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Southern Tick-Associated Rash Illness (STARI)

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· Lone Star Tick a Concern, but Not for Lyme Disease

Southern Tick-Associated Rash Illness

A rash similar to the rash of Lyme disease has been described in humans following bites of the lone star tick, Amblyomma americanum. The rash may be accompanied by fatigue, fever, headache, muscle and joint pains. This condition has been named southern tick-associated rash illness (STARI).

Image: classic erythema migrans. Photograph used with permission from the Journal of Infectious Diseases.
Image: Patient with STARI; 1) site of tick bite, 2) red, radial, expanding edge of rash. 3) central clearing.

Photograph used with permission from the Journal of Infectious Diseases.

The rash of STARI is a red, expanding “bulls eye” lesion that develops around the site of a lone star tick bite. The rash usually appears within 7 days of tick bite and expands to a diameter of 8 centimeters (3 inches) or more. The rash should not be confused with much smaller areas of redness and discomfort that can occur commonly at tick bite sites. Unlike Lyme disease, STARI has not been linked to any arthritic, neurological, or chronic symptoms.

The cause of STARI is unknown. Studies have shown that is not caused by Borrelia burgdorferi, the bacterium that causes Lyme disease. Another spirochete, Borrelia lonestari, was detected in the skin of one patient and the lone star tick that bit him. However, subsequent study of over two dozen STARI patients has found no evidence of B. lonestari infection. In the cases of STARI studied to date, the rash and accompanying symptoms have resolved promptly following treatment with oral antibiotics.

Image of adult female Amblyomma americanum, also called "lone star," tick.


Image: Map showing distribution of lone star ticks in the United States. (click to open 27KB pdf)
Adult female Amblyomma americanum tick. Note the characteristic “lone star.” (View enlarged image.)
Image: Map showing distribution of lone star ticks in the United States. View enlarged image pdf icon(27KB, 1page)
Redrawn and updated from Hair and Bowman, 1986.

STARI is specifically associated with bites of Amblyomma americanum, known commonly as the lone star tick. Lone star ticks can be found from central Texas and Oklahoma eastward across the southern states and along the Atlantic coast as far north as Maine. The adult female is distinguished by a white dot or “lone star” on her back. All three life stages of A. americanum aggressively bite people.

In general, tick-borne illness may be prevented by avoiding tick habitat (dense woods and brushy areas), using insect repellents containing DEET or permethrin, wearing long pants and socks, and performing tick checks and promptly removing ticks after outdoor activity. Persons should monitor their health closely after any tick bite, and should consult a physician if they experience a rash, fever, headache, joint or muscle pains, or swollen lymph nodes within 30 days of a tick bite. In most circumstances, treating persons who only have a tick bite is not recommended.

The Centers for Disease Control and Prevention is interested in obtaining samples from STARI patients under an Institutional Review Board-approved investigational protocol. Physicians seeing patients with a recent lone star tick bite and an expanding rash at least 5 centimeters in diameter are encouraged to contact CDC at 970-221-6400 for more information. Patients must be at least 4 years old to participate.

Additional Reading

Barbour AG, Maupin GO, Teltow GJ, Carter CJ, Piesman J. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: possible agent of a Lyme disease-like illness. Journal of Infectious Diseases 1996;173:403-409.

Burkot TR, Mullen GR, Anderson R, Schneider BS, Happ CM, Zeidner NS. Borrelia lonestari DNA in adult Amblyomma americanum ticks, Alabama. Emerging Infectious Diseases 2001;7:471-473.

Campbell GL, Paul WS, Schriefer ME, Craven RB, Robbins KE, Dennis DT. Epidemiologic and diagnostic studies of patients with suspected early Lyme disease, Missouri, 1990-1993. Journal of Infectious Diseases 1995;172:470-480.

Felz MW, Chandler FW Jr, Oliver JH Jr, Rahn DW, Schriefer ME. Solitary erythema migrans in Georgia and South Carolina. Archives of Dermatology 1999;135:1317-1326.

Fukunaga M, Okada K, Nakao M, Konishi T, Sato Y. Phylogenetic analysis of Borrelia species based on flagellin gene sequences and its application for molecular typing of Lyme disease borreliae. International Journal of Systematic Bacteriology 1996;46:898-905.

Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch. Tick Bites and Erythema Migrans in Georgia: It Might NOT be Lyme Disease! icon faded pdf(565 KB, 4 pages). Georgia Epidemiology Report 2001 Aug;17:1-3.

Hair JA, Bowman JL. Behavioral ecology of Amblyomma americanum (L.). In: Sauer RJ and Hair HA, eds. Morphology, physiology, and behavioral biology of ticks. West Sussex England: Ellis Worwood Limited, 1986:407.

James AM, Liveris D, Wormser GP, Schwartz I, Montecalvo MA, Johnson BJB. Borrelia lonestari infection after a bite by an Amblyomma americanum tick. Journal of Infectious Diseases 2001;183:1810-4.

Kirkland KB, Klimko TB, Meriwether RA, Schriefer M, Levin M, Levine J, MacKenzie WR, Dennis DT. Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease? Archives of Internal Medicine 1997;157:2635-2641.

Luckhart S. Mullen GR, Durden LA, Wright JC. Borrelia species in ticks recovered from white-tailed deer in Alabama. Journal of Wildlife Diseases 1992;28:449-452.

Masters E, Granter S, Duray P, Cordes P. Physician-diagnosed erythema migrans and erythema migrans-like rashes following Lone Star tick bites. Archives of Dermatology 1998;134:955-960.

Melski JW. Language, logic, and Lyme disease. Archives of Dermatology 1999;135:1398-1400.
Moody EK, Barker RW, White JL, Crutcher JM. Ticks and tick-borne diseases in Oklahoma. Journal of the Oklahoma State Medical Association 1998;91:438-445.

Oliver JH Jr, Kollars TM Jr, Chandler FW Jr, James AM, Masters EJ, Lane RS, Huey LO. First isolation and cultivation of Borrelia burgdorferi sensu lato from Missouri. Journal of Clinical Microbiology 1998;36:1-5.

Piesman J, Happ CM. Ability of the Lyme disease spirochete Borrelia burgdorferi to infect rodents and three species of human-biting ticks (blacklegged tick, American dog tick, lone star tick) Acari:Ixodidae). Journal of Medical Entomology 1997;34:451-456.

Piesman J, Sinsky RJ. Ability of Ixodes scapularis, Dermacentor variabilis, and Amblyomma americanum (Acari: Ixodidae) to acquire, maintain, and transmit Lyme disease spirochetes (Borrelia burgdorferi). Journal of Medical Entomology 1988;25:336-339.

Ras NM, Lascola B, Postic D, Cutler SJ, Rodhain F, Baranton G, Raoult D. Phylogenesis of relapsing fever Borrelia spp. International Journal of Systematic Bacteriology 1996;46:859-865.

Rich SM, Armstrong PM, Smith RD, Telford SR 3rd. Lone star tick-infecting borreliae are most closely related to the agent of bovine borreliosis. Journal of Clinical Microbiology 2001;39:494-497.

Ryder JW, Pinger RR, Glancy T. Inability of Ixodes cookei and Amblyomma americanum nymphs (Acari: Ixodidae) to transmit Borrelia burgdorferi. Journal of Medical Entomology 1992;29:525-530.

Stromdahl EY, Evans SR, O'Brien JJ, Gutierrez AG. Prevalence of infection in ticks submitted to the human tick test kit program of the U.S. Army Center for Health Promotion and Preventive Medicine. Journal of Medical Entomology 2001;38:67-74.

Wormser GP, Masters E, Liveris D, Nowakowski J, Nadelman RB, Holgren D, Bittker A, Cooper D, Wang G, Schwartz I. Microbiologic evaluation of patients from Missouri with erythema migrans. Clinical Infectious Diseases 2005;40:423-8.

Wormser GP, Masters E, Nowakowski J, McKenna D, Holgren D, Ma K, Ihde L, Cavaliere LF, Nadelman RB. Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions. Clinical Infectious Diseases 2005;41:958-65.

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