Case Presentation: A 3-year-old female who recently returned from a bear-hunting trip in Idaho presented with a 4-day history of progressive ascending paralysis and hyporeflexia. Her symptoms initially started 4 days prior to presentation with difficulty walking and progressed to difficulty urinating and eventual upper extremity weakness. The family did not seek medical care until the mother found an engorged tick on the patient’s left occipital region. Her mother removed the tick and brought the child to the emergency center, where she was found to have weakness in all extremities, diminished reflexes, and difficulty urinating. Despite having already removed the tick, a workup was pursued including CT of the head and blood work including complete blood counts, a metabolic panel, and inflammatory markers, which were largely unremarkable. Additionally, the patient was admitted for monitoring signs of deterioration in case of misdiagnosis of tick paralysis. The next morning, her strength was much improved and she was discharged home.
Discussion: Tick paralysis is a rapidly progressing, ascending paralysis typically caused by the Dermacantor tick in those who have traveled to a region endemic to these ticks. The pathophysiology is thought to be due to the release of neurotoxin from the saliva of the tick, with the greatest quantity of toxin produced between days 3-7 of attachment. Treatment involves tick removal, with special attention to the head, and supportive care. Recovery usually begins within hours of removal. The differential diagnosis for tick paralysis is broad and includes Guillain-Barré, acute cerebellar ataxia, botulism, and poliomyelitis. Tick paralysis is rare and delays in diagnosis are common, causing patients often to be subjected to unnecessary extensive workups including head imaging and lumbar puncture. This case is interesting as the tick was already found and removed by the mother prior to presentation. Despite this, the patient was exposed to unnecessary care including CT scan, lab draws, and overnight hospitalization. Unnecessary medical interventions such as these are costly and may reveal incidental findings that lead to a cascade of further medical care. Children presenting with neurological syndromes such as tick paralysis, acute cerebellar ataxia, and new-onset seizure disorders may be at particular risk of receiving unnecessary interventions due to fear of more insidious processes. Unnecessary workups such as these, although well-meaning, may not benefit the patient or their family and may, in fact, be harmful.
Conclusions: Children presenting with neurologic complaints, tick paralysis, in this case, are at particular risk of receiving unnecessary interventions due to fear of insidious processes. Providers should familiarize themselves with indications for further workup including head imaging and spinal fluid analysis to avoid unnecessary utilization and patient burden.