- Email: [email protected]
Tick bites in the external auditory canal
Auris Nasus Larynx 34 (2007) 375–377 www.elsevier.com/locate/anl
Tick bites in the external auditory canal Satoshi Iwasaki *, Satoru Takebayashi, Takahiro Watanabe Department of Otolaryngology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu City 431-3192, Japan Received 8 August 2006; accepted 21 September 2006 Available online 18 October 2006
Abstract We report a case of Ixodes ovatus tick in the external auditory canal. Chief complaints of earfullness and pruritis appeared after the contact with dog. Using a removal method consisting of excising the abdomen of the tick and suctioning its body fluids, followed by removal of the tick body 3 days later, the patient was successfully treated without the development of complications. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Ticks; External auditory canal
1. Introduction Inappropriate removal methods of tick bodies have been reported to result in complications in some cases [1,2]. Pressure on the tick abdomen causes the infusion of pathogens from the capitula in the host. Ticks can transmit pathogens such as rickettsiae and spirochetes, which induce spotted fever, Lyme disease, and spirochetal infectious disease. In Japan, Ixodes ovatus ticks are known to transmit other bacteria such as Borrelia japonica and Rickettsia helvetica-like spotted-fever rickettsuae. Ticks are often found on domestic dogs in Japan. As dogs are in close contact with human beings, they would be possible carriers of tick vectors to the human environment. Recently, tickborne diseases have been increasing because of increasing exposure to nature and pet [3]. Here we report a rare case of I. ovatus tick in the external auditory canal, which may be carried from dog and this paper shows an instructive and safe way to remove viable tick from the external ear canal.
2. Case report The case reported here was that of a 56-year-old woman with chief complaints of earfullness and pruritis in her left * Corresponding author. Tel.: +81 53 435 2252; fax: +81 53 435 2253. E-mail address: [email protected] (S. Iwasaki).
ear, which appeared on the same day that she disposed the body of a pet dog that had passed away after many years under her care. Three days later, she visited our clinic for examination. A mass lesion was observed in the external auditory canal of the left ear, with the base of the lesion located in the posterior region of the external auditory canal. The mass was soft and was surrounded by numerous clusters of what were believed to be blood clots (Fig. 1). Furthermore, the external auditory canal was red and swollen, and it was impossible to make observations of the tympanic membrane. Although mild conductive hearing loss was detected in the left ear, there were no abnormalities in blood data. Three days after the initial consultation, the motion of arthropod limbs confirmed the presence of a tick. In addition, tick feces in the form of red grains that had earlier been identified as blood clots were detected during observation. However, obstruction of the field of view by the tick’s abdomen made it difficult to observe the bite site. Crushing the tick’s abdomen during removal carries the risk of introducing tick-borne pathogens such as spirochetes, which may lead to complications such as Lyme disease, into the host, and also raises the possibility of secondary infection due to the tick capitula remaining on the host’s skin [3]. Thus, we decided to excise the tick abdomen, followed by the removal of the tick body 2–3 days later. First, the abdomen of the tick was excised using a pair of Shea scissors under microscope. Discharge of body fluids
0385-8146/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2006.09.013
376
S. Iwasaki et al. / Auris Nasus Larynx 34 (2007) 375–377
Fig. 1. The abdomen of the tick ( ) was observed as mass lesion and excised using a pair of Shea scissors. There were tick feces in the form of red grains like blood clots in the external auditory canal (A). The extracted tick specimen was an adult Ixodes ovatus (B) and all four capitula had been removed (arrow and C).
was observed at the excision site and sucked up. Three days after the excision, the tick had died, the body had been dried up, and it was easily removed by forceps. After the procedure, a bite site was observed on the posterior region of the external auditory canal of the left ear. Effusion fluid was sucked up from the inside of the bite site for a period of time. There was no injury to the tympanic membrane. Four weeks later, the inflammatory swelling observed in the entire external auditory canal had disappeared. The initially diagnosed conductive hearing loss had also been recovered. During the progression, there were no signs of fever or rashes such as erythema on any part of the body, nor any abnormalities in hepatobiliary enzymes. According to a parasitology study group, the extracted tick specimen (body length, 6 mm) was an adult I. ovatus, which is capable of transmitting pathogens such as spirochetes. Further, all four capitula, which are thought to cause secondary infections, had been completely removed.
3. Discussion A number of tick species are often found on dogs. I. ovatus ticks transmit many specific pathogens such as Borrelia and R. helvetica like spotted fever rickettsiae. As for the route of infection, ticks are thought to fall off from their host animal and infect humans at campsites and in open fields. Common bite sites are the abdomen and eyelids, but bites on the external auditory canal are extremely rare. In addition, the number of cases is thought to be on the increase due to increased exposure to nature due to diversification of lifestyles. From a life history perspective, ticks naturally fall off of their host after sucking in a sufficient amount of blood, and thus, simply waiting for them to fall off naturally has been considered as a treatment
method. In the case of removal, it is recommended for the tick to be removed along with the surrounding skin and that this be accomplished without applying pressure on the tick abdomen, in order to ensure that the capitula, which may induce secondary infections, will not remain on the skin [1,2,4]. Known complications include spotted fever, Lyme disease, i.e. rickettsial and spirochetal infectious diseases [3]. Since infection could occur during removal unless it is carried out appropriately by a doctor, education of residents in and around endemic areas should be enhanced. Inappropriate removal methods may place pressure on the tick abdomen, causing the introduction of pathogens from the capitula into the host, thereby resulting in an infection. Main symptoms of complications include high fever, cutaneous lesions, and hepatopathy, and the elevation of Borrelia antibody, which is specific to spirochetal infectious diseases. However, it is assumed that there are positive cases of Borrelia antibody showing no actual infection in endemic areas, and reliability of seroconversion of Borrelia antibody has not yet been established. Tetracycline and macrolide are thought to be effective in the treatment of these complications [5]. In the present case, due to the patient’s request for a quick removal, the tick was removed without waiting for it to fall out naturally. However, given that the bite site was inside the narrow spaces of the external auditory canal, it was surmised that usual excision and removal of the tick along with surrounding skin would have required general anesthesia. In attempting to devise a minimally invasive removal method, we carried out a removal method involving abdominal excision of the tick followed by suctioning to remove body fluid, followed by removal of the desiccated tick body 3 days later. As this procedure was also successful in averting complications, it may be considered as a new method for tick removal.
S. Iwasaki et al. / Auris Nasus Larynx 34 (2007) 375–377
References [1] Morais JD, Dawson JE, Greene C, Filipe AR, Galhardas LC, Bacellar F. First European case of ehrlichiosis. Lancet 1991;388:633–4. [2] Dumler JS, Bakken JS. Ehrlichial diseases of humans: emerging tickborne infections. Clin Infect Dis 1995;20:1102–10. [3] Shimada Y, Beppu T, Inokuma H, Okuda M, Onishi T. Ixodid tick species recovered from dogs in Japan. Med Vet Entomol 2003;17:38–45.
377
[4] Daniels TJ, Falco RC, Schwartz I, Varde S, Robbins RG. Deer ticks (Ixodes scapularis) and the agents of Lyme disease and human granulocytic ehrlichiosis in a New York City park. Emerg Infect Dis 1997;3:353–5. [5] Bakken JS, Krueth J, Wilson-Nordskog C, Tiden RL, Asanovich K, Dumler JS. Clinical and laboratory characteristics of human granulocytic ehrlichiosis. JAMA 1996;275:199–205.
Tick bites in the external auditory canal Satoshi Iwasaki *, Satoru Takebayashi, Takahiro Watanabe Department of Otolaryngology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Hamamatsu City 431-3192, Japan Received 8 August 2006; accepted 21 September 2006 Available online 18 October 2006
Abstract We report a case of Ixodes ovatus tick in the external auditory canal. Chief complaints of earfullness and pruritis appeared after the contact with dog. Using a removal method consisting of excising the abdomen of the tick and suctioning its body fluids, followed by removal of the tick body 3 days later, the patient was successfully treated without the development of complications. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Ticks; External auditory canal
1. Introduction Inappropriate removal methods of tick bodies have been reported to result in complications in some cases [1,2]. Pressure on the tick abdomen causes the infusion of pathogens from the capitula in the host. Ticks can transmit pathogens such as rickettsiae and spirochetes, which induce spotted fever, Lyme disease, and spirochetal infectious disease. In Japan, Ixodes ovatus ticks are known to transmit other bacteria such as Borrelia japonica and Rickettsia helvetica-like spotted-fever rickettsuae. Ticks are often found on domestic dogs in Japan. As dogs are in close contact with human beings, they would be possible carriers of tick vectors to the human environment. Recently, tickborne diseases have been increasing because of increasing exposure to nature and pet [3]. Here we report a rare case of I. ovatus tick in the external auditory canal, which may be carried from dog and this paper shows an instructive and safe way to remove viable tick from the external ear canal.
2. Case report The case reported here was that of a 56-year-old woman with chief complaints of earfullness and pruritis in her left * Corresponding author. Tel.: +81 53 435 2252; fax: +81 53 435 2253. E-mail address: [email protected] (S. Iwasaki).
ear, which appeared on the same day that she disposed the body of a pet dog that had passed away after many years under her care. Three days later, she visited our clinic for examination. A mass lesion was observed in the external auditory canal of the left ear, with the base of the lesion located in the posterior region of the external auditory canal. The mass was soft and was surrounded by numerous clusters of what were believed to be blood clots (Fig. 1). Furthermore, the external auditory canal was red and swollen, and it was impossible to make observations of the tympanic membrane. Although mild conductive hearing loss was detected in the left ear, there were no abnormalities in blood data. Three days after the initial consultation, the motion of arthropod limbs confirmed the presence of a tick. In addition, tick feces in the form of red grains that had earlier been identified as blood clots were detected during observation. However, obstruction of the field of view by the tick’s abdomen made it difficult to observe the bite site. Crushing the tick’s abdomen during removal carries the risk of introducing tick-borne pathogens such as spirochetes, which may lead to complications such as Lyme disease, into the host, and also raises the possibility of secondary infection due to the tick capitula remaining on the host’s skin [3]. Thus, we decided to excise the tick abdomen, followed by the removal of the tick body 2–3 days later. First, the abdomen of the tick was excised using a pair of Shea scissors under microscope. Discharge of body fluids
0385-8146/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2006.09.013
376
S. Iwasaki et al. / Auris Nasus Larynx 34 (2007) 375–377
Fig. 1. The abdomen of the tick ( ) was observed as mass lesion and excised using a pair of Shea scissors. There were tick feces in the form of red grains like blood clots in the external auditory canal (A). The extracted tick specimen was an adult Ixodes ovatus (B) and all four capitula had been removed (arrow and C).
was observed at the excision site and sucked up. Three days after the excision, the tick had died, the body had been dried up, and it was easily removed by forceps. After the procedure, a bite site was observed on the posterior region of the external auditory canal of the left ear. Effusion fluid was sucked up from the inside of the bite site for a period of time. There was no injury to the tympanic membrane. Four weeks later, the inflammatory swelling observed in the entire external auditory canal had disappeared. The initially diagnosed conductive hearing loss had also been recovered. During the progression, there were no signs of fever or rashes such as erythema on any part of the body, nor any abnormalities in hepatobiliary enzymes. According to a parasitology study group, the extracted tick specimen (body length, 6 mm) was an adult I. ovatus, which is capable of transmitting pathogens such as spirochetes. Further, all four capitula, which are thought to cause secondary infections, had been completely removed.
3. Discussion A number of tick species are often found on dogs. I. ovatus ticks transmit many specific pathogens such as Borrelia and R. helvetica like spotted fever rickettsiae. As for the route of infection, ticks are thought to fall off from their host animal and infect humans at campsites and in open fields. Common bite sites are the abdomen and eyelids, but bites on the external auditory canal are extremely rare. In addition, the number of cases is thought to be on the increase due to increased exposure to nature due to diversification of lifestyles. From a life history perspective, ticks naturally fall off of their host after sucking in a sufficient amount of blood, and thus, simply waiting for them to fall off naturally has been considered as a treatment
method. In the case of removal, it is recommended for the tick to be removed along with the surrounding skin and that this be accomplished without applying pressure on the tick abdomen, in order to ensure that the capitula, which may induce secondary infections, will not remain on the skin [1,2,4]. Known complications include spotted fever, Lyme disease, i.e. rickettsial and spirochetal infectious diseases [3]. Since infection could occur during removal unless it is carried out appropriately by a doctor, education of residents in and around endemic areas should be enhanced. Inappropriate removal methods may place pressure on the tick abdomen, causing the introduction of pathogens from the capitula into the host, thereby resulting in an infection. Main symptoms of complications include high fever, cutaneous lesions, and hepatopathy, and the elevation of Borrelia antibody, which is specific to spirochetal infectious diseases. However, it is assumed that there are positive cases of Borrelia antibody showing no actual infection in endemic areas, and reliability of seroconversion of Borrelia antibody has not yet been established. Tetracycline and macrolide are thought to be effective in the treatment of these complications [5]. In the present case, due to the patient’s request for a quick removal, the tick was removed without waiting for it to fall out naturally. However, given that the bite site was inside the narrow spaces of the external auditory canal, it was surmised that usual excision and removal of the tick along with surrounding skin would have required general anesthesia. In attempting to devise a minimally invasive removal method, we carried out a removal method involving abdominal excision of the tick followed by suctioning to remove body fluid, followed by removal of the desiccated tick body 3 days later. As this procedure was also successful in averting complications, it may be considered as a new method for tick removal.
S. Iwasaki et al. / Auris Nasus Larynx 34 (2007) 375–377
References [1] Morais JD, Dawson JE, Greene C, Filipe AR, Galhardas LC, Bacellar F. First European case of ehrlichiosis. Lancet 1991;388:633–4. [2] Dumler JS, Bakken JS. Ehrlichial diseases of humans: emerging tickborne infections. Clin Infect Dis 1995;20:1102–10. [3] Shimada Y, Beppu T, Inokuma H, Okuda M, Onishi T. Ixodid tick species recovered from dogs in Japan. Med Vet Entomol 2003;17:38–45.
377
[4] Daniels TJ, Falco RC, Schwartz I, Varde S, Robbins RG. Deer ticks (Ixodes scapularis) and the agents of Lyme disease and human granulocytic ehrlichiosis in a New York City park. Emerg Infect Dis 1997;3:353–5. [5] Bakken JS, Krueth J, Wilson-Nordskog C, Tiden RL, Asanovich K, Dumler JS. Clinical and laboratory characteristics of human granulocytic ehrlichiosis. JAMA 1996;275:199–205.