Tick Paralysis by Ixodes holocyclus in a Japanese Traveler Returning from Australia HISASHI INOKUMA,a HIROAKI TAKAHATA,b PIERRE-EDOUARD FOURNIER,c PHILIPPE BROUQUI,c DIDIER RAOULT,c MASARU OKUDA,a TAKAFUMI ONISHI,a KAZUE NISHIOKA,b AND MASATO TSUKAHARAd aFaculty
of Agriculture, Yamaguchi University, 753-8515 Yamaguchi, Japan
bDepartment cFacultè
of Dermatology, Yamaguchi Red Cross Hospital, 753-0092, Japan
de Mèdecine, Universitè de la Mèditerranèe, 13385 Marseille, France
dFaculty
of Health Sciences, Yamaguchi University School of Medicine, 755-8554 Ube, Japan
KEYWORDS: tick paralysis; Ixodes holocyclus; Japan; Australia
A 59-year-old man who lives in Yamaguchi Prefecture, Japan, traveled to the Gold Coast area in Australia from 1 to 14 December 2000 and stayed on a farm. He developed a fever on 9 December that was soon reduced. After returning home to Japan, he had a fever of more than 39.0°C on the night of 15 December, and he removed a semi-engorged female Ixodes holocyclus by himself on 17 December. On the following day, he went to a hospital with complaints of erythema, paralysis and tick infestation on his scalp, lethargy, and fever. On examination, erythema and sensory loss around a small eschar on the scalp, and enlargement of mandibular lymph nodes were observed. Two-day administration of minocycline was not effective in treating the symptoms. Fever continued, edema and sensory loss around the eschar on his scalp became worse, lymph nodes were enlarged and headache began. He was hospitalized on 20 December. On admission the body temperature was 38.6°C, and narrowing of the visual field of the right eye caused by paralysis of the ocular muscles, and weakness of oscillating sense in the right leg were observed. Routine laboratory studies including hematology, biochemical blood examination, and spinal fluid analysis showed no abnormalities. Bacterial culture from the eschar region was negative. Neutrophils and eosinophils infiltration and edema were observed as pathological findings of the eschar region. After hospitalization, a combination of minocycline, ciprofloxacin, amoxicillin, and d-chlorpheniramine maleate was started. Fever abated after 21 December, and the signs of paralysis disappeared gradually. Although a slight sensory loss around the eschar remained, he left the hospital on 29 December. The patient described here was a rare adult case of tick paralysis caused by I. holocyclus in a Japanese traveler returning from Australia, and typical symptoms of the tick paralysis were observed. View constriction of the right eye caused by paralysis of ocular muscles, headache, general weakness, and lethargy were recorded as Address for correspondence: Hisashi Inokuma, Faculty of Agriculture, Yamaguchi University, 753-8515 Yamaguchi, Japan. Voice/fax (81)-83-933-5895.
[email protected] Ann. N.Y. Acad. Sci. 990: 357–358 (2003).
©2003 New York Academy of Sciences.
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typical signs of tick paralysis. Unsteadiness in walking, sensory loss around the eschar on his scalp, and weakness of oscillating sense in the right leg were also observed in the patient. All these signs can be explained by the neurotoxin produced by I. holocyclus. In addition to the symptoms of typical tick paralysis, he also had uncommon findings including a fever, erythema around an eschar on the scalp, and enlargement of mandibular lymph nodes,1,2 suggesting possible concomitant infection with tick-borne pathogens. The indirect immunofluorescense assay (IFA) revealed that the patient’s acute-serum on 18 December had low antibody titers to R. helvetica (1:32 for IgG and 1:16 for IgM), R. conorii (1:32 and 1:8), R. slovaca (1:32 and less than 1:4), and R .australis, R. honei and R. japonica (1:16 and less than 1:4). The convalescent serum on 10 January also showed low antibody titers to R. helvetica (1:32 and 1:16), R. conorii and R. slovaca (1:32 and less than 1:4), and R. australis, R. honei and R. japonica (1:16 and less than 1:4). Additional western blot analysis showed reactivity of the serum against the high molecular weight outer membrane proteins that are species-specific for R. helvetica.3 The IFA titer of R. helvetica was too low to allow cross-adsorption test for the patient serum. The WeilFelix reaction, the antibodies against Orientia tsutsugamushi (Gilliam, Karp and Kato), Bartonella henselae, and Borrelia garini were all negative. Results of the IFA and the western blot analysis for Rickettsia revealed the existence of weak but specific antibodies against R. helvetica, suggesting that this patient had been in contact with R. helvetica in the past. R. helvetica is widely distributed in Europe.3,4 Combined with the fact that the patient often hunts and is frequently bitten by ticks in Japan, the present result also suggests the possibility of existence of the agent in Japan or Australia. In fact, a Rickettsia species identical or closely related to R. helvetica was recently reported from Japan.5 More epidemiological studies are required to investigate the distribution of R. helvetica in both countries.
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