A Six-Year-Old Girl with Tick Paralysis

Felz, Michael W.; Smith, Carrie Davis; Swift, Thomas R.

doi:10.1056/nejm200001133420204

Cited by 88 publications

(65 citation statements)

References 28 publications

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“…North American tick paralysis is usually characterized by two distinct clinical phases: (1) a nonspecific prodromal phase of fatigue and weakness; and (2) a subsequent neurotoxic phase of acute ataxia, progressing to symmetric ascending flaccid paralysis with loss of deep tendon reflexes, involvement of bulbar structures (dysphagia, dysarthria, facial weakness, or ocular weakness), respiratory muscle weakness, lethargy, coma and death. The Sensory system seems to be spared [4,[8][9][10].…”

Section: Discussionmentioning

confidence: 99%

“…Poliomyelitis presented with meningeal signs, fever, asymmetric weakness and CSF lymphocytosis. Other differential diagnoses of tick paralysis include acute spinal cord lesion, cerebellar ataxia, myasthenia gravis, diphtheria, heavy metal intoxication, insecticide poisoning, accidental ingestion, porphyria and hysteria [8,10].…”

Section: Discussionmentioning

confidence: 99%

“…The nerve conduction abnormalities include reduced amplitude of Compound Muscle Action Potentials (CMAPS), Normal Sensory Action Potentials (SNAPs) and normal response to repetitive nerve stimulation [6,10].…”

Section: Discussionmentioning

confidence: 99%

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Tick Paralysis: A Treatable Disease Not to Be Missed

Karki¹,

Castri²,

Abrams³

et al. 2017

J Neuroinfect Dis

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Tick paralysis is a rare condition which can be treated easily but if undiagnosed can lead to significant morbidity and mortality. It is prevalent in certain areas especially in North America and Australia. It is characterized by acute onset symmetric lower extremity weakness and if not diagnosed early the weakness involves the upper extremities, cranial nerves, respiratory musculature leading to respiratory failure requiring mechanical ventilation. The clinical picture is often confused with other causes of acute onset paralysis eg., Guillain-Barre syndrome, the Miller Fisher variant, leading to unnecessary investigations and interventions complicating the clinical picture. The condition can be easily diagnosed by careful history and physical examination. Tick removal will lead to early and complete recovery of the condition.It is very important for the clinicians to be aware of this condition so that it can be recognized early to avoid unnecessary and expensive investigations, interventions, morbidity and mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Tick Paralysis: A Treatable Disease Not to Be Missed

Karki¹,

Castri²,

Abrams³

et al. 2017

J Neuroinfect Dis

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“…1 In contrast to pediatric populations, which are typically affected, adults are rarely affected, as the neurotoxin concentration is thought to be attenuated by the larger adult body mass. 3 Without tick removal, the disease can quickly become life-threatening, compromising respiratory muscle strength and resulting in respiratory failure. If missed, tick paralysis can portend significant morbidity and mortality.…”

Section: Introductionmentioning

confidence: 99%

A Case of Subacute Ataxia in the Summertime: Tick Paralysis

Laufer

Chiota‐McCollum

2015

J GEN INTERN MED

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Tick paralysis is caused by a neurotoxin secreted in the saliva of a gravid female tick, and manifests with ataxia, areflexia, ascending paralysis, bulbar palsy, and ophthalmoparesis. An 84-year-old man presented in June in coastal Mississippi with several days of subacute ataxia, bulbar palsy, unilateral weakness, and absent deep tendon reflexes. MRI/MRA and extensive serum and cerebrospinal fluid investigations were unrevealing. His symptoms progressed over several days, until his nurse discovered and removed an engorged tick from his gluteal fold. Within hours of tick removal, his subacute symptoms completely resolved. While tick paralysis is rare in adults, it is a condition that internists should be familiar with, particularly in seasons and areas with high prevalence of disease. This case also highlights the importance of performing a thorough skin exam on patients with the aforementioned neurologic abnormalities. INTRODUCTIONTick paralysis is a rare condition caused by the secretion of a neurotoxin in the saliva of a gravid female tick. 1,2It manifests with ascending paralysis, ataxia, areflexia, bulbar symptoms (dysphagia, dysphonia, dysarthria), and ophthalmoparesis (weakness of the extraocular muscles) after several days of tick attachment.1 Peak incidence is in the summertime, when the tick emerges from hibernation.1 In contrast to pediatric populations, which are typically affected, adults are rarely affected, as the neurotoxin concentration is thought to be attenuated by the larger adult body mass.3 Without tick removal, the disease can quickly become life-threatening, compromising respiratory muscle strength and resulting in respiratory failure. If missed, tick paralysis can portend significant morbidity and mortality.2 The hallmark feature of tick paralysis is a dramatic resolution of symptoms with one of the easiest treatments available-tick removal. 4 CASE PRESENTATIONAn 84-year-old man presented in June in coastal Mississippi with two days of unsteady gait and slurred speech. He was oriented to person, place, time, and situation, and did not have any memory loss. He had a past medical history of hypothyroidism, chronic kidney disease stage 3, and hyperlipidemia, but no prior history of stroke or alcoholism. At baseline, he reported having a normal gait and performance status. There were no antecedent illnesses, vaccinations, travel, new medications, known insect bites, or alcohol binges. Social history revealed that he was an avid outdoorsman in a rural community and that he consumed 1-2 drinks per week but had no history of heavy alcohol use. On exam, the patient was a wellgroomed man whose vital signs were within normal limits and whose body mass index was 25. On neurologic exam, he was alert and oriented to person, place, time, and situation. His speech was slurred, but with normal comprehension. Cranial nerve exam revealed bilateral ophthalmoparesis, evidenced by weakness in his extraocular movements. Motor exam revealed bilateral upper extremity pronator drift, with the left arm more prom...

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“…TP in the United States is more common in girls younger than 8 years with long hair, presumably due to the ability of the tick to go unnoticed on the scalp. 2,3 Most cases reported in the literature have been identified in Australia, where the causative species is Ixodes holyclus. In North America, most cases reported in the Rocky Mountain region, US Pacific Northwest, and Southwestern Canada are transmitted by Dermacentor andersoni species and in the Southeast region are transmitted by Dermacentor variabilis.…”

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confidence: 99%

Child Neurology: Tick paralysis

2014

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A diagnosis not to missA 4-year-old girl presented to our tertiary care hospital with a complaint of lower extremity weakness and unsteady gait for 2 days. She was able to pull herself to stand but could not stand unsupported. She had no sensory symptoms or pain. She did not complain of any weakness in her arms, trunk, face, or neck. She had no bowel or bladder incontinence or retention. On presentation to the emergency department, she had minimal antigravity strength of the lower extremities but normal strength elsewhere. In addition, she was areflexic in both lower extremities and had a wide-based, unsteady gait but no appendicular dysmetria or titubation. Sensory examination was normal.After consultation by the neurology service, MRI of the brain and total spine were completed and a plan was made for subsequent lumbar puncture. Lyme disease antibodies were drawn because of exposure to a wooded area in West Virginia; these were negative. MRI of the spine showed syringomyelia extending from T5 to T8 and an extramedullary, intradural cystic lesion dorsal to the spinal cord from T1 to T4, which was believed to be consistent with an arachnoid cyst. Due to this unexpected finding, the neurosurgical service was consulted, who believed that this cyst and the associated syrinx were the source of her paralysis. The following day, she was taken to the operating room for fenestration. Subsequent to the fenestration, repeat imaging showed resolution of syringomyelia.The following night, the patient developed increasing respiratory distress, requiring mechanical ventilation. Over the subsequent postoperative period, she failed multiple attempts at extubation. Extensive evaluation including infectious workup, chest x-ray, ultrasonography of the diaphragm, and upper airway endoscopy revealed no reason for her ongoing breathing difficulties. In addition, it was noted that the patient had not been able to move her upper extremities at any point during the day of surgery or in the following days.The neurology service was consulted again for further evaluation. Seven days after the initial surgery, the patient's neurologic examination revealed flaccid paralysis of all 4 extremities, bifacial weakness, minimal gag reflex, and complete areflexia. She had full extraocular movements and normal pupillary response to light. Bulbar function was difficult to evaluate due to intubation. Repeat MRI of the brain and cervical spine revealed continued resolution of syringomyelia and no new abnormalities. A lumbar puncture showed mild albuminocytologic dissociation with protein of 90, 2 leukocytes, and 1 erythrocyte. IV immunoglobulin (IVIg) therapy was instituted for presumed acute inflammatory demyelinating polyneuropathy.On postoperative day 8, EMG and nerve conduction studies were completed. Nerve conduction studies revealed low compound motor action potentials in multiple nerves with preserved sensory nerve action potentials. There was no prolonged conduction velocity seen and normal F-wave responses were noted. EMG/needle study revealed...

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A Six-Year-Old Girl with Tick Paralysis

Cited by 88 publications

References 28 publications

Tick Paralysis: A Treatable Disease Not to Be Missed

Tick Paralysis: A Treatable Disease Not to Be Missed

A Case of Subacute Ataxia in the Summertime: Tick Paralysis

Child Neurology: Tick paralysis

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