Clinical Pearl of the Month – Ticks and Tickborne Diseases

Gerard Kiernan, MD, FAAFP, FHMClinical Pearls, Emergency Medicine, Family Medicine, Guideline Knowledge Check, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Pediatric Medicine, Physician Assistant, Urgent Care

tickborne disease clinical pearl of the month from Med-Challenger

Tickborne Disease in a 53-year-old Woman

Ticks and Tick-borne Disease Clinical Pearls of Wisdom Q&A Case

Tickborne diseases in the United States include Rocky Mountain spotted fever, Lyme disease, ehrlichiosis, tularemia, babesiosis, Colorado tick fever, and many others according to the CDC. It is important for physicians to consider these illnesses when patients present with influenza-like symptoms.

Early, accurate diagnosis allows treatment that may help prevent significant morbidity and possible mortality. Because 24 to 48 hours of attachment to the host are required for infection to occur, early removal can help prevent disease.

Patient Case:

A 53-year-old woman presents, in August, with complaints of fever, myalgias, headache, fatigue and cough. She does not have ill household contacts. She recently travelled from Massachusetts, where she lives, to visit family in North Carolina. She returned a week ago. She does remember having been bitten frequently by mosquitos while hiking in the mountains of North Carolina.

On physical examination, she is pale, with clear breath sounds and a regular cardiac exam. Abdominal examination is notable for mildly tender splenomegaly. No erythema migrans lesions are noted on skin examination.

A chest x-ray is negative. Laboratories reveal a low hemoglobin of 8.0 g/dL (normal 12.0-16.0 g/dL). Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are both elevated, at 70 U/L and 80 U/L, respectively (normal for both 8-20 U/L).

Bilirubin, lactate dehydrogenase (LDH) and haptoglobin are all elevated, as well.

A rapid PCR for influenza is negative for both influenza A and influenza B.

Dipstick urinalysis reveals elevated bilirubin with negative leukocyte esterase and negative nitrite.

A peripheral blood smear is significant for the presence of schistocytes, as well as maroon red blood cell inclusions that form rings in the shape of a Maltese cross.


Of the following illnesses, which is most likely in this patient, given the presentation and laboratory findings?

Answer Options:

Human Monocytic Ehrlichiosis

Lyme Disease


Rocky Mountain Spotted Fever

See the Answer:

About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

About Clinical Pearl of the Month:

Med-Challenger's Clinical Pearl Blog Series is a recurring segment of Med-Challenger's popular Medical Education BlogSubscribe for more free pearls of wisdom. Opt-out anytime.

About Med-Challenger:

Med-Challenger provides online medical education products and services to physicians, nurses, and other medical specialists as well as medical training programs and healthcare groups world-wide via its web-based medical education library and world-class assessment platform at

babesiosis tickborne disease

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