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Published Date: 2017-12-20 20:38:56
Subject: PRO/AH/EDR> Tick-bite fever - Nepal (02)
Archive Number: 20171220.5516182
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Mon 18 Dec 2017
From: Sher Bahadur Pun <drsherbdr@yahoo.com> [edited]

Case 1: On [Wed 13 Dec 2017], a 35-year old male resident of Kathmandu, who had returned from Rupandehi district 5 days previously, presented to the outpatient department of Sukraraj Tropical and Infectious Disease Hospital (STIDH) with a history of tick bite in his right axilla. He removed the tick 3 days ago. He developed a red spot and severe pain at the site of the tick bite. However, other symptoms such as fever, joint pain, fatigue, rash or eschar were absent during his hospital visit. He shared the picture of the tick with me during his hospital visit.

Case 2: On [Mon 18 Dec 2017], a 42-year old female visited our hospital (OPD), she was bitten by a tick on her left thigh during a trip to Mugu district. According to her, she found and removed the tick 4 days after the bite. However, to her surprise, 15 days after the bite, she developed severe pain and itching (at the site of the bite) followed by gradual onset of pain and swelling, which moved towards the left foot. She denied any history of fever, chills or rash. She did not take the photo of the tick, but she immediately recognized the tick when I shared the picture of the tick with her, which was shown by the case 1 patient.

The tick was a hard-bodied and blacklegged (8-legged tick, picture was shared with me by case 1), which was similar to that reported previously by me in ProMED-mail [see archive 20170417.4976181].

It seems that tick bite cases (or tick-borne diseases) are being heavily underreported but emerging in Nepal. It is probably due to lack of adequate knowledge among health care providers and laboratory facilities. To the best of my knowledge, these are probably the 1st reported tick bite cases in Nepal.

Dr. Sher Bahadur Pun, MD, PhD
Clinical Research Unit,
Sukraraj Tropical and Infectious Disease Hospital,
Kathmandu, Nepal.

[The 1st reported case had a history of high grade fever (up to 104.5 deg.F [approx. 40.3 deg.C]), chills and rigors, severe joints pain, and severe muscle pain, symptoms that did not occur in the above 2 cases. In that previous case, serological tests for scrub typhus, dengue, brucellosis, leptospirosis, and typhoid fever were negative.

In the post of that previous case, Mod.ML commented on several possible tick-borne infectious agents:

"Tick/mite-borne diseases include those caused by:
- _Rickettsia_ species: _Rickettsia rickettsii_ (Rocky Mountain spotted fever); _R. parkeri_ (spotted fever); _R. philipii_ (Pacific Coast tick fever); _R. akari_ (rickettsialpox)
- _Orientia tsutsugamushi_ (scrub typhus)
- _Ehrlichia chaffeensis_ (ehrlichiosis)
- _Anaplasma phagocytophilum_ (anaplasmosis)
- _Borrelia_ species: _Borrelia burgdorferi_, _B. mayonii_, B. afzelii_, _B. garinii_ (Lyme disease); _B. hermsii_, _B. parkeri_, and _B. turicatae_ (relapsing fever)
- _Francisella tularensis_ (tularemia)
- _Coxiella burnetii_ (Q fever)
- _Babesia microti_ (babesiosis)
- Various viruses (Colorado tick fever virus, Bourbon virus, Heartland virus, Powassan encephalitis virus).

"In addition, in the US and Europe, _Borrelia miyamotoi_, transmitted by hard-bodied ticks, causes a relapsing fever-like illness (high fever, chills, marked headache, myalgia and arthralgia with elevated liver enzymes, neutropenia and thrombocytopenia) (https://www.ncbi.nlm.nih.gov/pubmed/26053877). Central nervous system involvement has been described in 2 immunocompromised patients.

"Although high fever (such as, 104.5 deg F/40.3 deg C) and eschar is wrong for Lyme borreliosis, eschars are present in some rickettsial spotted fevers (Australian, African, and Mediterranean spotted fevers), Pacific Coast tick fever, rickettsialpox, and _R. parkeri_ relapsing fever (_R. parkeri_ is transmitted by soft-bodied ticks), and some borrelial diseases. For example, a French traveler was reported to have developed on returning home from Ethiopia an eschar and radiculopathy, caused by a _Borrelia_ spp., transmitted by a tick suspected to be hard-bodied (https://www.ncbi.nlm.nih.gov/pubmed/22776391). - Mod.ML"

It will be interesting to learn if more of these types of tick-related cases occur in Nepal in the future. If they do appear, it would be interesting to send samples (serum, ticks themselves) to a WHO reference laboratory in order to determine the etiological agents involved. - Mod.TY

HealthMap/ProMED-mail map
Nepal: http://healthmap.org/promed/p/139]

See Also

Tick-bite fever - Nepal: (DO) eschar, hard-bodied tick 20170417.4976181
Scrub typhus - Nepal (02): (RO) 20170217.4846555
Scrub typhus - Nepal: winter season 20170111.4757908
Scrub typhus - Nepal (10): (CT) fatal, more cases 20161118.4639756
Scrub typhus - Nepal (09): (Banke) 20161103.4603729
Scrub typhus - Nepal (08): (CT) fatal, more cases 20161010.4549812
Scrub typhus - Nepal (07): (DH) hearing loss 20160910.4478353
Scrub typhus - Nepal (06): (CT) fatal 20160831.4455863
Scrub typhus - Nepal (05): (DH) 20160830.4450349
Scrub typhus - Nepal (04): (TN) fatal 20160826.4442332
Scrub typhus - Nepal (03): (KT) unusual clinical presentation 20160822.4433568
Scrub typhus - Nepal (02): fatal 20160816.4417397
Scrub typhus - Nepal: (UD) 20160728.4377598
Spotted fever - USA: (AZ) Rickettsia parkeri, Amblyomma triste (tick vector) 20160522.4237407
B. burgdorferi, B. microti, A. phagocytophilum - USA: (CT) incr. tick infection 20160224.4045838
Scrub typhus - Nepal (03): (NA) 20151127.3824087
Scrub typhus - Nepal (02): (KT) 20151020.3728816
Scrub typhus - Nepal: (KT,DH) fatal 20151006.3693673
Hard tick-borne relapsing fever - USA (02): (MA) comment, correction 20150725.3535934
Hard tick-borne relapsing fever - USA: (MA) B. miyamotoi
Anaplasmosis - China: (HL) new species, humans, goats, tick-borne 20150404.3275851
Tick-borne relapsing fever - USA (02): 1990-2011 20150130.3130104
Tick-borne relapsing fever - USA: (MT) expanded state range 20150117.3099681

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