What is the likelihood of tick-borne illness in a 7-year-old female with a recent dog tick removal and potential attachment for greater than 36 hours?

From the Guidelines

For a 7-year-old with a tick bite (dog tick) that may have been attached for more than 36 hours, I recommend close observation without prophylactic antibiotics at this time. The patient should be monitored for 30 days for symptoms of tick-borne illnesses including fever, rash (particularly an expanding "bull's-eye" rash), headache, fatigue, muscle/joint pain, or swollen lymph nodes. The bite area should be cleaned with soap and water and monitored for signs of local infection such as increasing redness, warmth, or drainage. Since dog ticks (Dermacentor variabilis) are not primary vectors for Lyme disease, prophylactic antibiotics are not routinely recommended in this case, as supported by the guidelines from the Infectious Diseases Society of America 1. However, dog ticks can transmit Rocky Mountain spotted fever and tularemia, though the risk remains low. If symptoms develop, the child should be evaluated promptly, as early treatment of tick-borne illnesses is most effective, as emphasized in the 2020 guidelines for the prevention, diagnosis, and treatment of Lyme disease 1. Parents should be educated about proper tick removal techniques for future incidents: using fine-tipped tweezers to grasp the tick as close to the skin as possible and pulling upward with steady pressure. It's also important to note that the most recent guidelines, such as those from 2021 1, prioritize a wait-and-watch approach for tick bites that are not classified as high-risk, which aligns with the recommendation for close observation in this case. Additionally, the 2024 American Heart Association and American Red Cross guidelines for first aid 1 highlight the importance of early tick removal and monitoring for symptoms, further supporting the approach of close observation without prophylactic antibiotics.

From the Research

Tick Bite Evaluation

• The patient, a 7-year-old, presents with a history of a tick bite, with the tick being removed at 3:15 and the mother reporting that the tick could have been attached for greater than 36 hours 2.
• The tick appears to be a dog tick, which is a vector for various tick-borne diseases, including Lyme disease 3, 4.

Risk of Lyme Disease

• Lyme disease is the most common tick-borne disease in the United States, with approximately 20,000 cases reported annually 2.
• Children and individuals spending extended time outdoors in wooded areas are at increased risk of contracting Lyme disease 2, 5.
• The disease is transmitted to humans through the bite of the Ixodes tick, and typically, the tick must feed for at least 36 hours for transmission of the causative bacterium, Borrelia burgdorferi, to occur 2.

Diagnosis and Treatment

• Diagnosis of Lyme disease is usually made clinically, with the presence of an erythema migrans rash being a key indicator 3, 6.
• Treatment of Lyme disease typically involves doxycycline or amoxicillin, with cefuroxime axetil or erythromycin as alternative options 2, 6.
• Single-dose doxycycline (200 mg orally) can be used as prophylaxis in selected patients, particularly those at high risk of Lyme disease 5, 2.

Prophylactic Treatment

• Prophylactic treatment after tick exposure in patients without symptoms is generally not recommended but may be considered within 72 hours of tick removal in specific patients at high risk of Lyme disease 3.
• The patient's mother reports that the tick could have been attached for greater than 36 hours, which may increase the risk of Lyme disease transmission 2.