Tick Paralysis—A Rare but Important Tick-Borne Disease

Abstract

To the Editor In a recent Clinical Insights article in JAMA Internal Medicine, Telford et al 1 proficiently addressed tick-borne diseases; however, one additional condition remains worthy of mention. 1 Tick paralysis is a rare, toxin-mediated disorder that results after a bite from numerous tick species, including Dermacentor andersoni (the wood tick) in the northwestern US, and D variabilis (the dog tick) in the eastern US. 2 Rarely, Ixodes scapularis (the black-legged tick), the vector of Lyme disease, is the offending tick. 3 When tick paralysis occurs, it is often in pediatric patients, particularly girls with long hair. 2,4 However, the disease affects patients of all ages and is found worldwide. 2,4 The mechanism of paralysis is mediated by a toxin released by the tick that blocks acetylcholine release at the presynaptic nerve terminal of the neuromuscular junction. 5 Patients present with an ascending flaccid paralysis that evolves over 12 to 24 hours. 2,4 Muscles innervated by the lower cranial nerves may become involved. Some prodromal paresthesias, myalgias, fatigue, and restlessness may also occur. Fever is absent, and the patient's mental status is normal unless hypoxia and hypercarbia occur.Without treatment or implementation of mechanical ventilation, death can occur from respiratory failure due to diaphragmatic paralysis. 2,4 Tick paralysis has been confused with Guillain-Barré syndrome, cerebellar ataxia, and other causes of acute weakness, at times leading to unnecessary tests such as lumbar puncture or advanced brain imaging. 2,4 The treatment is one of the simplest in all of medicine: tick removal, which results in improvements in muscle function, often within hours.