What You Need to Know About STARI

The Bull's Eye of Lyme Disease can also be seen in STARI

A Bull's Eye Rash on the back of your leg. If you know about ticks, there's one thing that leaps to mind - Lyme Disease. But not all Bull's Eye Rashes are are due to Lyme Disease. Not even all Bull's Eye Rashes associated with ticks are due to Lyme. The rash can also be associated with Southern Tick-Associated Rash Illness (STARI).

Since the 1980's, doctors in the US have been seeing patients with a particular Bull's Eye Rash -erythema migrans (EM) rash - like Lyme Disease - at the site of a bite by a Lone Star tick (Amblyomma americanum).

Their blood tests would not show evidence of Lyme Disease (Borrelia burgdorferi). They would often be in an area where Lyme wasn't usually found as Lyme disease was associated with a different tick (Ixodes scapularis) found frequently in different locales. The patients would do well and normally just have flu-like symptoms.

These patients were usually in Texas, Oklahoma, Missouri, or other parts of the South-Central or Southeastern US. This illness can, however, be found in the same areas as Lyme, including regions particularly known for having Lyme disease, such as in a child from Connecticut who visited Long Island.

The rash itself can be similar to a condition called Erythema Multiforme (EM) which create multiple red ring or "target lesions". This condition can have multiple triggers; Herpes, mycoplasma, and EBV are common. Other EM rashes can be due to a reaction to antibiotic or another drug, a reaction to a fungal infection (like Valley Fever), as well as some bacteria and parasites.

Your healthcare provider should help you know what the cause is, if it can be identified. If the rash is not diffuse, does not spread, and not associated with any worrisome symptoms or a disease, then the rash itself isn't a problem. It can be associated however with diseases that need treatment or can be the beginnings of a more serious rash.

This is something that should be discussed with a healthcare provider. 

What is unusual about STARI and Lyme disease is the presence of a notable, and often single, EM rash associated with a tick bite.

What is associated with STARI?

The rash of STARI is a red, “Bull's-Eye” rash. The illness can involve flu-like symptoms, such as  fatigue, headache, fever, and muscle pains. The lone star tick saliva can be irritating. If the bite is red or uncomfortable, that alone does not indicate infection. Those affected usually do quite well.

What causes STARI?

The cause of the illness is not yet know. What we do know is the illness is associated with the lone star tick bites (Amblyomma americanum). The lone star ticks are mostly in central Texas and Oklahoma as well as in Missouri, and also in southern US states and along the Atlantic coast up to Maine.

It had been thought that the illness was caused by Borrelia lonestari; further research, however, has not supported this. 

What does the lone star tick look like?

The adult female has a white dot (which is the "lone star") on her back.

All 3 life stages of the lone star tick are associated with bites.

Other illnesses associated with lone star ticks are Ehrlichia, Heartland virus, and Tularemia.

Should it be treated with antibiotics?

As the CDC states, "It is not known whether antibiotic treatment is necessary or beneficial for patients with STARI. " However, physicans often prescribe antibiotics.

Are there any lab tests?

There aren't lab tests to identify STARI, but a doctor may wish to rule out other diseases, like Lyme disease - or even Bourbon Virus, Anaplasmosis, Ehrlichia, and others, if symptoms are more severe (and especially if the tick wasn't known).

How is this different from Lyme disease?

Lyme disease is caused by a bacteria Borrelia burgdorferi and is associated with bites from Ixodes scapularis, while STARI is not.

Lyme disease is documented to at times be associated with a number of serious, separate effects - from heart block (serious heart electrical problems), arthritis, meningitis, and facial palsy (face droop).

Also, as the CDC and a past study have pointed out, those with STARI are more likely to recall the tick bite. The time period from tick bite to rash is shorter (6 days) in STARI patients. STARI patients with this rash were less likely to have other symptoms than were Lyme patients. They were less likely to have other skin lesions and rashes that were smaller (6-10 cm for STARI vs. 6-28 cm for Lyme disease). After antibiotics, STARI patients recovered more quickly than Lyme disease patients.

How to avoid ticks:

Avoid areas with high grasses, bushes, and wooded areas

When in these potential tick areas:

  • Use insect repellent with DEET
  • Wear clothing with long sleeves and pants; pull socks over pant legs
  • Use permethrin on clothing

Immediately after visiting tick areas:

  • Do a full-body tick check – especially through bathing/showering
  • Check pets and any gear for ticks

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