Practical Pearls for Tick-Borne Illness: Diagnosis, Treatment, Prophylaxis, and What's on the Horizon for Lyme Disease and its Co-Infections

 

NP CHRONICLES Practical Pearls for Tick-Borne Illness Diagnosis, treatment, prophylaxis, and what's on the horizon for Lyme disease and its co-infections

Clinical education for NP students and new graduates  •  Board-relevant  •  Peak tick season 2026

Summer and fall bring the seasonal wave of tick bites into primary care and urgent care visits — and with it, the perennial questions: does this bite need prophylaxis, does this rash need treatment, and which co-infection am I missing? Tick-borne illness is common (the CDC received reports of over 89,000 Lyme disease cases in 2023, with modeling suggesting the true annual treated burden may be closer to 476,000) and its presentations overlap enough that a systematic approach pays off. This post walks through the current 2020 IDSA/AAN/ACR guideline recommendations, four representative cases, and the diagnostics and treatment tables you'll want at hand.

CLINICAL BOTTOM LINE

●        Not every tick bite needs antibiotics — post-exposure prophylaxis is reserved for high-risk bites meeting all three criteria below. ●        A classic erythema migrans (EM) rash in an endemic area is a clinical diagnosis. Don't wait on serology to treat — and don't send serology at all for a textbook EM. ●        Persistent post-treatment symptoms without objective signs of relapse do not warrant additional antibiotics; guidelines recommend against it. ●        Think outside Lyme: babesiosis, anaplasmosis, ehrlichiosis, and alpha-gal syndrome share the same vector and season, but not the same treatment.

Know Your Vectors

Four tick species drive the bulk of U.S. tick-borne disease, and their geographic ranges — and the pathogens they carry — differ enough to shape your differential before the labs come back.

●        Blacklegged tick (Ixodes scapularis) — Northeast, upper Midwest, and expanding into the Southeast: Lyme disease, Borrelia miyamotoi, anaplasmosis, babesiosis, Powassan virus.

●        Lone Star tick (Amblyomma americanum) — South and lower Midwest, expanding northeast: ehrlichiosis, tularemia, STARI, and alpha-gal syndrome.

●        American dog tick (Dermacentor variabilis) — widespread east of the Rockies and on the West Coast: Rocky Mountain spotted fever, tularemia.

●        Rocky Mountain wood tick (Dermacentor andersoni) — Rocky Mountain states: Rocky Mountain spotted fever, tularemia.

Doxycycline-responsive vs. non-responsive pathogens

This distinction matters because doxycycline is the default empiric choice for a summer fever-plus-tick-exposure presentation — but it won't touch everything on the list.

Doxycycline-responsive		Not doxycycline-responsive
Lyme disease		Babesiosis
Borrelia miyamotoi		Powassan encephalitis
Anaplasmosis		Heartland virus
Ehrlichiosis		Bourbon virus
Tularemia		STARI
Rocky Mountain spotted fever (and other rickettsia)
	CASE FROM PRACTICE — Case 1
	A healthy 52-year-old woman presents to urgent care in July after her husband noticed a rash on her arm. She lives on a farm in Massachusetts — no fever, no other symptoms. The rash: an expanding, blanching, non-painful erythematous patch, roughly 5–6 cm, without a classic bullseye pattern (remember — only 60–80% of EM lesions show central clearing). Management: this is a classic presentation for early localized Lyme disease in a high-incidence state during peak season. The correct move is to treat empirically with a full course of doxycycline 100 mg BID for 10–14 days — do not wait on serology. Early Lyme serology has poor sensitivity (roughly 14–17%) in the first weeks of infection, so a negative test at this stage would be falsely reassuring, not diagnostic.

Staging Lyme Disease

Lyme disease unfolds in three overlapping clinical stages. Not every patient passes through all three in order — some present at a later stage with no recollection of an earlier rash or bite (only about a quarter of patients with EM recall the tick bite itself).

Stage	Time from bite	Cardinal features	Treatment (adult), duration
Early localized	7–28 days	Erythema migrans; fatigue, headache, neck stiffness, myalgias, arthralgias, fever	Doxycycline 100 mg BID, 10–14 d Amoxicillin 500 mg TID, 14 d Cefuroxime 500 mg BID
Early disseminated	Weeks to months	Neuro: meningitis, cranial nerve palsy, radiculopathy, peripheral neuropathy CV: Lyme carditis, AV block	Doxycycline 100 mg BID, 14–21 d Ceftriaxone 2 g IV daily, 14–28 d Cefotaxime 2 g IV q8h
Late disease	Months to years	MSK: arthritis (classically the knee), acrodermatitis chronica atrophicans Neuro: encephalopathy	Doxycycline 100 mg BID, 28 d Ceftriaxone 2 g IV daily, 28 d

 

In most adults with EM, oral therapy for 7–14 days is preferred over IV in every scenario except hospitalized or severely ill patients — efficacy is equivalent, tolerability is better, and access is easier. Azithromycin is a second-line alternative reserved for patients with contraindications to first-line agents, given its comparatively lower efficacy.

Testing: Two-Tier Serology

Serology is stage-dependent and should never be used to confirm a classic EM rash — treat that clinically. Where testing is appropriate (disseminated or late disease, or an atypical presentation), two-tier testing is standard:

●        Standard Two-Tier Test (STTT): ELISA, reflexing to Western blot if positive/equivocal (Western blot positive at ≥5 IgG bands or ≥2 IgM bands).

●        Modified Two-Tier Test (MTTT): ELISA followed by a second ELISA (C6 peptide) instead of Western blot — faster, cheaper, more objective, and now a 2020 guideline-endorsed alternative.

Stage of Lyme disease	Sensitivity	Specificity
Early localized	14–17%	>99%
Early disseminated	89.7%	>99%
Late disseminated	99.4%	>99%

 

NUANCE TO REMEMBER

Don't use serology as a test of cure. A meaningful share of successfully treated patients remain seropositive afterward — roughly 50% when treated at stage 1, and up to 80% when treated at stage 2/3. A positive antibody test after treatment reflects immune memory, not active infection, and re-infection can be genuinely difficult to distinguish serologically from a lingering antibody response.

CASE FROM PRACTICE — Case 2

A 42-year-old man with a history of splenectomy presents with fever, shaking chills, and confusion for 24 hours. Labs show pancytopenia (WBC 4.3, platelets 135) with hemolysis markers: elevated total bilirubin (3.2), elevated LDH, and low haptoglobin. A splenectomized patient with hemolytic anemia and thrombocytopenia in tick season should raise babesiosis, not Lyme disease — asplenia is a specific risk factor for severe, high-parasitemia disease. A peripheral blood smear confirmed Babesia microti at 7.2% parasitemia. Treatment for babesiosis is atovaquone plus azithromycin for 7–10 days (longer in immunocompromised patients to prevent relapse) — doxycycline has no activity against Babesia, which is why a patient who isn't improving on empiric doxycycline for a tick-borne illness deserves a second look at the diagnosis.

Co-Infections: Babesia, Anaplasma, and Ehrlichia

Babesia microti

●        Incubation: 1–4 weeks after tick bite.

●        Presentation: chills, sweats, fevers, headache, myalgias.

●        Notable labs: hemolytic anemia, thrombocytopenia.

●        More severe in immunocompromised or asplenic patients; complications include ARDS, splenic infarct, warm autoimmune hemolytic anemia, and relapse.

●        Preferred test: blood parasite smear or Babesia PCR.

●        Treatment: atovaquone + azithromycin, 7–10 days (longer if immunocompromised).

Anaplasma phagocytophilum and Ehrlichia

●        Incubation: under 1 week.

●        Presentation: fever plus non-specific symptoms; clinically indistinguishable from each other.

●        Notable labs: leukopenia, thrombocytopenia, elevated transaminases.

●        Preferred test: PCR.

●        Both respond rapidly to doxycycline.

CASE FROM PRACTICE — Case 3

A 31-year-old woman found a tick in her popliteal fossa this morning. She had been hiking two days prior and is asymptomatic, with no rash or fever. She does not meet criteria for prophylaxis, because attachment time cannot be reliably estimated as ≥36 hours and engorgement should be assessed. The correct next step is no intervention — educate her on the signs and symptoms of Lyme disease and other tick-borne illness, and have her return promptly if a rash or fever develops.

Post-Exposure Prophylaxis: The Three-Part Test

A single dose of doxycycline reduces the risk of Lyme disease after a high-risk bite — the landmark Nadelman trial found transmission in 0.4% of prophylaxed patients versus 3.2% of placebo, an 87% relative efficacy, with a number needed to treat of roughly 36. But prophylaxis is not for every bite. IDSA/AAN/ACR strongly recommend it only when all three of the following are true:

●        The bite occurred in a state or area with high Lyme disease incidence (or where >20% of local ticks are infected with B. burgdorferi).

●        The attached tick is identified as an adult or nymphal blacklegged (Ixodes) tick, and estimated attachment time is at least 36 hours, based on degree of engorgement.

●        Prophylaxis can be started within 72 hours of tick removal.

Dosing: adults receive doxycycline 200 mg orally once; children receive 4.4 mg/kg orally (max 200 mg) once, regardless of age — the single-dose regimen's risk profile is favorable even in children under 8, for whom longer courses of doxycycline carry more caution. Amoxicillin and other agents have not been adequately studied for prophylaxis and are not recommended. In pregnancy, a single prophylactic dose of doxycycline can be considered if the tick bite is high-risk and the benefit is judged to outweigh the risk — this is a shared decision with the patient.

NUANCE TO REMEMBER

Prophylaxis only covers Lyme disease. It has not been shown to prevent anaplasmosis, babesiosis, ehrlichiosis, or Rocky Mountain spotted fever — so symptom-watch counseling still applies even after a prophylactic dose is given.

Tick removal and counseling

●        Use fine-tipped tweezers, grasp as close to the skin as possible, and pull upward with steady, even pressure — don't twist or jerk.

●        Clean the bite site and hands with rubbing alcohol or soap and water afterward.

●        Save the tick (alcohol or a sealed container) for species identification and engorgement assessment — this directly informs prophylaxis eligibility.

●        General prevention: shower soon after outdoor exposure, do a tick check (including partner/buddy checks), tumble clothes in a hot dryer, and consider permethrin-treated clothing for high-exposure activities.

Alpha-Gal Syndrome

Alpha-gal is a carbohydrate found in mammalian meat and dairy. In susceptible individuals, repeated tick bites — classically from the Lone Star tick — can sensitize the immune system to this molecule, producing a delayed food allergy that can catch both patients and clinicians off guard.

●        Reactions typically develop 2–6 hours after eating red meat or dairy — the delay is the key differentiator from a typical IgE food allergy, and patients may not react to every exposure.

●        Both IgE-mediated and non-IgE-mediated mechanisms have been described.

●        Consider it in a patient with recurrent, unexplained urticaria, pruritus, or anaphylaxis-like reactions hours after meals, especially with a tick-exposure history.

●        Partner with allergy/immunology for confirmatory testing and long-term management.

CASE FROM PRACTICE — Case 4 (December)

A healthy 62-year-old physician found a tick embedded in his abdomen about 4 weeks earlier and received doxycycline 200 mg x1 for post-exposure prophylaxis. Several hours after eating a bison steak dinner, he woke from sleep with diffuse pruritus and a rash across his torso and upper extremities — sparing the palms, soles, and face. The timing (hours after eating red meat, sparing palms/soles/face, in a patient with a recent tick bite) points toward alpha-gal syndrome rather than a drug eruption from a single prophylactic dose taken weeks earlier. It's a useful reminder to ask about diet, not just medications, when a delayed rash follows a tick exposure — and that alpha-gal reactions can surface well outside the classic summer tick season, since red meat and dairy exposure happens year-round.

On the Horizon: Lyme Vaccination

The VALOR trial (Vaccine Against Lyme disease for Outdoor Recreationists) is a phase 3 study of a 6-valent OspA-targeted vaccine (LBV6), dosed at 0, 2, and 6 months, studied in Lyme-endemic areas of the U.S. and Europe. Pfizer and Valneva announced in March 2026 that the vaccine demonstrated 73.2% efficacy from 28 days post-dose 4 (season 2), with a 95% CI of 15.8–93.5. A licensed Lyme vaccine has been absent from the U.S. market for two decades — this is one to watch for patient counseling in coming seasons.

BOARD PREP

A patient in a high-incidence state finds an engorged Ixodes tick that has clearly been attached over 36 hours, and presents within 72 hours of removal. What's the appropriate management? → Single-dose doxycycline prophylaxis (200 mg adult / 4.4 mg/kg pediatric, max 200 mg) — all three high-risk criteria are met. An asplenic patient has fever, hemolytic anemia, and thrombocytopenia after a tick bite and isn't improving on doxycycline. What test and treatment should you pursue? → Peripheral blood smear or PCR for Babesia; treat with atovaquone + azithromycin, since doxycycline has no activity against Babesia. A patient successfully treated for early Lyme disease six months ago still has a positive Lyme antibody test. Does this indicate treatment failure? → No — serology is not a test of cure. Persistent seropositivity is expected in a substantial proportion of successfully treated patients.

Clinical Bottom Line, Revisited

●        Classic EM rash in an endemic area during tick season = treat empirically. Don't wait on serology.

●        Prophylaxis requires all three: high-incidence area, identified Ixodes tick attached ≥36 hours, and dosing within 72 hours of removal.

●        Not improving on doxycycline for a presumed tick-borne illness? Think Babesia — and check a smear.

●        Persistent symptoms after guideline-directed treatment, without objective signs of relapse, don't warrant more antibiotics.

●        Ask about diet as well as bites when a delayed rash follows tick season — alpha-gal syndrome is on the rise.

References

Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis and treatment of Lyme disease. Clin Infect Dis. 2021;72(1):e1-e48.

Committee on Infectious Diseases, American Academy of Pediatrics. Lyme disease. Red Book: 2024-2027 Report of the Committee on Infectious Diseases, 33rd ed. American Academy of Pediatrics; 2024.

Nadelman RB, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med. 2001;345(2):79-84.

Centers for Disease Control and Prevention. Guidance for Clinicians: Caring for Patients after a Tick Bite. CS# 304282-B, December 14, 2021. cdc.gov/ticks/tickbornediseases/

Centers for Disease Control and Prevention. Lyme disease surveillance and data. March 13, 2025. cdc.gov/lyme/data-research/facts-stats/index.html

Branda JA, Steere AC. Laboratory diagnosis of Lyme borreliosis. Clin Microbiol Rev. 2021.

Marques AR. Laboratory diagnosis of Lyme disease. J Clin Microbiol. 2018.

Wagner L, et al. Efficacy of a six-valent OspA Lyme disease vaccine (VALOR trial). Lancet Infect Dis. 2025.

Solomon DA. Practical Pearls for Tickborne Disease. Pri-Med Institute CME, Brigham and Women's Hospital / Harvard Medical School.

Brunner R. What are the most up to date guideline recommendations for the treatment of Lyme disease? University of Illinois Chicago Drug Information Group, Monthly FAQs. July 2025.

NP Chronicles — Clinical education for NP students and new graduates. For educational purposes; always practice within your scope and consult current full-text guidelines for patient-specific decisions.

Tick Season Is Peaking: What NPs Need to Know About Lyme, Alpha-Gal, Babesiosis, and Powassan Virus

 

Tick Season Is Peaking: What NPs Need to Know About Lyme, Alpha-Gal, Babesiosis, and Powassan Virus

ED visits for tick bites are at their highest rate since 2017. Here's how to recognize, diagnose, and counsel patients on the diseases behind them.

Source: Stern O. Summer marks peak season for tick-borne diseases: how to educate patients. Published August 10, 2026, citing CDC data and Rodino KG, Theel ES, Pritt BS, J Clin Microbiol. 2025.

Mosquitoes usually get top billing in summer patient-education conversations, but ticks deserve equal attention this year. Emergency department visits for tick bites are at their highest rate since 2017, and the CDC estimates roughly 31 million tick bites occur annually across the US. Tick-borne disease cases overall have more than doubled since 2004 — and that figure is likely an undercount, since many of these illnesses present with vague, overlapping symptoms and patients often don't recall being bitten.

The black-legged (deer) tick now inhabits roughly 45% of continental US counties, a substantial range expansion since the early 1900s, according to Bobbi S. Pritt, MD, chair of the division of clinical microbiology at Mayo Clinic. Warming climates, expanding deer and rodent populations, and increased land use are all expected to keep pushing tick ranges — and the diseases they carry — into new territory. Peak season runs April through October, which makes now the right time to sharpen recognition of the major tick-borne illnesses.

Disease Overview

Disease	Primary Vector	Region of Concentration	Hallmark Feature
Lyme disease	Ixodes (black-legged/deer tick)	Northeast/Mid-Atlantic, WI, MN, MI (~96% of cases)	Erythema migrans rash in ~70% of cases; 3-stage progression
Alpha-gal syndrome	Lone-star tick	South, East, Central US	Delayed allergic reaction to red meat/mammalian products
Babesiosis	Ixodes (black-legged/deer tick)	Overlaps with Lyme-endemic areas	Can also spread via transfusion, transplant, or perinatally; frequent Lyme co-infection
Powassan virus	Ixodes (black-legged/deer tick)	Northeast, Upper Midwest	Only tick-borne encephalitis in the US; can transmit in as little as 15 minutes

 

Lyme Disease

Lyme remains the most common tick-borne illness in the US. Reported cases (34,945 in 2019) likely understate true incidence by 8- to 12-fold. Disease typically unfolds in three stages: an early localized stage marked by erythema migrans (present in roughly 70% of cases, expanding in about 75% of those, not always in a classic bullseye pattern); early disseminated infection days to weeks later, which can bring secondary rashes, neurologic symptoms (~10%), or Lyme carditis (~4%); and late/persistent infection, averaging 6 months after rash onset, with recurrent arthritis — usually in the knee — in roughly 60% of patients. About 10% of patients go on to develop post-treatment Lyme disease syndrome (fatigue, myalgia, cognitive impairment).

Treatment is a course of doxycycline, amoxicillin, or cefuroxime axetil, ideally started within 72 hours of removing a high-risk tick. “High-risk” means an identified Ixodes species, attachment of more than 36 hours, and a bite in a highly endemic area; bites that don't meet all three criteria warrant watchful waiting rather than empiric treatment.

Alpha-Gal Syndrome

Lone-star tick bites can transmit the alpha-gal molecule into the bloodstream, triggering a potentially life-threatening delayed allergy to red meat and other mammalian products. The CDC estimates nearly 450,000 people may be affected, with more than 110,000 cases identified over the past 25 years; the first reported death linked to alpha-gal syndrome occurred in New Jersey last year. Range expansion is expected to continue northward and westward with ongoing climate change. Adult female lone-star ticks are identifiable by a distinctive white dot on the back; South, East, and Central states currently carry the highest exposure risk.

Babesiosis

Babesiosis is notable for its non-tick transmission routes — blood transfusion, organ transplant, and perinatal transmission are all possible in addition to tick bites. It's the third most common Ixodes-transmitted disease (2,418 cases reported in 2019). Presentation ranges from asymptomatic (about half of children, one-quarter of adults) to severe, with fever, malaise, joint pain, GI symptoms, hemolytic anemia, thrombocytopenia, or organ dysfunction in serious cases. Hospitalized patients face 6–9% fatality, rising to 21% among immunosuppressed patients. Concurrent Lyme disease occurs in an estimated 6–23% of babesiosis cases and increases severity — worth screening for when either diagnosis is suspected. First-line treatment is azithromycin plus atovaquone, with clindamycin plus quinine as an alternative; immunocompromised or asplenic patients may need higher, prolonged dosing.

Powassan Virus

Rarer than the other three, but rising: cases stayed under 20 annually from 2004 to 2015, then climbed to 60 cases (9 deaths) and 76 cases (10 deaths) in the two most recent years reported, with 29 cases already logged across 9 states this year — 27 of them neuroinvasive. Powassan is the only tick-borne encephalitis found in the US, with a fatality rate near 10% and lasting neurologic effects in roughly half of survivors. Transmission can begin in as little as 15 minutes of attachment, with infection onset possible within 6 hours — far faster than the 24–48-hour window typical of most other tick-borne diseases. Diagnosis requires a two-pronged approach: molecular testing 5–7 days after symptom onset, plus serology after the first week.

Diagnostic Considerations

Serology remains the default for most tick-borne diseases, but it has real limitations for anaplasmosis, ehrlichiosis, and babesiosis specifically: seroconversion can take 7–14 days, some patients never mount a detectable IgG response, antibodies can persist for months to years after resolved infection, and specificity issues can produce false positives or negatives. For those three diseases, nucleic acid amplification tests (NAATs) are preferred over serology despite the lack of an FDA-approved NAAT specific to this use — the tests are limited by a short viremic window but still outperform antibody testing in this context. Broader metagenomic testing is also emerging as an option when the clinical picture is nonspecific enough that casting a wide net for any bacterium, virus, or parasite is warranted.

 

■ CLINICAL BOTTOM LINE •     Reserve single-dose/short-course prophylactic doxycycline for confirmed high-risk exposures: Ixodes species, ≥ 36 hours attachment, highly endemic area, treated within 72 hours of removal. •     Don't rule out Lyme disease just because a rash is absent — roughly 30% of patients never develop erythema migrans. •     Ask about new-onset red meat reactions (hours after eating, not immediate) in patients from lone-star tick territory — alpha-gal syndrome is easy to miss without a specific index of suspicion. •     When babesiosis is confirmed, screen for concurrent Lyme disease, and vice versa — co-infection is common and changes the clinical picture. •     For anaplasmosis, ehrlichiosis, and babesiosis, favor NAAT testing over serology when available, given serology's seroconversion lag and specificity limits. •     Counsel on same-day tick checks, prompt mechanical removal with forceps, and EPA-registered repellents (DEET, picaridin, permethrin) as the highest-yield prevention strategies.

 

■ CASE FROM PRACTICE A 42-year-old returns from a camping trip in western Wisconsin 10 days ago with fatigue, joint aches, and a low-grade fever. He doesn't recall a tick bite or rash and initially attributes his symptoms to a summer cold. On exam, there's no visible erythema migrans, but he mentions his knee has felt “achy and swollen” for the past two days. This presentation is a reminder that absence of a rash doesn't rule out Lyme disease, and that joint symptoms can be an early clue even before the classic late-stage arthritis picture develops. Given the endemic location and symptom cluster, this warrants Lyme serology, consideration of co-testing for babesiosis given regional overlap, and a treatment conversation rather than waiting for a more “textbook” presentation to appear.

 

■ A NUANCE WORTH FLAGGING Rising case counts don't always mean rising true incidence. Powassan virus cases are climbing partly because of genuinely expanding tick ranges, but also because of limited diagnostic testing and low clinician awareness historically — better detection can look like an outbreak even when some of the increase reflects better ascertainment. The same caution applies to alpha-gal syndrome: a single reported death establishing causality doesn't quantify overall mortality risk, and the ~450,000-person prevalence estimate is exactly that, an estimate, built from a condition that is likely substantially underdiagnosed given its atypical delayed-allergy presentation. Treat these figures as directionally meaningful rather than precise.

 

📚 Board Prep: What to Know

Tick-borne disease questions often hinge on precise criteria and stage-based presentations. Key points to have cold:

•     Prophylactic doxycycline criteria: Ixodes species tick, ≥ 36 hours attachment, high-endemic area, given within 72 hours of removal — all four must be met.

•     Lyme diseases' three stages: early localized (erythema migrans), early disseminated (secondary rashes, neuro symptoms, carditis), and late/persistent (recurrent arthritis, usually knee).

•     Babesiosis transmission is not limited to tick bites — also via transfusion, transplant, and perinatal routes; know this as a distractor against “tick-only” transmission questions.

•     Powassan virus is the only tick-borne encephalitis native to the US, with transmission possible in as little as 15 minutes of attachment.

•     NAAT over serology for anaplasmosis, ehrlichiosis, and babesiosis, due to seroconversion delay and specificity limitations of antibody testing.

•     Alpha-gal syndrome is a delayed (not immediate) IgE-mediated allergic reaction to mammalian meat, transmitted via lone-star tick saliva — distinct mechanism from the Ixodes-transmitted diseases.

References

Centers for Disease Control and Prevention. CDC data show weekly ER visits for tick bites higher than usual. Published April 23, 2026.

Rodino KG, Theel ES, Pritt BS. Update on North American tick-borne diseases and how to diagnose them. J Clin Microbiol. 2025;63(8):e00807-23.

Eilbert W, Matella A. Tick-borne diseases. Emerg Med Clin N Am. 2024;42(2):287-302.

Centers for Disease Control and Prevention. Data and Maps for Powassan. Updated June 3, 2026.

Ho BM, Davis HE, Forrester JD, et al. Wilderness Medical Society clinical practice guidelines for the prevention and management of tick-borne illness in the United States. Wilderness Environ Med. 2021;32(3):474-494.

Varon AR, Prusinski MA, O'Connor C, et al. Epidemiology and risk analysis of Powassan virus infection, New York state, USA, 2013-2023. Epidemiol Infect. 2026;154:e21.

Centers for Disease Control and Prevention. About alpha-gal syndrome. Published January 5, 2026.

Stern O. Summer marks peak season for tick-borne diseases: how to educate patients. Published August 10, 2026.

This post is intended for clinical education purposes and does not replace individualized clinical judgment or current prescribing guidance.