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CASE REPORT
Year : 2022 | Volume
: 23
| Issue : 2 | Page : 142-144
Tick masquerading as skin tag − A rare case report
Seethalakshmi Ganga Vellaisamy1, Navakumar Manickam1, Anbulenin Kulandaivel2, Kannan Gopalan1
1 Department of Skin and STD, Vinayaka Mission's Kirupananda Variyar Medical College & Hospital, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India
2 Department of Pathology, Vinayaka Mission's Kirupananda Variyar Medical College & Hospital, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India
Correspondence Address:
Dr. Seethalakshmi Ganga Vellaisamy
No: 11, Mullai Nagar, Near Chandra Mahal, Seelanaickenpatty, Salem - 636 201, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijpd.ijpd_39_21
We report the case of a 16-year-old boy who presented with a painful skin lesion over the left lower eye lid following a history of travel to forest which masqueraded as skin tag. Excision biopsy showed features suggestive of hard tick. We report this unusual case of tick bite mainly to stress the importance of proper clinical evaluation, appropriate treatment like limited surgical excision, regular follow-up in view of prevention of potential disease transmission by the tick. Timely detection and treatment of tick bite is important to prevent multisystem complication that may develop later in life.
Keywords: Hard tick, Lyme disease, skin tag, zoonosis
Ticks are blood-sucking arachnids which are important as hosts and transmitters of a wide range of diseases. They have been recognized as human parasites for thousands of years and were described by ancient Greek writers, including Homer and Aristotle. Due to increased contact between humans and wildlife, these zoonotic pathogens are coming in limelight now. The main factor contributing to these types of diseases are mainly by encroachment of human activity in to forest zones, which further leads to the movement of wild animals into areas of human activity. We report a rare case of tick bite near eye in a 16-year-old boy following a history of travel to a forest area which otherwise masqueraded as skin tag.
Case ReportA 16-year-old boy presented with a painful, rapidly progressing, raised skin lesion over the lateral aspect of left lower eyelid of 4 days' duration. There was no history of bleeding from lesion or any history of trauma. There was no history of fever, chills, or any other systemic manifestations. He reported a history of travel to Sabarimala (pilgrimage place in Kerala), prior to the onset of lesion.
Dermatological examination showed a skin-colored papule over the lateral aspect of left lower eyelid which was tender to touch [Figure 1].There was no regional lymphadenopathy. Complete blood count, renal function test, liver function test, and urine analysis were normal. Ophthalmological examination was normal. We considered a differential diagnosis of inflamed skin tag. Excision biopsy was done and sent for histopathological examination which showed the following features. It revealed a parasite possessing a thick cuticle [Figure 2] with outer eosinophilic and inner basophilic layer and the cuticle showed annulations/saw tooth like pattern. Pore canal connecting inner and outer layer of cuticle was made out. Appendageal structures and tubular structures [Figure 2] were also seen along with well-developed skeletal muscle bundle. Midgut structures lined by the single layer of flat to cuboidal epithelial cells were made out [Figure 3]. All these findings led to the final diagnosis of hard tick.
Figure 1: Skin coloured papule over the lateral aspect of left lower eyelid
Figure 3: Photomicrograph showing midgut structures (H and E stain, ×100)During subsequent follow-up, for a period of 6 months, our patient did not show any systemic symptoms suggestive of any tick-transmitted diseases which indicated that he just suffered a tick bite.
DiscussionTicks are highly specialized obligate hematophagous ectoparasites of mammals, birds, and reptiles, distributed worldwide and are of enormous medical and veterinary relevance owing to the direct damage they cause to their hosts and as vectors of a large variety of human and animal pathogens. Ticks are among the most competent and versatile vectors of pathogens and are second to mosquitoes as vectors of a number of human pathogens, such as viruses, bacteria, rickettsia, spirochetes, and nematodes.[1]
Ticks are divided in to two families, namely Ixodidae (hard ticks) and Argasidae (soft ticks). They pass through multiple stages namely egg, larvae, nymph, and adult. The development of ticks depends on a series of moults, especially in the nymph developmental stage. Each blood meal helps them move onto the next stage of their life cycle.[2] Ticks are distinguished from other mites by the presence of a barbed hypostome, which is inserted in to the skin for feeding.[2] Hard ticks have a hard dorsal plate (scutum) and account for most medically important ticks, transmitting human diseases including lyme disease, ehrlichiosis, babesiosis, rocky mountain spotted fever, Colorado tick fever, Q fever, and tularemia.[2]
A single bite can transmit multiple pathogens, thereby leading to atypical presentations of some classic tick-borne diseases.[3] Tick bites usually occurs in spring and summer coinciding with their life cycle. Tick bites are usually painless, as they introduce an anesthetic and anticoagulant substance when biting.[2] Their salivary secretions may produce systemic toxaemia (tick paralysis), and their embedded mouth parts may produce a local erythematous lesion or a persistent granulomatous response. Unusual reactions include panniculitis, localized alopecia, papular urticaria, bullae, hemorrhage, and anaphylaxis.[4] Tick bite of the lower eyelid is rare and may cause contact dermatitis[5] which may be associated with pruritus. Other common symptoms may include stinging, a burning sensation, and pain,[6] but our patient did not show any signs of contact dermatitis.
Prevention is better than cure, so reducing the chance of tick bite is of paramount importance. It is recommended that one should avoid tick-infested areas, such as leaf litter under trees, avoid brushing against long grasses and brush on the edges of paths, not to sit on stumps or fallen logs, wear light-colored long pants and long sleeves so that ticks can be easily seen, tuck the shirt into pants and tuck pants into socks, to use N, N-diethyl-meta-toluamide on the skin and treat clothing with spray containing permethrin, do a thorough tick check upon coming inside and for several days following exposure, check bedding for ticks that drop off, and take the help of a veterinarian for protection of pets and domestic animals.[7]
Various techniques which have been suggested for tick removal are application of iodine, ether, chloroform, petrol, and kerosene. Removal of the tick by holding it as close to the skin as possible with a fine curved forceps or tweezers using a steady, even pressure seems to be the most preferred method.[8] Limited surgical excision is an appropriate and safe tick removal technique and could remove the tick completely,[9] which we have done in our case. Nowadays, dermoscope is used for the diagnosis, identification of the type, and complete removal of the tick. Early detection and treatment may reduce the morbidity and mortality of different tick-borne diseases.
ConclusionWe report this unusual case of tick bite mainly to stress the importance of proper clinical evaluation, appropriate treatment such as limited surgical excision, regular follow-up in view of prevention of potential disease transmission by the tick. Timely detection and treatment of tick bite are important to prevent multisystem complication that may develop later in life.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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