Immunological Skin Reaction and Local Enfection Due To Tick Bites

Abstract

Turkish Abstract

Introduction

Ticks which are vectors of the rickettsial, spiroketals, bacterial and parasitic diseases  are blood sucking ectoparasites.Ticks living in animals may cause to local and systemic diseases in both animals lived as a host  and humans¹. Microorganisms passed by thick secrations as a result of bite to the humans may cause systemic infections  and also due to damage of the bite site they multiple on the ground and may cause local skin and soft tissue infections. Tick bites may be asymptomatic or may cause to aystemic diseases such as Crimean-Congo haemorrhagic fever (CCHF) which has local symptoms such as abscess and lymphadenopathy or causes serious morbidity and mortality, Lyme disease, tularemia, rocky mountain fever, babesiyoz, Colorado tick fever ^2,3. In our study a case with local skin complications  caused by a tick bite has presented. Local complications may be overlooked  due to the CCHF disease which comes to mind first because of the high mortaility and are on the aeganda among the people. Our goal is to remind needs to be done in tick bites which are not very common and if neglected serious  local complications could develop.

Case Report

45 years old male patient referred to the emergency department with complaining of pain and swelling at the front left leg. In detailed anamnesis tick stuck his leg in the picnic area the day before and remove it by hisself in the evening  was learned. Lesion which was first ithcy than watery was further grown in the morning hours.  In the skin examination bullous lesion approximately 4x2 cm size was detected in front of the left tibia (Figure 1). 

Figure 1 The bullous lesion in front of the left tibia due to tick bite

 As laboratory findings;  White blood  cell count was 12.300/mm³, hemoglobin count 15 g/dl, platelet count 315.000 mm³, sedimantation rate 1 mm/hour, CRP 0.6 mg / dL, aspartat transaminaz (AST): 14 mg/dL, alanin transaminaz (ALT): 8 mg/dL, prothrombin time (PT): 12, partial tromboplastin  time (PTT): 25.8, and INR was 1.05.  The lesion was dressed with debridment.  Antibiotic prophylaxis was started. Hospitalization for follow up was recommended to the patient consulted with the infectious disease department. First blood samples taken from patient do not want to hospitalize for CCHF differantial diagnosis are normally reported.  The patient was discharged with outpatient follow-up recommendations.

Discussion

Infections due to tick bites is often seen in employees in forested areas, where ticks are frequent, children between the ages of 5-10 and people dealing with lumber bussiness or living in endemic areas. In our case there is a picnicking history in the forested area the day before. Tick injects a toxin which could cause lokal irritation during bite or moderate allergic reactions. However, many of the tick bites either give very symptoms or none at all ². To the host?s skin they hold with a  central punch element which has hooks called as hypostom.  Some ticks secrete an adhesive to attach themselves to the host.In addition. İxodes ticks secrete anticoagulant, immunosuppressive and antiinflammatory agents to the bite site. These substances allow blood absorbstion without noticing the host bacteria and also input other pathogens such as bacteria, spirochetes, rickettsia, protozoa, viruses, nematodes  and toxins to the body ⁴. When a tick attached to the human body  prostaglandins passed through from salivary glands to skin. These prostaglandins  reduce  IL-1 and  TNF-alpha  production from macrophages and IL-2 and IFN-gamma secretion from T lymphocytes. This situation makes the suppressive effect of the local immune response of the host. Apyrase enzyme found in tick saliva allows blood flow to ticks stimulating vasodilatation and maintaining platelet aggregation. In addition in ticks saliva there are factors  suppressing clotting cascade that increases blood flow to the lesion. These factors both increase tick feding with blood and facilitate passing infectious agent to the tick ⁵. The toxins produced by ticks cause local irritation or medium level allergic reaction. After tick bite, host C5 is activated and lead to cemotactic agent secretion by activating neutrophil and as a result neutrophil mediated tissue damage occurs⁶. In our case 4x2 cm bullous lesion , depending on the tissue damage caused by a local irritation was present. Psödolenfamatöz reaction which occurs after the tick bite cases have also been reported ⁷. Severity of infection  depends on where the infection occurs and the type of organisms that cause infections. Causative pathogen is often Staphylococcus aureus or group A  B-hemolytic streptococci. In addition, many other microorganisms like Staphylococcus epidermidis, Hemofilus influenza,  gram-negative bacilli, Korinebakteriums , Klostridiums , Propionibakteriums and  Pasturella multilocida can be isolated from skin infections as an agent. On the other hand granuloma which can not prevent by local exicion of ticks and tick bites has been reported ^8,9. In our case antibiogram could not be made because of hospitalization reject and therefore broad-spectrum antibiotics were started. Local wound debridement and dressing were made. The patient was informed about the possible clinical development and follow-up recommendations were reminded.

Ticks should be removed from skin by authorized personel,  cultures should be done necessarily from skin region and appropriate antibiotics were given to thecultura antibiogram referances. As all skin injuries wound care due to tick bite, appropriate dressing perform is so important. Tick bite cases may present clinical manifestations of the serious systemic  disease or lymphadenit which connected to a tick bite and abscess in the bite site. Local complications may be overlooked due to systemic manifestations and popularities of the diseases. The cases of tick bite, not only followed in terms of systemic symptoms  but also followed for signs of local skin is required. Society education about the possible tick bite results and information about the importance of the removal of ticks from the stucking site in the appropriate conditions is so important in terms of  public health.

References

1. Murray P R,  Rosenthal KS , Pfaller M A. Medical Microbiology. 6th Edition. Elsevier Health Sciences.  2009:361-3.
2. Tanır G, Özgelen Ş, Tuygun N. Kenelerin biyolojik özellikleri, kene ile bulaşan hastalıklar ve Türkiye?deki epidemiyolojik veriler. Çocuk Enf Derg. 2008; 3: 117-23.
3. Kara A. Kene çıkartılması. Çocuk Sağlığı ve Hastalıkları Dergisi.  2008; 51: 117-22.
4. Edlow JA. Tick-borne diseases. Emergency  medicine-infectious disease. Available at: http://www.emedicine.com/emerg/topic584.htm.
5. Walker DH. Tick-transmitted infectious diseases in the United States. Annu Rev Public Health. 1998; 19: 237-69.
6. Berenberg J L, Ward P A, Sonenshine D E. Tick-bite injury: Mediation by a complement-derived chemoticticchemotacticfactor.  J Immunol.  1972; 109: 451-6.
7. Gündüz A, et al.  Kene Isırması. TSK Koruyucu Hekimlik Bülteni.  2008; 7: 173-8.
8. Olgun H,  et al. Kene Isırığına Bağlı Gelişen İki Farklı Lokal Komplikasyon.  J Pediatr Inf 2009; 3: 132-4
9. Sarkar R, Thami GP, Kanwar AJ. Pseudolymphomatous cutaneous reaction to tick bite. Indian J Dermatol.  2001; 46: 46-7.

Information Presentation

9th Turkish Emergency Medicine Congress,  Eskişehir, 2-6 October, 2013.