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Tick Borne Diseases

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Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Monday, January 26, 2026

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CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

CEUFast, Inc. is an AOTA Provider of professional development, Course approval ID#9517. This distant learning-independent format is offered at 0.2 CEUs Intermediate, Categories: OT Foundational Knowledge AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9757.

CEUFast, Inc. (BOC AP#: P10067) is approved by the Board of Certification, Inc. to provide education to Athletic Trainers (ATs).

FPTA Approval:CE24-759620. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

≥92% of participants will know how tick-borne disease is transmitted and understand the treatment of tick-borne diseases.


After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Describe the epidemiology of tick-borne disease.
  2. Describe ways to prevent tick-borne disease.
  3. Identify the symptomatology of a tick-borne disease.
  4. Explain three common lab findings for tick-borne diseases.
  5. Summarize two treatment options for tick-borne disease.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Tick Borne Diseases
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Author:    Heather Rhodes (APRN-BC)


Tickborne diseases are a group of illnesses caused by various pathogens that are transmitted to humans through the bite of infected ticks. Often, people are not aware they have had a tick bite unless they find the tick attached. Ticks are small arachnids that feed on the blood of mammals, birds, and sometimes reptiles. When a tick bites an infected host, it can pick up the pathogen, and when it subsequently feeds on a human or animal, it can transmit the disease-causing agent (CDC, 2023a). These diseases can vary in severity from mild to potentially life-threatening. In the United States, nine common diseases are transmitted by ticks. These include the following:

  • Bacterial diseases:
    • Lyme Disease
    • Rocky Mountain Spotted Fever (RMSF)
    • Anaplasmosis
    • Ehrlichiosis
    • Tularemia
  • Parasitic diseases
    • Babesiosis
  • Viral diseases
    • Powassan Virus Disease
    • Colorado Tick Fever
    • Bourbon Virus Disease (CDC, 2022). 

Recognizing the signs and symptoms of these nine common tickborne diseases found in the United States will help drive evidence-based practice to keep the general public informed and safe.

Introduction Case Study 1

Jerry is a 42-year-old avid hiker who resides in the Hill Country of Texas, where he frequently explores the natural beauty of the state. In late spring, Jerry went on a hiking expedition in the Barton Creek Greenbelt, a renowned nature reserve near Austin, Texas. His journey was marked by lush vegetation, waterfalls, and rocky terrains, which made for an ideal adventure. However, after returning from his trip, Jerry began to experience a range of troubling symptoms: high fever of 102.5 F, muscle aches, fatigue, skin rash, headache, joint pain, dizziness, and nausea, and vomiting.

Concerned about his deteriorating health, Jerry visited a local urgent care clinic where he shared his symptoms and recent hiking trip. The healthcare provider immediately suspected a tickborne disease, considering the rash’s appearance and Jerry’s outdoor activities.

Introduction Case Study 2

Katie is a 35-year-old female who lives near the lush timber in the heart of upstate New York. She is a dedicated gardener and spends much of her free time outside in her garden or meandering the wooded trails near her home. In late June, Katie began spiking a high fever, up to 101.8 degrees Fahrenheit. She experienced profuse diaphoresis, generalized weakness, fatigue, dark urine, no significant cough, shortness of breath, chest pain, or other respiratory symptoms. There were no gastrointestinal symptoms either (e.g., diarrhea, vomiting).

When her symptoms did not improve, Katie went to her primary care provider, who reviewed her chart and found that her hypertension was well controlled with antihypertensive medication. She had no history of immunosuppressive conditions and no recent travel outside of upstate New York. She has no known allergies or prior history of tick-borne illnesses. She presented to her provider as pale and fatigued, with a high fever of 101.2 degrees Fahrenheit, blood pressure of 140/90 mmHg, and oxygen saturation of 98% on room air. She was jaundiced on the sclera and skin. Mild splenomegaly was detected on abdominal palpitation, but there were no other significant findings on cardiovascular, respiratory, or neurological exams. The healthcare provider then ordered labs to be drawn.


Lyme Disease

Lyme Disease is a spirochetal infection caused by the bite of infected ticks of the Ixodes Ricinus complex. In the United States, it is caused primarily by the bacterium Borrelia burgdorferi and, rarely by Borrelia mayonii(CDC, 2023; IDSA, 2020). It is one of the most well-known tickborne illnesses and is transmitted by the infected black-legged tick or deer tick most frequently encountered in backyards and outdoor recreational areas. In the northeastern United States, rodents such as the white-footed mouse are the primary reservoir of Borrelia species.

photo of blacklegged tick in hand

Figure 1: Blacklegged Ticks

photo of blacklegged tick in hand close up

Figure 2 Close-up of blacklegged Tick

There are approximately 476,000 cases of Lyme disease reported to the Centers for Disease Control (CDC) each year (CDC, 2023).It was first recognized clinically in 1977 as “Lyme arthritis” during studies of a cluster of children in Connecticut who were thought to have juvenile rheumatoid arthritis (Steere et al., 1977). It is currently the most reported tickborne disease in the United States and Europe. The peak incidence for the onset of early Lyme disease occurs during the summer months of June, July, and August. Arthritis, a late disease manifestation, may present at any time of the year (CDC, 2023; IDSA, 2020).

Rocky Mountain Spotted Fever

RMSF is caused by the intracellular bacterium Rickettsia rickettsii and is one of several diseases categorized as “Spotted fever rickettsiosis” (SFR)(CDC, 2022). SFR is found in all 48 lower states but has a higher incidence in North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri. It is transmitted primarily through American dog ticks (Dermacentor variabilis), Rocky Mountain wood ticks (Dermacentor andersoni), and Brown dog ticks (Rhipicephalus sanguineus). (CDC, 2023). Infection of R. rickettsia is extremely rare via blood transfusion and, although physiologically possible, has never been documented via organ transplant (CDC, 2022).

Anaplasmosis and Ehrlichiosis

Anaplasmosis is a bacterium disease that is transmitted to humans by tick bites, primarily from the black-legged tick (Ixodes scapularis) and the western black-legged tick (Ixodes pacificus) (CDC, 2023, p. 2). “Ehrlichiosis is the general name used to describe diseases caused by the bacteria Ehrlichia chaffeensisE. ewingii, or E. muris eauclairensis in the United States. These bacteria are spread to people primarily through the bite of infected ticks, including the lone star tick (Amblyomma americanum) and the black-legged tick (Ixodes scapularis)” (CDC, 2023, p. 1).


This bacterial disease is transmitted by the dog tick (Dermacentor variabilis), the wood tick (Dermacentor andersoni) and the lone star tick (Amblyomma Americanum). Tularemia is found throughout the continental United States” (CDC, 2023, pp 17).

Babesiosis Parasitic Disease

Babesia microti are microscopic parasites transmitted to humans by the black-legged tick (Ixodes scapularis).These parasites attack and infect red blood cells (CDC, 2023).

Powassan Virus Disease

The blacklegged tick (Ixodes scapularis) is the culprit again, although the groundhog tick (Ixodes cookei) should also be a suspected cause of this viral infection (CDC, 2023). The bite of an infected tick can transmit this virus very quickly.

Colorado Tick Fever

This virus is transmitted by the Rocky Mountain wood tick (Dermacentor andersoni). It occurs in the Rocky Mountain states at elevations of 4,000 to 10,500 feet (CDC, 2023, p. 6).

Bourbon Virus Disease

This infection has been “identified in a limited number of patients in the Midwest and southern United States. At this time, we do not know if the virus might be found in other areas of the United States” (CDC, 2023, p. 5).


When outside, it is strongly recommended to use Environmental Protection Agency (EPA) registered insect repellent containing one of the following active ingredients: DEET (N.N-diethyl-meta-toluamide) (e.g., Off! Cutter, Sawyer, Ultrathon), Picaridin (KBR 3023), and permethrin (Benjamin et al., 2021; IDSA, 2020).Tick checks, washing and drying clothing at high temperatures, and mechanical tick removal within 36 hours of attachment are all highly recommended by the Wilderness Medical Society (2021) to prevent tickborne disease.


The incubation period for Lyme disease is 3-30 days. Early signs include Erythema migrans (EM), a red ring or homogeneous rash at the site of the tick bite that expands gradually over several days to more than five centimeters in diameter. “There is a central clearing that may develop as the rash expands, resulting in a “target” or “bull’s eye” appearance. The rash may be warm to the touch but is rarely itchy or painful (CDC, 2022; IDSA, 2020). In the early stages, a client may experience a high fever, chills, fatigue, headache, malaise, myalgia, and arthralgia. Lymphedema is common. Untreated Lyme disease will progress to disseminated disease in about 60% of clients. Most manifestations will appear in the first few weeks to months of infection but may be delayed (CDC, 2022; IDSA, 2020).

Neurological manifestations are also found, including cranial neuritis, most commonly Bell’s palsy (facial paralysis that can be bilateral), lymphocytic meningitis, painful radiculoneuritis involving one or more dermatomes, painful peripheral motor and sensory neuropathy (mononeuritis multiplex) and in rare instances, intracranial hypertension (CDC, 2022; IDSA, 2020).

Cardia manifestations commonly found include Lyme carditis resulting in conduction abnormalities (e.g., atrioventricular node block; myopericarditis) that are rarely fatal. Rheumatological manifestations include oligoarticular arthritis (transient, migratory arthritis and effusion in one or multiple joints) and Baker’s cyst. Migratory pain in tendons, bursae, muscles, and bones is common as well (CDC, 2022; IDSA, 2020; Steere et al, 1977).

RMSF is one of the deadliest of all tickborne illness in the United States. It is a bacterial infection that presents with the common flu-like symptoms of fever, headache, nausea, vomiting, stomach pain, muscle pain, and rash. The rash usually occurs within 48-72 hours after infection. The rash is non-descript but, in some cases, will appear as red splotches or pinpoint dots all over the body. Severe forms of RMSF can result in amputation of limbs, hearing loss, paralysis, mental disability, and or death (Benjamin et al., 2021; CDC, 2023; CDC, 2019; ISDA, 2022).

The incubation period for both Anaplasmosis and Ehrlichiosis is between 5 and 14 days. Signs and symptoms include fever, chills, rigors, severe headache, malaise, myalgia, and gastrointestinal symptoms (nausea, vomiting, diarrhea, anorexia). A rash is uncommon in Anaplasmosis infection and occurs in less than ten percent of those infected (CDC, 2022). It is more common in people with the E. chaffeensis ehrlichiosis (CDC, 2023). If a rash develops, it often appears as red splotches or pinpoint dots all over the body.

All forms of Tularemia present with a fever that can go as high as 104 degrees Fahrenheit. In ulceroglandular tularemia, swelling of lymph glands in the armpit or groin area is common, and a skin ulcer will develop where the tick bite occurred. This is the most common form of tularemia. Typhoidal and pneumonic are more serious forms of tularemia and usually develop when other forms of tularemia (e.g., ulceroglandular or glandular) are unrecognized or untreated. The incubation period typically ranges from one to 14 days (CDC, 2023).

Babesiosis is a Parasitic disease. This malaria-like parasite infects red blood cells and causes flu-like symptoms. Older populations and those who are immunocompromised can have more severe symptoms that can be fatal (Krause et al., 2020; ISDA, 2022).

Powassan Virus Disease, like all other tickborne diseases, initial symptoms mimic the flu and are initially present at the onset of illness. Powassan virus can progress to more severe illness such as encephalitis, seizures, and death. Half of all people who experience severe illness have long-term complications, including reoccurring headaches, loss of muscle mass, and memory issues. One in ten people with severe disease die (CDC, 2023).

The defining symptom of Colorado Tick Fever is a biphasic fever, meaning that the infected client will have several days of high fever, a respite for a few days, and then a reoccurring fever. A life-threatening illness is rare for Colorado Tick Fever, and the illness usually resolves without complication (Benjamin et al., 2021).

Bourbon Virus Disease is named after Bourbon County, Kansas, where the first man who carried this disease resided and was first diagnosed in 2014. Previously, the virus was only found in Africa, southern Europe, and Central Asia. Tick bites occur approximately two weeks before the onset of symptoms, and like other viruses, signs and symptoms mimic the flu (e.g., fever, fatigue, arthralgia, myalgia, nausea, diarrhea, etc.) (Benjamin et al., 2021; CDC, 2022; CDC, 2023).

Laboratory Findings

Laboratory Findings
DiseaseLaboratory FindingsReference
Lyme DiseaseSubmit the removed tick for species identification if possible. Diagnosis is based on clinical findings rather than laboratory testing if one or more skin lesions are present, suggestive of erythema migrans. If no lesion is present, antibody testing should be completed, followed by a convalescent-phase serum sample if the initial result is negative.Benjamin et al, 2021; IDSA, 2022
RMSFThrombocytopenia; elevated hepatic transaminases and hyponatremia. A four-fold rise in IgG-specific antibody titer by indirect immunofluorescence antibody (IFA) assay is often seen. Immunohistochemical (IHC) staining of organisms from the skin or a tissue biopsy can also be completed. IgG antibody testing is likely to generate a false positive.Benjamin et al, 2021; CDC, n.d.; CDC, 2019
AnaplasmosisMild anemia, Thrombocytopenia, Leukopenia, mild to moderate elevations in hepatic transaminases. Detection of DNA by PCR of whole blood is more sensitive during the first week of illness.Benjamin et al., 2021 CDC, n.d.
EhrlichiosisThrombocytopenia, Leukopenia (absolute), Anemia, and mild to moderate elevations in hepatic transaminases.Benjamin et al., 2021; CDC, n.d.
TularemiaIsolation of F. tularensis in culture is preferred. This organism is a highly infectious, slow-growing bacteria. Blood cultures are often negative. Cultures of scrapings or swabs of ulcers, lymph node fluid, or respiratory specimens are recommended if Tularemia is suspected.Benjamin et al., 2021; CDC, n.d.
BabesiosisIdentification of Babesia parasites is made by light microscopic examination of a peripheral blood smear or positive Babesia (or B. microti) polymerase chain reaction (PCR) analysis or demonstration of a Babesia-specific antibody titer by indirect fluorescent antibody (IFA) testing for total immunoglobulin (Ig) or IgG. Antibody detection by serologic testing cannot distinguish from active or prior infection.Benjamin et al, 2021; CDC, n.d.; Kowalski, et al., 2010.
Powassan Viral DiseaseLaboratory testing of blood or spinal fluid. CSF findings include lymphocytic pleocytosis (neutrophils can predominate early), normal or mildly elevated protein, and normal glucose.Benjamin et al., 2021; CDC, n.d.
Colorado Tick Fever (CTF)Preliminary diagnosis is based on clinical findings. RNA or virus-specific immunoglobulin (Ig)M and neutralizing antibodies can be found by RT-PCR (reverse transcriptase polymerase chain reaction). However, it may not be detectable until 2 to 3 weeks post-infection. General laboratory findings include Leukopenia and moderate thrombocytopenia.Benjamin et al., 2021; CDC, 2023; CDC, n.d.
Bourbon Virus DiseaseLeukopenia, Thrombocytopenia, and mild to moderate elevation of hepatic transaminases.Benjamin et al., 2021; CDC, n.d.


The Infectious Disease Society of America, the American Academy of Neurology, and the American College of Rheumatology all guide treatment regimens for Lyme disease. Even with early and aggressive treatment, clients may continue to have persistent post-infection symptoms of pain, fatigue, and impaired cognition. The recommended initial treatment is Doxycycline, Amoxicillin, or Cefuroxime, depending on the health status of the client (Kowalski et al., 2010).

Anaplasmosis, ehrlichiosis, and spotted fever group rickettsioses are all treated with doxycycline. It should be noted that any clinical suspicion of these diseases is grounds for beginning treatment, as delay in treatment may result in severe illness or death. If an adult client is suspected of having anaplasmosis infection, he or she should be treated with doxycycline for a full 10-14 days to provide appropriate length of therapy for possible co-infection with Lyme disease (CDC, 2022; CDC, 2023).

For Tularemia, Doxycycline (100 mg orally BID X 14 days) is generally recommended for prophylaxis in adults. Ciprofloxacin (500 mg orally BID) is not FDA-approved for prophylaxis of tularemia but has demonstrated efficacy in various studies and may be an alternative for patients unable to take doxycycline (CDC, 2023, p 6).

According to Krause et al. (2020), treatment for Babesiosis should include a combination approach of atovaquone plus azithromycin. An alternative recommended treatment would be clindamycin plus quinine. The clindamycin and quinine approach is recommended more for patients who are immunocompromised or have relapsed while on the initial treatment. In severe cases, Krause et al. (2020) recommend transfusion of red blood cells to reduce parasitemia quickly.

There are no medications to treat Powassan, Colorado Tick Fever, and Bourbon Viral Disease. Medications to relieve symptoms include fever-reducing drugs, breathing support, and other therapies as required.

Conclusion Case Study 1

The healthcare provider seeing Jerry ordered blood tests to confirm the presence of tick-borne pathogens. The results came back positive for Borrelia burgdorferi, the bacterium responsible for Lyme disease. This diagnosis explained his flu-like symptoms, the characteristic erythema migrans (bull’s eye) rash, and joint pain. Jerry was prescribed a course of antibiotics, specifically doxycycline, to combat the Lyme disease infection. Over-the-counter pain relievers and anti-nausea medications were recommended to alleviate his symptoms. Jerry was advised to rest stay well hydrated to help his body fight the infection, and a follow-up appointment was scheduled to monitor his progress.

Jerry responded well to the treatment, and within a few weeks, his symptoms gradually improved. The bull’s eye rash faded, and his fever subsided. His joint pain and fatigue diminished as well. As he regained his health, Jerry was cautioned to remain vigilant for any lingering symptoms or potential complications, such as Lyme arthritis, which can occur in some cases.

Conclusion Case Study 2

Katie’s lab work came back with a Hemoglobin of 9.5 g/dL (normal range: 13.5-17.5 g/dL), Hematocrit 29% (normal range 38-50%), Platelet count: 95,000/mm³ (normal range: 150,000-450,000/mm³), Total bilirubin: 2.5 mg/dL (normal range: 0.2-1.2 mg/dL), Elevated levels of indirect bilirubin (consistent with hemolysis), Peripheral blood smear revealed intraerythrocytic parasites resembling Babesia, Polymerase chain reaction (PCR) confirmed the presence of Babesia DNA in the blood.

Based on the clinical presentation, laboratory findings, and PCR confirmation, Katie was diagnosed with Babesiosis, a tick-borne parasitic disease caused by protozoan parasites of the genus Babesia. She was started on a treatment regimen that included:

  1. Atovaquone (750 mg twice daily).
  2. Azithromycin (500 mg on day 1, followed by 250 mg daily).
  3. Supportive measures, including blood transfusion and hydration for anemia and hemolysis.

Katie was advised to monitor her temperature and symptoms regularly and return for follow-up appointments. She responded well to treatment, with the resolution of fever and improvement in hemoglobin levels. A repeat blood smear after two weeks of treatment demonstrated the absence of intraerythrocytic parasites.


Both Jerry and Katie experienced tick-borne diseases after exposure in areas highly endemic with infected vectors. Neither client was aware of being bitten, which is common with this disease. In both cases, the clients were able to seek care fairly soon after their symptoms began, but that is not always possible due to rising healthcare costs and dwindling access to care in some areas of the country. Public health education is imperative to reaching clients who fall into these latter categories.

Timely diagnosis and appropriate treatment play a critical role in the recovery of tickborne diseases. Understanding that there are bacterial, parasitic, and viral tickborne infectious diseases will help the healthcare provider recognize the signs and symptoms of these nine common tickborne diseases found in the United States. It will help drive evidence-based practice to keep the general public informed and safe while they enjoy the outdoors in regions where these cases are endemic.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • Benjamin M. Ho, Hillary E. Davis, Joseph D. Forrester, Johnathan M. Sheele, Taylor Haston, Linda Sanders, Mary Caroll Lee, Stephanie Lareau, Michael Caudell, Christopher B. Davis (2021). Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States, Wilderness & Environmental Medicine, 32 (4), pp 474–494. Visit Source.
  • Centers for Disease Control and Prevention. (2019a). Anaplasmosis. Centers for Disease Control and Prevention. Visit Source.
  • Centers for Disease Control and Prevention. (2023a). Diseases transmitted by ticks. Centers for Disease Control and Prevention. Visit Source.
  • Centers for Disease Control and Prevention. (2023). Ehrlichiosis. Visit Source.
  • Centers for Disease Control and Prevention. (2019b). Ehrlichiosis. Centers for Disease Control and Prevention. Visit Source.
  • Centers for Disease Control and Prevention. (2023b). CDC - Babesiosis - resources for Health Professionals. Centers for Disease Control and Prevention. Visit Source.
  • Centers for Disease Control and Prevention. (2023c). Lyme Disease. Centers for Disease Control and Prevention. Visit Source.
  • Centers for Disease Control and Prevention. (2023). Managing potential laboratory exposures to Francisella tularensis. Visit Source.
  • Centers for Disease Control and Prevention (2023d). Powassan Virus. Visit Source.
  • Centers for Disease Control and Prevention. (2019c). Rocky Mountain Spotted Fever (RMSF). Visit Source.
  • Centers for Disease Control and Prevention. (n.d.) Tickborne Diseases of the United States. Visit Source.
  • The Infectious Disease Society of America (IDSA) (2022). Clinical Practice Guidelines by the Infectious Diseases Society of America (ISDA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis and treatment of Lyme disease. Visit Source.
  • Kowalski, T. J., Tata, S., Berth, W., Mathiason, M. A., & Agger, W. A. (2010). Antibiotic treatment duration and long-term outcomes of patients with early Lyme disease from a Lyme disease-hyperendemic area. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 50(4), 512–520. Visit Source.
  • Krause PJ, Auwaerter PG, Bannuru RR, et al. Clinical practice guidelines by the Infectious Diseases Society of America (IDSA): 2020 guideline on diagnosis and management of babesiosisClin Infect Dis. Published online November 30, 2020. doi:10.1093/cid/ciaa1216.
  • Steere, A.C., Malawista, S.E., Snydman, D.R., Shope, R.E, Andiman, W.A., Ross, M.R., Steele, F.M. (1977). Lyme arthritis: An epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis and Rheumatism, 20(7), 7-17.