key: cord-1028122-b0k91b91 authors: Wormser, Gary P.; Jacobson, Eliana; Shanker, Elayna M. title: Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections date: 2020-09-26 journal: Diagn Microbiol Infect Dis DOI: 10.1016/j.diagmicrobio.2020.115226 sha: f5c244e8900bcd702842f78d05fe31fc423da590 doc_id: 1028122 cord_uid: b0k91b91 We describe 3 adult patients who did not have COVID-19 but instead had a treatable tick-borne infection. In each case, however, the duration of time until diagnosis was delayed due to issues that have arisen because of the COVID-19 pandemic. These issues need to be addressed to preserve patient well-being. We describe 3 adult patients who did not have COVID-19 but instead had a treatable tick-borne infection. In each case, however, the duration of time until diagnosis was delayed due to issues that have arisen because of the COVID-19 pandemic. These issues need to be addressed to preserve patient well-being. The COVID-19 pandemic has led to many cases of this viral infection in the United States, varying in severity from extremely mild to life-threatening [1] . The pandemic has had numerous indirect health effects as well. Concerns about spreading the infection has reduced outpatient visits with health care providers [2] . Even without symptoms, patients are sometimes required to demonstrate negative test results for COVID-19 before they are allowed undergo certain medical/surgical procedures. Symptomatic patients may also be presumed to have COVID-19 until negative test results are obtained, implying that evaluations for other diseases will be delayed, potentially leading to adverse outcomes. We describe three patients who did not have COVID-19 but instead had a treatable tick-borne infection, but in each case the duration of time until diagnosis was delayed due to issues that have arisen because of the COVID-19 pandemic. Three illustrative cases in which the timely diagnosis of a deer tick-transmitted infection in an adult patient was delayed are discussed here ( Table 1) . Two of the three had had a preceding tick bite. One patient had compelling clinical evidence for cardiac Lyme disease with a coinfection due to Babesia microti [3] , one patient had babesiosis, and one patient had human granulocytic anaplasmosis (HGA). Failure to diagnose erythema migrans in a telemedicine J o u r n a l P r e -p r o o f evaluation is believed to have played a significant role in the later development of severe cardiac Lyme disease for Case #1. This patient was hospitalized for six days due to heart block. For the three patients, the mean time from onset of symptoms to testing for COVID-19 was 14.3 days compared with 23.7 days for testing for the relevant tick-borne infection. Case #1. A 36 year old man with no significant past medical history presented with an erythematous skin lesion on the anterior aspect of his right thigh on 6/1/20, which increased in size to ~25 cm in diameter by 6/6/20 (in retrospect, the skin lesion was almost certainly an erythema migrans skin lesion based on review by the author [GPW] of a photograph the patient had taken). The patient had no known tick bite but lived in Westchester County, NY where Lyme disease is endemic. The rash was diagnosed as cellulitis, however, during a telemedicine consult, which was only done because of the COVID-19 pandemic. This was the first telemedicine experience this patient ever had, and it was with a doctor the patient had never met previously. Based on the telemedicine evaluation, the patient was treated for cellulitis with a five day course of cephalexin from 6/6/20 to 6/11/20, an antibiotic known to be ineffective for Lyme disease [4] . Although the skin lesion resolved, he developed multiple symptoms starting on ~6/23/20 that eventually included myalgias, stiff neck, fatigue, low back pain, paresthesias, right knee swelling, inability to concentrate, lightheadedness, palpitations, and dyspnea on exertion. He also had two days of fever to 38.9 0 C on 7/6 and 7/7 for which no evaluation was done, except for COVID-19 RNA testing of a nasal swab specimen on 7/7, which was negative. Nine days prior the LDDC visit he tested negative for COVID-19 RNA by a nasal swab, with repeat negative testing six days prior to the LDDC visit. The patient was found to be infected with A. phagocytophilum based on PCR testing of a blood specimen obtained the day he was seen at the LDDC, in conjunction with positive antibody testing (IgG antibody titer to A. phagocytophilum was 1:320, and the IgM antibody titer was >1:256). The patient's human granulocytic anaplasmosis resolved without antibiotic treatment. Because of concerns about spreading COVID-19, clinical practices are limiting in-person visits, increasing telemedicine visits which preclude performing a complete physical examination, and in some cases are requiring negative laboratory testing for COVID-19. other conditions are potentially either not being diagnosed at all or not being diagnosed in a timely fashion. We illustrate this issue with deer tick-transmitted infections, but the same concerns would apply to virtually any other type of infection, and many other illnesses. Deer tick-transmitted infections can present with fever and specifically Lyme carditis, babesiosis and human granulocytic anaplasmosis are each potentially life-threatening, particularly if there is a delay in diagnosis and in initiating appropriate antimicrobial therapies [5, 6] . The most severely ill patients with babesiosis or with human granulocytic anaplasmosis may also develop acute respiratory distress syndrome similar to COVID-19 [7, 8] . Health care providers and patients need to be aware of the potential undesirable consequences of just performing COVID-19 tests and by so doing, delaying a more comprehensive evaluation of a patient's illness. Arguably, all appropriate testing should be conducted at the same time, not sequentially after COVID-19 is excluded. 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