Tick Bite Anaphylaxis
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7/27/2019 Tick Bite Anaphylaxis http://slidepdf.com/reader/full/tick-bite-anaphylaxis 1/3 Short report 111 resuscitation and are accompanied at all times.8 This practice has been accepted by all the staff involved in resuscitation. Relatives require full practical and emotional support, and occasion- ally have to be escorted out of the resuscitation room. Several possible benefits might follow from relatives being present during cardiopulmo- nary resuscitation. They would see that every- thing possible was done6 8; fantasy may often be worse than reality. They might help the medical team to decide when to discontinue resuscitation. Being present during resuscita- tion could help the next of kin in coming to terms with the death of a relative,8 just as it is now accepted good practice to offer bereaved relatives the opportunity to see the dead body. While doctors may have reservations about the presence of relatives during resuscitation,2 the Foote Hospital experience suggests that when appropriate support and supervision is provided some of these fears (such as interfer- ence by the relatives in resuscitation) may be exaggerated.8 In conclusion, we believe that a prospective study with larger numbers may help clarify the significance ofour results. In the meantime the recent publication from the Resuscitation Council (UK)6 provides valuable guidelines for practice. We would like to acknowledge assistance and advice from Dr E Glucksman. 1 Adams S, Whitlock M, Basket P, Bloomfield JF, Higgs R. Should relatives be allowed to watch resuscitation? BMJ 1994;308: 1687-9. 2 S ch il li ng RJ. No room for spectators [letter]. BMJ 1994;309:406. 3 Da y J. Opportunity is appreciated [letter]. BM J 1994;309: 670. 4 Back D, Rooke V. The presence of relatives in the resuscita- tion room. Nursing Times 1994;90(30):34-5. 5 Redley B, Hood K. Staff attitudes towards family presence during r'esuscitation. Accid Emerg Nursing 1996;4:145- 51. 6 Should relatives witness resuscitation? A report from a project team of theResuscitation Council (UK). London: Resusci- tation Council (UK), 1996. 7 Barnet V. Sample survey: principles and methods, 2nd ed. London: Hodder and Stoughton, 1991. 8 Hanson C, Strawser D. Family presence during cardiopul- monary resuscitation: Foote Hospital emergency depart- ment's nine-year perspective. J Emerg Nursing 1992;18: 104-6. Tick bite anaphylaxis in Australia Anthony F T Brown, Duncan L Hamilton Abstract Tick bite anaphylaxis has rarely been reported. It may follow the bite of any of the different tick life cycle forms, is related to the release of salivary juices, and may range from mild itch to severe wheeze or shock. Data obtained suggest that it is more common and potentially life threatening than tick paralysis, which is more widely reported. Emergency phy- sicians should recognise this possibility following a tick bite and be prepared to give treatment such as adrenaline rapidly. Patients should be referred to an allergist after recovery. (7Accid Emerg Med 1998;15:111-113) Keywords: anaphylaxis; tick infestations; tick borne diseases Ticks and mites of the order Acari are special- ised arachnids, successfully exploiting a wide variety of habitats. While mites are responsible for causing scabies, dermatitis including "gro- cers itch" or "grass itch," and various plant and animal infestations,' ticks appear better known, particularly for causing paralysis. Eight hun- dred species of ticks are described internation- ally, with 70 species in Australia,2 of which at least 15 are known to have attacked man. Tick paralysis in Australia is caused by the common bush or scrub tick Ixodes holocyclus found in eastern coastal regions from northern Queens- land to Victoria, although occasional cases have been reported due to Ixodes cornuatus found in southern New South Wales, Victoria, and Tasmania.3 Adult female ticks are usually responsible, with the earliest symptoms follow- ing several days of engorging,4 most commonly in spring and summer during warm, moist weather.5 Up until 1945, 20 deaths from tick paralysis had been reported, mostly in children under three years of age.6 Tick paralysis is encountered worldwide, from North America, Western Canada, and Africa to Europe including the United Kingdom.7 Several different genera of tick are responsible including Dermacentor, Amblyo- mma, Ixodes, Haemaphysalis, Hyaloma, and Rhinicephalus, most often affecting animals such as dogs, sheep, and cattle. Fewer species are definitely implicated in human disease, which typically affects young girls during the spring and summer months or adult males exposed occupationally during farming or for- estry work.8 9 In addition to paralysis, ticks have many other important medical effects including bite site infection, foreign body granuloma due to retained mouth parts, local allergy including dermatitis, systemic anaphy- laxis, and such vector borne diseases as Lyme disease, tularaemia, tick typhus, Rocky Moun- tain spotted fever, erhlichiosis, and babe- siosis5 8 I(table 1). The ill effects of native Australian ticks were first recorded in 1827, with definite human Department of Emergency Medicine, Royal Brisbane Hospital, Queensland 4029, Australia A F T Brown D L Hamilton Correspondence to: Dr Anthony F T Brown, Staff Specialist, Department of Emergency Medicine, Royal Brisbane Hospital, Brisbane, Queensland 4029, Australia. Accepted for publication 8 September 1997
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7/27/2019 Tick Bite Anaphylaxis
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S h o r t r e p o r t 1 1 1
r e s u s c i t a t i o n a n d a r e a c c o m p a n i e d a t a l l t i m e s . 8T h i s p r a c t i c e h a s b e e n a c c e p t e d b y a l l t h e s t a f fi n v o l v e d i n r e s u s c i t a t i o n . R e l a t i v e s r e q u i r e f u l lp r a c t i c a l a n d e m o t i o n a l s u p p o r t , a n d o c c a s i o n -
a l l y h a v e t o b e e s c o r t e d o u t o f t h e r e s u s c i t a t i o nr o o m .
S e v e r a l p o s s i b l e b e n e f i t s m i g h t f o l l o w f r o mr e l a t i v e s b e i n g p r e s e n t d u r i n g c a r d i o p u l m o -
n a r y r e s u s c i t a t i o n . They w o u l d s e e t h a t e v e r y -
t h i n g p o s s i b l e w a s d o n e 6 8 ; f a n t a s y may o f t e nb e w o r s e t h a n r e a l i t y . They m i g h t h e l p t h e
m e d i c a l t e a m t o d e c i d e when t o d i s c o n t i n u e
r e s u s c i t a t i o n . B e i n g p r e s e n t d u r i n g r e s u s c i t a -t i o n c o u l d h e l p t h e n e x t o f k i n i n c o m i n g t ot e r m s w i t h t h e d e a t h o f a r e l a t i v e , 8 j u s t a s i t i snow a c c e p t e d g o o d p r a c t i c e t o o f f e r b e r e a v e d
r e l a t i v e s t h e o p p o r t u n i t y t o s e e t h e d e a d b o d y .
W h i l e d o c t o r s may h a v e r e s e r v a t i o n s a b o u t
t h e p r e s e n c e o f r e l a t i v e s d u r i n g r e s u s c i t a t i o n , 2t h e F o o t e H o s p i t a l e x p e r i e n c e s u g g e s t s t h a twhen a p p r o p r i a t e s u p p o r t a n d s u p e r v i s i o n i s
p r o v i d e d s o m e o f t h e s e f e a r s ( s u c h a s i n t e r f e r -e n c e b y t h e r e l a t i v e s i n r e s u s c i t a t i o n ) may b e
e x a g g e r a t e d . 8
I n c o n c l u s i o n , we b e l i e v e t h a t a p r o s p e c t i v e
s t u d y w i t h l a r g e r n u m b e r s may h e l p c l a r i f y t h e
s i g n i f i c a n c e o f o u r r e s u l t s . I n t h e m e a n t i m e t h e
r e c e n t p u b l i c a t i o n f r o m t h e R e s u s c i t a t i o n
C o u n c i l ( U K ) 6 p r o v i d e s v a l u a b l e g u i d e l i n e s f o rp r a c t i c e .
We w o u l d l i k e t o a c k n o w l e d g e a s s i s t a n c e a n d a d v i c e f r o m Dr EG l u c k s m a n .
1 Adams S , W h i t l o c k M, B a s k e t P , B l o o m f i e l d J F , H i g g s R .
S h o u l d r e l a t i v e s b e a l l o w e d t o w a t c h r e s u s c i t a t i o n ? BMJ1 9 9 4 ; 3 0 8 : 1 6 8 7 - 9 .
2 S c h i l l i n g R J . No room f o r s p e c t a t o r s [ l e t t e r ] . BMJ1 9 9 4 ; 3 0 9 : 4 0 6 .
3 Da y J . O p p o r t u n i t y i s a p p r e c i a t e d [ l e t t e r ] . BM J 1 9 9 4 ; 3 0 9 :6 7 0 .
4 B a c k D , R o o k e V . The p r e se n ce o f r e l a t i v e s i n t h e r e s u s c i t a -t i o n r o o m . N u r s i n g T i m e s 1 9 9 4 ; 9 0 ( 3 0 ) : 3 4 - 5 .
5 R e d l e y B , Hood K . S t a f f a t t i t u d e s t o w a r d s f a m il y p r e s e n c ed u r i n g r ' e s u s c i t a t i o n . A c c i d E m e r g N u r s i n g 1 9 9 6 ; 4 : 1 4 5 -5 1 .
6 S h o u l d r e l a t i v e s w i t n e s s r e s u s c i t a t i o n ? A r e p o r t f r o m a p r o j e c tteam o f t h e R e s u s ci t at i o n C o u n c i l ( U K ) . L o n d o n : R e s u s c i -
t a t i o n C o u n c i l ( U K ) , 1 9 9 6 .
7 B a r n e t V . S a m p l e s u r v e y : p r i n c i p l e s a n d m e t h o d s , 2 n d e d .L o n d o n : H o d d e r a n d S t o u g h t o n , 1 9 9 1 .
8 H a n s o n C , S t r a w s e r D . F a m i l y p r e s e n c e d u r i n g c a r d i o p u l -monary r e s u s c i t a t i o n : F o o t e H o s p i t a l e m e r g e n c y d e p a r t -m e n t ' s n i n e - y e a r p e r s p e c t i v e . J Emerg N u r s i n g 1 9 9 2 ; 1 8 :
1 0 4 - 6 .
T i c k b i t e a n a p h y l a x i s i n A u s t r a l i a
A n t h o n y F T B r o w n , Duncan L H a m i l t o n
A b s t r a c t
T i c k b i t e a n a p h y l a x i s h a s r a r e l y beenr e p o r t e d . I t may f o l l o w t h e b i t e o f any o ft h e d i f f e r en t t ic k l i f e c y c l e f o r m s , i sr e l a t e d t o t h e r e l e a s e o f s a l i v a r y j u i c e s ,
and may range from m i l d i t c h t o s e v e r e
wheeze o r s h o c k . Data o b t a i n e d s u g g e s t
t h a t i t i s more c o m m o n and p o t e n t i a l l y
l i f e t h r e a t e n i n g t h a n t i c k p a r a l y s i s , which
i s more w i d e l y r e p o r t e d . Emerge n c y p h y -s i c i a n s s h o u l d r e c o g n i s e t h i s p o s s i b i l i t y
f o l l o w i n g a t ic k b i t e and be p r e p a r e d t o
g i v e t r e a t m e n t s u c h a s a d r e n a l i n e r a p i d l y .
P a t i e n t s s h o u l d be r e f e r r e d t o an a l l e r g i s t
a f t e r r e c o v e r y .( 7 A c c i d E m e r g Me d 1 9 9 8 ; 1 5 : 1 1 1 - 1 1 3 )
K e y w o r d s : a n a p h y l a x i s ; t i c k i n f e s t a t i o n s ; t i c k b o r n e
d i s e a s e s
T i c k s a n d m i t es o f t h e o r d e r A c a r i a r e s p e c i a l -i s e d a r a c h n i d s , s u c c e s s f u l l y e x p l o i t i n g a w i d ev a r i e t y o f h a b i t a t s . W h i l e m i t e s a r e r e s p o n s i b l e
f o r c a u s i n g s c a b i e s , d e r m a t i t i s i n c l u d i n g " g r o -
c e r s i t c h " o r " g r a s s i t c h , " a n d v a r io u s p l an t a n da n i m a l i n f e s t a t i o n s , ' t i c k s a p p e a r b e t t e r k n o w n ,p a r t i c u l a r l y f o r c a u s i n g p a r a l y s i s . E i g h t h u n -d r e d s p e c i e s o f t i c k s a r e d e s c r i b e d i n t e r n a t i o n -
a l l y , w i t h 7 0 s p e c i e s i n A u s t r a l i a , 2 o f w h i c h a tl e a s t 1 5 a r e known t o h a v e a t t a c k e d man. T i c k
p a r a l y s i s i n A u s t r a l i a i s c a u s e d b y t h e c o m m o nb u s h o r s c r u b t i c k I x o d e s h o l o c y c l u s f o u n d i ne a s t e r n c o a s t a l r e g i o n s f r o m n o r t h e r n Q u e e n s -
l a n d t o V i c t o r i a , a l t h o u g h o c c a s i o n a l c a s e s
h a v e b e e n r e p o r t e d d u e t o I x o d e s c o r n u a t u sf o u n d i n s o u t h e r n Ne w S o u t h W a l e s , V i c t o r i a ,a n d T a s m a n i a . 3 A d u l t f e m a l e t i c k s a r e u s u a l l y
r e s p o n s i b l e , w i t h t h e e a r l i e s t symptoms f o l l o w -i n g s e v e r a l d a y s o f e n g o r g i n g , 4 m o s t commonly
i n s p r i n g a n d summer d u r i n g warm, m o i s t
w e a t h e r . 5 Up u n t i l 1 9 4 5 , 2 0 d e a t h s f r o m t i c kp a r a l y s i s h a d b e e n r e p o r t e d , m o s t l y i n c h i l d r e n
u n d e r t h r e e y e a r s o f a g e . 6T i c k p a r a l y s i s i s e n c o u n t e r e d w o r l d w i d e ,
f r o m N o r t h A m e r i c a , W e s t e r n C a n a d a , a n d
A f r i c a t o E u r o p e i n c l u d i n g t h e U n i t e d
K i n g d o m . 7 S e v e r a l d i f f e r e n t g e n er a o f t i c k a r e
r e s po n s ib l e i nc l u d in g D e r m ac en t o r , A m b l y o -
mma, I x o d e s , H a e m a p h y s a l i s , H y a l o m a , a n dR h i n i c e p h a l u s , m o s t o f t e n a f f e c t i n g a n i m a l s
s u c h a s d o gs , s h ee p, a n d c a t t l e . F e w e r s p e c i e sa r e d e f i n i t e l y i m p l i c a t e d i n human d i s e a s e ,w h i c h t y p i c a l l y a f f e c t s y o u n g g i r l s d u r i n g t h e
s p r i n g a n d summer m o n t h s o r a d u l t m a l e s
e x p o s e d o c c u p a t i o n a l l y d u r i n g f a r m i n g o r f o r -e s t r y w o r k . 8 9 I n a d d i t i o n t o p a r a l y s i s , t i c k sh a v e many o t h e r i m p o r t a n t m e d i c a l e f f e c t si n c l u d i n g b i t e s i t e i n f e c t i o n , f o r e i g n b o d yg r a n u l o m a d u e t o r e t a i n e d mouth p a r t s , l o c a la l l e r g y i n c l u d i n g d e r m a t i t i s , s y s t e m i c a n a p h y -
l a x i s , a n d s u c h v e c t o r b o r n e d i s e a s e s a s Lyme
d i s e a s e , t u l a r a e m i a , t i c k t y p h u s , R o c k y Moun-t a i n s p o t t e d f e v e r , e r h l i c h i o s i s , a n d b a b e -
s i o s i s 5 8 I ( t a b l e 1 ) .The i l l e f f e c t s o f n a t i v e A u s t r a l i a n t i c k s w e r e
f i r s t r e c o r d e d i n 1 8 2 7 , w i t h d e f i n i t e human
Department o f
Emergency M e d i c i n e ,R o y a l B r i s b a n e
H o s p i t a l , Queensland
4 0 2 9 , A u s t r a l i aA F T BrownD L H a m i l t o n
C o r r e s p o n d e n c e t o :Dr A n t h o n y F T B r o w n ,
S t a f f S p e c i a l i s t , D e p a r t m e n to f E m e r g e n c y M e d i c i n e ,
R o y a l B r i s b a n e H o s p i t a l ,
B r i s b a n e , Q u e e n s l a n d 4 0 2 9 ,
A u s t r a l i a .
A c c e p t e d f o r p u b l i c a t i o n
8 S e p t e m b e r 1 9 9 7
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S h o r t r e p o r t 1 1 3
o n l y o c c u r s a f t e r s e v e r a l d a y s o f e n g o r g i n g b yt h e a d u l t f em a l e. S e v e r a l m a j o r a n d m i n o ra l l e r g e n s o f 2 3 t o 2 0 0 kDa h a v e b e e n i d e n t i f i e db y p r o t e i n b l o t t i n g f r o m I x o d e s h o l o c y c l u s , w i t h
t w o c o n s i s t e n t m a j o r a l l e r g e n s a t 3 7 a n d 4 5k D a , w h i c h a r e t h o u g h t t o b e d i g e s t i v ee n z y m e s r e l e a s e d i n s a l i v a r y j u i c e . ' 5 1 6
P r ev e n t i o n o f t i c k b i t e a na p h y l a x is i nc l u de s
a w a r e n e s s o f i n t e r m e d i a t e h o s t s s u c h a s t h e
b a n d i c o o t , d o g , c a t , p o s s u m , k a n g a r o o , a n de c h i d n a a n d a v o i d a n c e o f t i c k i n f e s t e d a r e a s .E x p o s u r e may b e r e d u ce d b y s e n s i b l e c l o t h i n g
a n d t h e u s e o f i n s e c t r e p e l l e n t . Long s l e e v e sa n d l o n g t r o u s e r s w i t h t h e l e g s t u c k e d i n w i l lr e d u c e a c c e s s b y t i c k s t h a t t e n d t o d r o p o n t o
humans h a v i n g b e e n a t t r a c t e d b y m o v e -m e n t . 4 1 5 I n s p e c t i n g f o r t i c k i n f e s t a t i o n s h o u l d
c o n c e n t r a t e on t h e t r u n k , a x i l l a e , n e c k , a n ds c a l p , a s t i c k s m i g r a t e u p w a r d s o v e r t h e b o d y . 8R e m o v a l i s b e s t a c h i e v e d b y f i r s t p r e s s i n g t h e
s k i n down a r o u n d t h e e mb e dd e d mou t h p a r t
o r h y p o s t o m e , w h i c h i s t h e n g r i p p e d f i r m l y a s
f a r f o r w a r d s a s p o s s i b l e w i t h a p a i r o f f o r c e p so r
f i n e s c i s s o r s . G e n t l e t r a c t i o n i s a p p l i e d , l i f t -i n g a n d d e t a c h i n g t h e e n t i r e t i c k . ' 3 4 I t i s
i m p o r t a n t n o t t o s q u e e z e t h e t i c k b o d y d u r i n gr e m o v a l a s t h i s may c a u s e f u r t h e r r e l e a s e o f
s a l i v a r y j u i c e . ' 4 I r r i t a n t s o r p o i s o n s s u c h a s
k e r o s e n e , a c e t o n e , e t h y l c h l o r i d e , a l c o h o l , o r
h e a t a r e i n e f f e c t i v e a n d a r e n o t r e c o m m e n d e d ,a s t h e y may d a m a g e t h e t i c k a n d i nc r ea se t h e
r i s k o f c o m p l i c a t i o n s . 3I g E m e d i a t e d a l l e r g i c r e a c t i o n s t o t i c k b i t e s
a r e o n e o f many a r t h r o p o d h y p e r s e n s i t i v i t yr e a c t i o n s known t o a f f e c t h u m a n s ( t a b l e 2 ) . A so u r a b i l i t y t o r e c o g n i s e a n d a c c u r a t e l y d i a g -n o s e a l l e r g i c r e a c t i o n s i n c r e a s e s , t h e l i s t o f p o s -
s i b l e c a u s e s w i l l c o n t i n u e t o g r o w .
CONCLUSIONS
I g E m e d i a t e d t i c k b i t e a n a p h y l a x i s i s w e l ld o c u m e n t e d , i s l i k e l y t o b e r e l a t e d t o s a l i v a r yj u i c e s r e l e a s e d f r o m a n y o f t h e t i c k s t a g e s ,r a n g e s f r o m u r t i c a r i a t o s e v e r e w h e e z e o r
s h o c k , a n d s u b j e c t s may h a v e c r o s s r e a c t i v i t yw i t h o t h e r a r t h r o p o d a l l e r g e n s . Our t h r e e c a s e ss e e n i n o n e y e a r i n a s i n g l e d e p a r t m e n t s u g g e s t
t h a t t i c k b i t e a n a p h y l a x i s i s n o t uncommon. By
c o n t r a s t , i n t h e p r e v i o u s f i v e y e a r s e n d i n g i no u r s t u d y y e a r o n l y t h r e e c a s e s o f t i c k p a r a l y s i sw e r e i d e n t i f i e d b y s e a r c h i n g c o m p u t e r i s e d
a d m i s s i o n d a t a f o r t h e t h r e e a d u l t , t w o
p a e d i a t r i c , a n d o n e m i x e d e m e r g e n c y d e p a r t -
m e n t s s er v in g t h e w h o l e B r i s b a n e m e t r o p o l i -t a n r e g i o n . A l l t h r e e w e r e i n c h i l d r e n ; o n l y o n e
r e c e i v e d a n t i t o x i n a n d n o n e r e q u i r e d i n t e n s i v ec a r e . Thus t i c k b i t e a n a p h y l a x i s a p p e a r s more
f r e q u e n t a n d i s p o t e n t i a l l y a g r e a t e r t h r e a t t ol i f e t h a n t i c k p a r a l y s i s , c e r t a i n l y i n s o u t h e a s tQ u e e n s l a n d .
1 S o u t h co t t R V . Some h a r m f u l A u s t r a l i a n a r t h r o p o d s . M e d JA u s t 1 9 8 6 ; 1 4 5 : 5 9 0 - 5 .
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