Tick ID Tick ID Maps Lyme Disease Babesiosis Anaplasmosis Tularemia Other Tickborne Diseases Rocky Mountain Spotted Fever Ehrlichiosis Tick Bites/ Prevention BLACKLEGGED TICK Ixodes scapularis Where found: Widely distributed in the northeastern and upper midwestern United States. Transmits: Lyme disease, anaplasmosis, babesiosis, and Powassan disease. Comments: The greatest risk of being bitten exists in the spring, summer, and fall. However, adults may be out searching for a host any time winter temperatures are above freezing. Stages most likely to bite humans are nymphs and adult females. 3 2 LONE STAR TICK Amblyomma americanum Where found: Widely distributed in the southeastern and eastern United States. Transmits: Ehrlichia chaffeensis and Ehrlichia ewingii (which cause human ehrlichiosis), tularemia, and STARI. Comments: A very aggressive tick that bites humans. The adult female is distinguished by a white dot or "lone star" on her back. Lone star tick saliva can be irritating; redness and discomfort at a bite site does not necessarily indicate an infection. The nymph and adult females most frequently bite humans and transmit disease.Where found: Widely distributed east of the Rocky Mountains. Also occurs in limited areas on the Pacific Coast. Transmits: Tularemia and Rocky Mountain spotted fever. Comments: The highest risk of being bitten occurs during spring and summer. Dog ticks are sometimes called wood ticks. Adult females are most likely to bite humans. Engorged female Ixodes scapularis tick. Color may vary. NOTE: Illustrations are not to scale. Tick ID Tick ID Maps Lyme Disease Babesiosis Anaplasmosis Tularemia Other Tickborne Diseases Rocky Mountain Spotted Fever Ehrlichiosis Tick Bites/ Prevention BROWN DOG TICK Rhipicephalus sanguineus Where found: Worldwide. Transmits: Rocky Mountain spotted fever (in the southwestern U.S. and along the U.S.-Mexico border). Comments: Dogs are the primary host for the brown dog tick in each of its life stages, but the tick may also bite humans or other mammals.#
Comments: Adult ticks feed primarily on large mammals. Larvae and nymphs feed on small rodents. Adult ticks are primarily associated with pathogen transmission to humans. - Cough - Rash (rare cases) 9 8
The Signs and Symptoms list presents symptoms commonly seen with anaplasmosis. However, it is important to note that few people will develop all symptoms and the number and combination of symptoms varies greatly from person to person.

# LABS
Confirmation of the diagnosis is based on laboratory testing, but antibiotic therapy should not be delayed in a patient with a suggestive clinical presentation.

# GENERAL LABORATORY FINDINGS LABORATORY CONFIRMATION
Typically Observed During the First Week of Clinical Disease: Antibodies to A. phagocytophilum are detectable 7-10
- days after illness onset. The gold-standard serologic Mild anemia - test looks for a four-fold change in antibody titers using Thrombocytopenia - immunofluorescence assay (IFA) on paired samples. The first Leukopenia (characterized by relative and absolute sample should be taken within the first week of illness and lymphopenia and a left shift)
- the second should be taken 2 to 4 weeks later. Mild to moderate elevations in hepatic transaminases may occur in some patients.
- Demonstration of a four-fold change in IgG-specific antibody - Visualization of morulae in the cytoplasm of granulocytes titer by immunofluorescence assay (IFA) test in paired serum during examination of blood smears is highly suggestive of samples; or a diagnosis; however, blood smear examination is insensitive - Detection of DNA by PCR of whole blood. This method is and should never be relied upon solely to rule anaplasmosis in most sensitive within the first week of illness; sensitivity may or out.
decrease after administration of antibiotics.
NOTE: IgM antibodies are less specific than IgG antibodies and are more likely to generate false positives. IgM results alone should not be used for laboratory diagnosis.

# NOTE:
Consider the possibility of coinfection with Babesia microti and/or Borrelia burgdorferi.

# NOTE:
Antibody titers are frequently negative in the first 7-10 days of illness, thus serologic tests may be falsely negative during this time period.
Anaplasmosis Anaplasmosis, ehrlichiosis, and Rocky Mountain spotted fever are treated in the same manner with doxycycline. Clinical suspicion of any of these diseases is sufficient to begin treatment. Delay in treatment may result in severe illness and even death. The regimens listed below are guidelines only and may need to be adjusted depending on a patient's age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist in cases of documented pregnancy or life-threatening allergies to doxycycline.
AGENT Anaplasma phagocytophilum TREATMENT

# WHERE FOUND
Ehrlichiosis is most frequently reported from the southeastern and south-central U.S., from the eastern seaboard extending westward to Texas. The areas from which cases are reported correspond with the known geographic distribution of the lone star tick (Amblyomma americanum), which is associated with transmission of both E. chaffeensis and E. ewingii. Three states (Oklahoma, Missouri, Arkansas) account for 35% of all reported E. chaffeensis infections. In 2009, a new Ehrlichia species, provisionally called Ehrlichia muris-like (EML) was identified among patients in the upper Midwest. Since that time more than 67 cases have been identified. At this time, the tick responsible for transmitting EML is unknown and clinical presentations have not been differentiated from that of other Ehrlichia species. Ehrlichiosis and anaplasmosis have a similar clinical presentation, but they are transmitted by two different species of ticks and generally occur in different regions of the U.S.
The Signs and Symptoms list presents symptoms commonly seen with ehrlichiosis. However, it is important to note that few people will develop all symptoms and the number and combination of symptoms varies greatly from person to person.

# LABS
Confirmation of the diagnosis is based on laboratory testing, but antibiotic therapy should not be delayed in a patient with a suggestive clinical presentation.

# GENERAL LABORATORY FINDINGS LABORATORY CONFIRMATION

# LABORATORY DIAGNOSIS
- Demonstration of diagnostic IgM or IgG antibodies in serum. A two-tier testing protocol is recommended-EIA or IFA should be performed first; if positive or equivocal it is followed by a Western blot.
- Isolation of organism from a clinical specimen.
- In suspected Lyme meningitis, testing for intrathecal IgM or IgG antibodies may be helpful.

# NOTES ON SEROLOGIC TESTS FOR LYME DISEASE
- Serologic tests are insensitive during the first few weeks of infection. During this stage, patients with an EM rash may be diagnosed clinically. While not necessary, acute and convalescent titers may be helpful in some cases.
- In persons with illness > 1 month, only IgG testing should be performed (not IgM). A positive IgM test alone is not sufficient to diagnose current disease.
- Due to antibody persistence, single positive serologic test results cannot distinguish between active and past infection.
- Serologic tests cannot be used to measure treatment response.
- Enzyme immunoassay (EIA) and immunofluorescence assay (IFA) tests have low specificity and may yield false-positive results. They may cross-react with antibodies to commensal or pathogenic spirochetes, some viral infections (e.g., varicella, Epstein-Barr virus), or certain autoimmune diseases (e.g., lupus).

# NOTE:
Lyme Disease AGENT Borrelia burgdorferi TREATMENT

# Tick Bites/ Prevention
The erythema migrans (EM) rash occurs in 70-80% of patients with Lyme disease. EM rashes expand slowly over a few days after which they may develop a "bull's-eye" appearance consisting of a red ring with central clearing. However, EM may take alternate forms-solid lesions, blue-purple hues, and crusted or blistering lesions have all been documented. The rash is not painful or pruritic, but it may be warm to the touch. If early localized Lyme disease is not treated, patients may develop multiple secondary circular rashes as spirochetes disseminate throughout the body.
Classic EM-Circular red rash with central clearing that slowly expands - Typically appears 2-5 days after the onset of fever - Small, flat, pink, non-itchy spots (macules) initially appear on the wrists, forearms, and ankles then spread to the trunk and sometimes palms and soles.
- Rash may not develop until late in the disease process, after treatment should have already begun. Approximately 10% of RMSF patients never develop a rash at all.
- Consider RMSF if other signs and symptoms support a diagnosis, even if a rash is not present.

# Petechial Rash
- Red to purple spots (petechiae) are usually not seen until day 6 or later after onset of symptoms.
- Petechial rash is considered a sign of progression to severe disease. Every attempt should be made to begin treatment before petechiae develop.

# GENERAL LABORATORY FINDINGS
- Thrombocytopenia - Mildly elevated hepatic transaminase levels - Hyponatremia

# LABORATORY CONFIRMATION
Antibodies to R. rickettsii are detectable 7-10 days after illness onset. The gold-standard serologic test looks for a four-fold change in antibody titers using immunofluorescence assay (IFA) on paired samples. The first sample should be taken within the first week of illness and the second should be taken 2 to 4 weeks later.
- Demonstration of a four-fold change in IgG-specific antibody titer by immunofluorescence assay (IFA) test in paired serum samples; or - Detection of DNA in a skin biopsy of rash by polymerase chain reaction (PCR) assay (generally unreliable for acute blood samples).
- Immunohistochemical (IHC) staining of organism from skin or tissue biopsy NOTE: IgM antibodies are less specific than IgG antibodies and are more likely to generate false positives. IgM results alone should not be used for laboratory diagnosis.
NOTE: Antibody titers are frequently negative in the first 7-10 days of illness, thus serologic tests may be falsely negative during this time period.

# Rocky Mountain
Spotted Fever AGENT Rickettsia rickettsii TREATMENT

# Tick Bites/ Prevention
Anaplasmosis, ehrlichiosis, and Rocky Mountain spotted fever are treated in the same manner with doxycycline.  Clinical suspicion of any of these diseases is sufficient to begin treatment. Delay in treatment may result in severe illness and even death. The regimens listed below are guidelines only and may need to be adjusted depending on a patient's age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist in cases of pregnancy or documented life-threatening allergies to doxycycline.

# WHERE FOUND
In the U.S., naturally occurring tularemia infections have been reported from all states except Hawaii. Ticks that transmit tularemia to humans include the dog tick (Dermacentor variabilis), the wood tick (Dermacentor andersoni), and the lone star tick (Amblyomma americanum). Other transmission routes include inhalation and direct inoculation.

# INCUBATION PERIOD:
SIGNS AND SYMPTOMS 3-5 days (range 1-21

# Tick Bites/ Prevention
The regimens listed below are guidelines only and may need to be adjusted depending on a patient's age, medical history, underlying health conditions, pregnancy status or allergies. Consult an infectious disease specialist for the most current treatment guidelines or for individual patient treatment decisions.

# Tickborne Diseases Abroad
Activities that increase risk for tick exposure worldwide include (but are not limited to): outdoor recreation such as camping, hiking, fishing, or bicycling; military training; outdoor occupations such as forestry; and collecting mushrooms, berries, or flowers in forested or agricultural areas.

# DISEASE & ETIOLOGIC AGENT(S) GEOGRAPHIC LOCATION AND ADDITIONAL RISK FACTORS

# Lyme Disease
Borrelia afzelii, Borrelia garinii, B. burgdorferi sensu stricto

# Eastern and central Europe, northern Asia

# Tick-Borne Encephalitis Tick-borne encephalitis virus
Temperate regions of Europe and northern Asia. May also be acquired by ingestion of unpasteurized dairy products from infected goats, sheep, or cows.
Spotted Fever Group Rickettsioses (includes tick typhuses) R. akari, R. parkeri, R. africae, R. japonica, R. felis, etc.
All continents except Antarctica. R. africae infection has been reported as a cause of fever in travelers returning from South Africa.

# Crimean-Congo Hemorrhagic Fever CCHF virus
Asia, Africa, and Europe. May also be acquired by contact with infected blood or saliva or inhalation of infected aerosols.

# Omsk Hemorrhagic Fever
Omsk hemorrhagic fever virus Southwestern Russia. May also be acquired by direct contact with infected muskrats.

# Kyasanur Forest Disease Kyasanur forest disease virus
Southern India, Saudi Arabia (aka Alkhurma disease in Saudi Arabia). Typically associated with exposure while harvesting forest products.
NOTE: Anaplasmosis, babesiosis, ehrlichiosis, tularemia, TBRF, and Powassan disease can also be acquired internationally. Please see disease-specific references for more information on worldwide distribution.

# Tick Bites/Prevention

# Tick Bites/ Prevention
Ticks are generally found near the ground, in brushy or wooded areas. They can't jump or fly. Instead, they climb tall grasses or shrubs and wait for a potential host to brush against them. When this happens, they climb onto the host and seek a site for attachment.

# PREVENTION
1. Wear repellent containing at least 20% DEET or permethrin-treated clothing. Additional repellent options are available. For more information, see /.
2. Treat dogs and cats for ticks as recommended by a veterinarian.
3. Check for ticks daily, especially under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and on the hairline and scalp.
4. Shower soon after being outdoors.
5. For tips on "tick-safe" landscaping, see www.cdc.gov/lyme/prev/in_the_yard.html.

# TICK REMOVAL
6. Use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible. You may use specialized tick removal tools, if you already have them. The key is to remove the tick as soon as possible. Avoid folklore remedies such as using nail polish, petroleum jelly, or heat to make the tick detach from the skin. 7. Pull upward with steady, even pressure. Don't twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with clean tweezers. If you are unable to remove the mouth parts easily, leave them alone and let the skin heal. 8. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water. Antibiotic treatment following a tick bite is not recommended as a means to prevent anaplasmosis, babesiosis, ehrlichiosis, or Rocky Mountain spotted fever. There is no evidence this practice is effective, and it may simply delay onset of disease. Instead, persons who experience a tick bite should be alert for symptoms suggestive of tickborne illness and consult a physician if fever, rash, or other symptoms of concern develop.
Tularemia prophylaxis is recommended only in cases of laboratory exposure to infectious materials:
- Doxycycline (100 mg orally BID X 14 days) is generally recommended for prophylaxis in adults.
- Ciprofloxacin (500 mg orally BID) is not FDA-approved for prophylaxis of tularemia but has demonstrated efficacy in various studies, and may be an alternative for patients unable to take doxycycline.