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Evaluation of a tick bite for possible Lyme disease

Linden Hu, MD
Section Editor
Allen C Steere, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Lyme disease is the most common tick-borne disease in the United States and Europe. It is a spirochetal infection caused by Borrelia species (Borrelia burgdorferi in the United States, and primarily Borrelia afzelii and Borrelia garinii in Europe and Asia) and is transmitted by the bite of infected Ixodes ricinus complex ticks. Lyme disease can involve the skin, joints, nervous system, and heart. In the United States, Ixodes ticks can also transmit human granulocytic anaplasmosis and babesiosis. In Europe, they can also transmit tick-borne encephalitis virus.

Ticks have three stages in their life cycle: larva, nymph, and adult. Lyme disease is most commonly transmitted by nymphal ticks, which are typically most active during the late spring and early summer in temperate regions. Adult ticks can also transmit Lyme disease, but this occurs less commonly because adult ticks are less likely to bite humans and because they are larger and thus more likely to be detected and removed promptly. Adult ticks are most active on warm days in the fall.

Individuals at highest risk for Lyme disease are those who live in an endemic region and have occupational (eg, forestry and telephone line workers) or recreational (eg, hunting, camping, hiking, gardening, children playing in wooded areas) exposure to ticks (figure 1). However, in highly endemic areas, people may be at risk even in their yards, particularly where grassy areas and woodlands meet.

The factors affecting transmission of Lyme disease, methods for tick removal, and indications for antibiotic prophylaxis following a tick bite are reviewed here. The epidemiology, microbiology, prevention, diagnosis, clinical manifestations, and treatment of Lyme disease are discussed separately. (See "Epidemiology of Lyme disease" and "Microbiology of Lyme disease" and "Prevention of Lyme disease" and "Diagnosis of Lyme disease" and "Clinical manifestations of Lyme disease in adults" and "Treatment of Lyme disease".)


Asking the following questions can aid in the risk assessment for Lyme disease following a tick bite:


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Literature review current through: Sep 2016. | This topic last updated: May 16, 2016.
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  1. Falco RC, Fish D, D'Amico V. Accuracy of tick identification in a Lyme disease endemic area. JAMA 1998; 280:602.
  2. Campbell GL, Paul WS, Schriefer ME, et al. Epidemiologic and diagnostic studies of patients with suspected early Lyme disease, Missouri, 1990-1993. J Infect Dis 1995; 172:470.
  3. Wormser GP, Masters E, Liveris D, et al. Microbiologic evaluation of patients from Missouri with erythema migrans. Clin Infect Dis 2005; 40:423.
  4. Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med 2001; 345:79.
  5. Piesman J, Maupin GO, Campos EG, Happ CM. Duration of adult female Ixodes dammini attachment and transmission of Borrelia burgdorferi, with description of a needle aspiration isolation method. J Infect Dis 1991; 163:895.
  6. des Vignes F, Piesman J, Heffernan R, et al. Effect of tick removal on transmission of Borrelia burgdorferi and Ehrlichia phagocytophila by Ixodes scapularis nymphs. J Infect Dis 2001; 183:773.
  7. Sood SK, Salzman MB, Johnson BJ, et al. Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis 1997; 175:996.
  8. Shapiro ED, Gerber MA, Holabird NB, et al. A controlled trial of antimicrobial prophylaxis for Lyme disease after deer-tick bites. N Engl J Med 1992; 327:1769.
  9. De Silva AM, Fikrig E. Growth and migration of Borrelia burgdorferi in Ixodes ticks during blood feeding. Am J Trop Med Hyg 1995; 53:397.
  10. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.
  11. Piesman J, Lewengrub S, Rudzinska MA, Spielman A. Babesia microti: prolonged survival of salavarian piroplasms in nymphal Ixodes dammini. Exp Parasitol 1987; 64:292.
  12. Needham GR. Evaluation of five popular methods for tick removal. Pediatrics 1985; 75:997.
  13. Steere AC, Sikand VK. The presenting manifestations of Lyme disease and the outcomes of treatment. N Engl J Med 2003; 348:2472.
  14. Nadelman RB, Luger SW, Frank E, et al. Comparison of cefuroxime axetil and doxycycline in the treatment of early Lyme disease. Ann Intern Med 1992; 117:273.
  15. Luft BJ, Dattwyler RJ, Johnson RC, et al. Azithromycin compared with amoxicillin in the treatment of erythema migrans. A double-blind, randomized, controlled trial. Ann Intern Med 1996; 124:785.
  16. Steere AC, Sikand VK, Schoen RT, Nowakowski J. Asymptomatic infection with Borrelia burgdorferi. Clin Infect Dis 2003; 37:528.
  17. Costello CM, Steere AC, Pinkerton RE, Feder HM Jr. A prospective study of tick bites in an endemic area for Lyme disease. J Infect Dis 1989; 159:136.
  18. Agre F, Schwartz R. The value of early treatment of deer tick bites for the prevention of Lyme disease. Am J Dis Child 1993; 147:945.
  19. Warshafsky S, Nowakowski J, Nadelman RB, et al. Efficacy of antibiotic prophylaxis for prevention of Lyme disease. J Gen Intern Med 1996; 11:329.
  20. Magid D, Schwartz B, Craft J, Schwartz JS. Prevention of Lyme disease after tick bites. A cost-effectiveness analysis. N Engl J Med 1992; 327:534.