March 2012 JMSMA

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• scienTific arTicle • sippi (Figure 4). Given the lack of confirmed Lyme disease in the southern states, including Mississippi, it is possible that these cases may have been misdiagnosed STARI cases. Researchers originally implicated a spirochete, Borrelia lonestari (Figure 5), occurring in A. americanum as the cause of STARI, and the agent has been linked to at least one case of Lyme-like illness.8,9 However, in a study by Wormser and colleagues,10 B. lonestari was not detected by PCR or culture from skin biopsies of patients in Missouri with EM. Patients also were seronegative to B. burgdorferi suggesting another cause of the lesions. Lastly, Philipp and colleagues found that STARI patients from Missouri were negative on the C6 Lyme enzyme-linked immunosorbent assay to detect antibodies to B. burgdorferi.11 Thus, evidence of a borreliosis in STARI patients is lacking based on typical assays for B. burgdorferi.

Figure 3. This rash, which resembles erythema migrans, developed following a tick bite in a person in the southern United States. (Photo courtesy Worth Williams, used with permission.)

Figure 1. The adult female Ixodes scapularis is the primary vector of Lyme disease. (Photo courtesy of Dr Blake Layton, Mississippi State University. Used with permission.) Figure 4. The adult female lone star tick, Amblyomma americanum, may be the primary cause of southern tickassociated rash illness. (Photo courtesy of Dr. Blake Layton, Mississippi State University. Used with permission.)

Figure 2. Distribution of Lyme disease cases, by county – United States, 2005 (CDC).

Figure 5. This fluorescent antibody stain demonstrates Borrelia lonestari using a monoclonal antibody to the flagellin antigen. (Photo courtesy of Dr Andrea VarelaStokes, Mississippi State University.)

March 2012 JOURNAL MSMA 69

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