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Southern tick-associated rash illness (STARI)

Daniel J Sexton, MD
Section Editors
Stephen B Calderwood, MD
Morven S Edwards, MD
Deputy Editor
Jennifer Mitty, MD, MPH


During the 1980s, clinicians in Missouri and the southeastern United States described a new illness characterized by the presence of a rash typical of erythema migrans (EM) and mild flu-like symptoms that was temporally associated with a bite by the Lone Star tick (Amblyomma americanum) (picture 1). EM-like skin lesions appeared at the site of these tick bites, but serologic tests in such patients consistently failed to show evidence of infection with Borrelia burgdorferi, a finding that fits with the fact that the vector for Lyme disease (Ixodes scapularis) (picture 2) was unknown or uncommon in these locations [1,2]. Experimental studies subsequently revealed that A. americanum is an incompetent vector for B. burgdorferi sensu stricto, the sole cause of Lyme disease in the United States [3]. (See "Epidemiology of Lyme disease".)

Over the next 20 years, this illness was given a variety of names, including Southern Lyme disease and Masters' disease. The most widely used name, Southern tick-associated rash illness (STARI), may be misleading since this syndrome and its presumed vector is now known to occur in other regions such as the Midwest and the Mid-Atlantic States.

The putative causative agent of this disease, Borrelia lonestari, has never been isolated from a human with STARI, and Koch's postulates have not yet been fulfilled in experimental studies. Nevertheless, STARI is widely presumed to be caused by B. lonestari and to be transmitted to humans by the Lone Star tick.

Numerous questions remain unanswered about the spectrum of clinical features and the pathophysiology of human illness following exposure to B. lonestari. In addition, the nature of its intermediate vertebrate host(s), the geographic range of illness, and the most effective treatment for STARI are unknown or incompletely understood.

At present, STARI should be considered to be a syndrome of unproven cause that is clinically diagnosed on the basis of its characteristic skin rash, mild clinical course, and occurrence in areas where Lyme disease is either uncommon or not present, but where A. americanum ticks are known to be present. Until there is a definitive diagnostic test for this illness and until the causative organism has been definitively isolated from humans, much of our understanding about epidemiology, clinical features, and treatment will remain speculative.


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Literature review current through: Sep 2016. | This topic last updated: Jul 14, 2015.
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  1. Felz MW, Durden LA. Attachment sites of four tick species (Acari: Ixodidae) parasitizing humans in Georgia and South Carolina. J Med Entomol 1999; 36:361.
  2. Felz MW, Durden LA, Oliver JH Jr. Ticks parasitizing humans in Georgia and South Carolina. J Parasitol 1996; 82:505.
  3. James AM, Liveris D, Wormser GP, et al. Borrelia lonestari infection after a bite by an Amblyomma americanum tick. J Infect Dis 2001; 183:1810.
  4. Burkot TR, Mullen GR, Anderson R, et al. Borrelia lonestari DNA in adult Amblyomma americanum ticks, Alabama. Emerg Infect Dis 2001; 7:471.
  5. Barbour AG, Maupin GO, Teltow GJ, et al. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: possible agent of a Lyme disease-like illness. J Infect Dis 1996; 173:403.
  6. Armstrong PM, Rich SM, Smith RD, et al. A new Borrelia infecting Lone Star ticks. Lancet 1996; 347:67.
  7. Stegall-Faulk T, Clark DC, Wright SM. Detection of Borrelia lonestari in Amblyomma americanum (Acari: Ixodidae) from Tennessee. J Med Entomol 2003; 40:100.
  8. Wormser GP, Masters E, Liveris D, et al. Microbiologic evaluation of patients from Missouri with erythema migrans. Clin Infect Dis 2005; 40:423.
  9. Varela AS, Luttrell MP, Howerth EW, et al. First culture isolation of Borrelia lonestari, putative agent of southern tick-associated rash illness. J Clin Microbiol 2004; 42:1163.
  10. Moore VA 4th, Varela AS, Yabsley MJ, et al. Detection of Borrelia lonestari, putative agent of southern tick-associated rash illness, in white-tailed deer (Odocoileus virginianus) from the southeastern United States. J Clin Microbiol 2003; 41:424.
  11. Luckhart S, Mullen GR, Wright JC. Etiologic agent of Lyme disease, Borrelia burgdorferi, detected in ticks (Acari: Ixodidae) collected at a focus in Alabama. J Med Entomol 1991; 28:652.
  12. Feder HM Jr, Hoss DM, Zemel L, et al. Southern Tick-Associated Rash Illness (STARI) in the North: STARI following a tick bite in Long Island, New York. Clin Infect Dis 2011; 53:e142.
  13. Moyer PL, Varela AS, Luttrell MP, et al. White-tailed deer (Odocoileus virginianus) develop spirochetemia following experimental infection with Borrelia lonestari. Vet Microbiol 2006; 115:229.
  14. Kirkland KB, Klimko TB, Meriwether RA, et al. Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease? Arch Intern Med 1997; 157:2635.
  15. 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.
  16. Felz MW, Chandler FW Jr, Oliver JH Jr, et al. Solitary erythema migrans in Georgia and South Carolina. Arch Dermatol 1999; 135:1317.
  17. Masters E, Granter S, Duray P, Cordes P. Physician-diagnosed erythema migrans and erythema migrans-like rashes following Lone Star tick bites. Arch Dermatol 1998; 134:955.
  18. Wormser GP, Masters E, Nowakowski J, et al. Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions. Clin Infect Dis 2005; 41:958.
  19. Means RG, White DJ. New distribution records of Amblyomma americanum (L.) (Acari: Ixodidae) in New York State. J Vector Ecol 1997; 22:133.
  20. Epi Note. North Carolina Department of Health and Human Service 2004; 2:1. Available at www.epi.state.nc.us/epi/ (Accessed 3/8/05).