A 22-year-old man living in Connecticut comes to the physician after finding a tick on his shoulder this morning. He cleared brush and mowed the lawn in his backyard yesterday morning. Before yesterday, he does not recall spending any prolonged time outdoors in the past 2 weeks.
The patient's temperature is 37.4 C (99 F), blood pressure is 112/72 mm Hg, pulse is 84/min, and respirations are 14/min. He is comfortable but anxious. There are no skin rashes. On his left shoulder, there is an attached 1.5 mm-long brown tick. The tick is removed carefully using forceps and the area is disinfected. No remnants of the tick are observed on the skin following removal.
Which of the following would be an appropriate next step in management?

Question

A 22-year-old man living in Connecticut comes to the physician after finding a tick on his shoulder this morning.  He cleared brush and mowed the lawn in his backyard yesterday morning.  Before yesterday, he does not recall spending any prolonged time outdoors in the past 2 weeks.
The patient's temperature is 37.4 C (99 F), blood pressure is 112/72 mm Hg, pulse is 84/min, and respirations are 14/min.  He is comfortable but anxious.  There are no skin rashes.  On his left shoulder, there is an attached 1.5 mm-long brown tick.  The tick is removed carefully using forceps and the area is disinfected.  No remnants of the tick are observed on the skin following removal.
Which of the following would be an appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_985b_4b43_853d_c9c76403dc6a_MD0002_00 Lyme disease is caused by Borrelia burgdorferi in the United States and usually presents initially with erythema migrans (EM). However, the infection is typically not transmitted in the first 48-72 hours of tick attachment. Infection risk is increased with tick engorgement and/or attachment for > 36 hours. The first step is tick removal, which is best done with tweezers or protected hands by pulling straight up. Antibiotic prophylaxis is recommended in patients meeting all 5 of the criteria in the Table, usually with doxycycline 200 mg in a single dose. If the patient cannot take (or refuses) doxycycline, most physicians do not advise prophylaxis with another antibiotic. Instead, observation is recommended with rapid treatment if EM develops. This patient is asymptomatic, has tick attachment for < 36 hours, and needs just reassurance with follow-up as the next step (Choices A and B). (Choice C) IgM antibodies for Lyme disease may take 2-6 weeks after infection to appear in the blood. Serologic testing (eg, ELISA followed by Western blot) in asymptomatic tick bites in the first 2 weeks may lead to false negatives and is usually not recommended. However, patients presenting initially with EM do not require serologic testing and should be treated for Lyme disease with antibiotics (eg, doxycycline, cefuroxime, or amoxicillin). (Choice E) Polymerase chain reaction testing of the tick is commercially available, but the clinical utility is low as duration of attachment determines transmission risk more than the tick's infection status. Educational objective: The risk of Borrelia burgdorferi transmission increases in the first 48-72 hours after tick attachment and usually does not require treatment in asymptomatic patients. Antibiotic prophylaxis with doxycycline 200 mg in a single dose is recommended for patients meeting all 5 criteria (eg, > 36 hours of engorged tick attachment in an endemic area). __________ References: Diagnosis and treatment of Lyme disease. (http://www.ncbi.nlm.nih.gov/pubmed/18452688) Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. (http://www.ncbi.nlm.nih.gov/pubmed/11450675)

A 22-Year-Old Man Living in Connecticut Comes to the Physician