Jack saw his GP urgently one morning because he had significant genital swelling which had worsened overnight. The evening before Jack had removed a tick from his groin and, despite the gymnastic challenge of this act, believed the creature had been removed in its entirety. He had not killed the tick first and had taken no antihistamines. He thought the tick had only been in since that afternoon. Jack was particularly disconcerted to find his penis and testicles were enlarged on waking and had continued to swell since.
The doctor was similarly disconcerted when she saw the degree of swelling and immediately asked Jack when he had last passed urine. Apparently this was becoming a problem. The GP examined her patient and noted the site of complete removal from the low left groin of the alleged tick. She also found, with some difficulty, a second (bush) tick in the region that used to correspond to in between the base of the penis and the testicles. The swelling had completely obliterated this area and the tick was deeply buried in the oedematous tissue. The GP removed the second tick with difficulty, after brief cryotherapy, with an assistant pulling the tissue away from the tick first.
Jack was given two 10mg tablets of loratadine and was given a urinal to empty his bladder into. When he came back he had very little urine in the container. His abdominal examination suggested his bladder was palpable just above the pubis. Jack was instructed to go to hospital as he needed assessment for catheterisation.
Several points come from this case history. Firstly, where there is one tick, others should be sought. Secondly, the ideal management of tick removal is to take an antihistamine prior to (or soon after) the attempted removal and to kill the tick as soon as possible. Killing the tick is ideally done through very brief cryotherapy (there are preparations containing dimethyl ether that can be purchased over the counter in pharmacies for removing warts). It is very important that ticks should be removed effectively with minimal crushing or prolonged manipulation, as this may increase the risk of tick allergy (even if the tick is killed first), and especially the risk of toxin release if the tick is alive.1
It is important to note that people who have been diagnosed with anaphylaxis, tick allergy, or who are at increased risk of tick allergy in the future (such as Jack, who has now had a significant local reaction) need to be given an action plan 1,2 for future tick bites. They should seek urgent medical advice if they find a tick on themselves. Individuals who are anaphylactic to ticks should ring 000 for an ambulance, whether or not an adrenaline autoinjector is used, and not disturb the tick. There is currently no good blood or skin prick test for tick allergy and this diagnosis largely clinically based.1
1. Australasian Society of Clinical Immunology Allergy: Tick Allergy