Southern Tick-Associated Rash Illness (STARI) and Lyme disease

Welcome to another Inside Lyme Podcast with your host Dr. Daniel Cameron. In this episode, Dr. Cameron will be discussing the case of a 63-year-old woman who was diagnosed with Southern Tick-Associated Rash Illness (STARI).

In their article “Southern Tick-Associated Rash Illness: Florida’s Lyme Disease” Abdelmaseih and colleagues describe the woman’s case, highlighting the differences between STARI and Lyme disease.¹

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The patient was bitten by a lone-star tick on her right leg while camping in Gainesville, Florida. She noticed a pruritic target erythematous lesion after removing the tick.

Two weeks later she was evaluated and reported having a persistent fever, headache, and diffuse myalgias for 4 days following the tick bite. On presentation, she had a fever of 100.5 F and a tachycardia of 127 BPM, low white count, anemia, low platelet count and elevated liver function tests.

Fortunately, the patient’s symptoms resolved with a 14-day course of doxycycline.

The authors discuss the differences and similarities of STARI and Lyme disease:

• “The associated rash is similar if not indistinguishable from Lyme disease erythema migrans, with lymphocytic dermal infiltrate.”
• Both the diagnosis of STARI and Lyme disease are based on clinical evidence. “At the present time, there is no approved diagnostic modality to identify STARI; thus, the diagnosis must be made on clinical evidence including erythema migrans and tick exposure.”
• The diagnosis of STARI and Lyme disease often rely on geography. “Diagnosis usually relies on geographic association (STARI from central Texas and Oklahoma eastward across the southern states and along the Atlantic coast as far north as Maine, versus Lyme disease in northeast, mid-Atlantic, and upper mid-west).”

However, the authors did not address reports documenting the presence of lone-star ticks in the Northeast, mid-Atlantic, and upper Midwest and of deer ticks in the South.

It has been assumed that STARI does not have any long-term sequelae.

“A recent study has suggested that STARI is transmitted by the lone-star tick Amblyoma americanum; however, it may take some time before all the necessary data can be collected, since much is still unknown about STARI.”

The treatment of STARI is also uncertain. “STARI is often treated as Lyme disease with doxycycline twice daily for 14 days; however, there is no approved treatment yet.”

The authors conclude, “STARI is an emerging Lyme-like illness that causes the characteristic rash, erythema migrans. The current incidence of STARI remains unknown as it is not nationally reportable.”

The following questions are addressed in this Podcast episode:

1. What is STARI?
2. Are there differences between STARI and Lyme disease rashes?
3. Are there differences in the ticks?
4. How is STARI diagnosed, compared to Lyme disease?
5. What clinical evidence does one need to diagnose STARI?
6. What are the consequences if Lyme disease or co-infections is overlooked?
7. What do we know about ticks in the South?

Thanks for listening to another Inside Lyme Podcast. Please remember that the advice given is general and not intended as specific advice to any particular patient. If you require specific advice, please seek that advice from an experienced professional.