances of endemic Lyme illness reported in Texas, the map exhibiting counties in Texas the place circumstances have been “seen” embrace nearly none within the Texas Panhandle, the place Amarillo is situated. After training in Texas for a complete of 34 years, I’ve by no means had a documented case of Lyme illness come by way of my clinic. The one documented circumstances I’ve ever seen was once I was within the Military, stationed at Walter Reed Military Medical Heart in Washington, D.C., and at West Level, New York.

STARI was first described within the Eighties. Apparently, it didn’t catch a lot traction till the late Nineties and early 2000s. On the time of this Lyme illness “faux out” case (2006), I had not seen a case of STARI (and nonetheless haven’t), and we have now an abundance of A. americanum ticks in Texas. The time from tick chunk to rash is about 2 weeks, and analysis is scientific. The advisable therapy is often doxycycline, particularly if there may be doubt about Lyme disease.

Lyme illness, which is attributable to Borrelia burgdorferi, is transmitted by the very small Ixodes scapularis tick, which is in regards to the dimension of the top of a pin. So, it might go unnoticed, and even unknowingly scratched off someday after it had embedded and transmitted the organism. The identical might be stated for the bigger A. americanum, particularly when coping with an energetic 10-year-old boy. Research have proven that attachment should happen for a minimum of 36 to 48 hours earlier than the vector can transmit the organism for Lyme illness. The attribute spreading annular lesion (Determine 2) of Lyme illness can look an identical to that of STARI and might get pretty massive (Determine 3).


Determine 3. Attribute intraerythrocytic ring type (trophozoite) of the attribute annular lesion of Lyme illness can look an identical to that of STARI, and it might develop pretty massive. Supply: Mike Weir, MD


Rocky Mountain spotted fever, the illness attributable to Rickettsia rickettsia, can be a tick-born illness that usually begins with fever, headache, myalgias and gastrointestinal signs, and the “noticed” rash. Additionally it is very unusual in Texas — and within the Rocky Mountain states as properly. The rash ranges from maculopapular to petechial, starting on the wrists, arms, ankles and ft, then spreading towards the trunk. Analysis could be quickly made with PCR of biopsy tissue from the rash, however this will not be available. Tradition of the organism is hazardous and never advisable. Due to this fact, analysis is often confirmed serologically with paired sera, however due to the excessive deadly potential, one can not await affirmation to deal with. The therapy of selection is doxycycline, whatever the affected person’s age. Our previous pal chloramphenicol is an alternate therapy if yow will discover it.

Rhus dermatitis, often attributable to contact with the Toxicodendron radicans (poison ivy) plant however can also embrace poison sumac. The allergen, urushiol, contained within the sap of the plant can provoke an intense inflammatory response to those that are delicate. There are not any systemic signs, and the rash is often restricted to the realm of pores and skin involved with the plant (Determine 4). It will be extremely unlikely for a affected person carrying denims to get poison ivy on the higher thigh however might occur when “nature calls within the woods.”


Determine 4. Poison ivy. Supply: James H. Brien, DO.

Columnist feedback

In pursuit of fact, one might sometimes have to admit the error and, as in golf, do a mulligan, or a “re-do”. Such is the case right here. As if diagnosing Lyme illness wasn’t sophisticated sufficient already, we have now to contemplate this “lookalike.”

Please communicate, and please ship alongside any good case you may prefer to see on this column. I could be reached at [email protected]

For extra data:

Brien is a member of the Healio Pediatrics and Infectious Illness Information Editorial Boards, and an adjunct professor of pediatric infectious ailments at McLane Kids’s Hospital, Baylor Scott & White Well being, in Temple, Texas.



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