Introduction: Tick paralysis is a rare disease characterized by ascending flaccid paralysis thought to be caused by a neurotoxin in tick saliva that typically resolves within 24 hours of tick removal. The American dog tick (Dermacentor variablilis) and Rocky Mountain wood tick (Dermacentor andersoni) are the two most common ticks associated with tick paralysis. The incidence of tick paralysis is difficult to determine as there is no national surveillance system, but a review of the literature suggests incidence is greater in the Western United States where most states still have an incidence of less than 1 case per year. The readily available treatment for this disease and the morbidity/mortality associated with a missed diagnosis make tick paralysis an important differential diagnosis for any child with acute ascending paralysis.

Case Presentation: We report a 2-year-old Caucasian female with no previous medical history who presented with 1-day history of refusal to walk. Patient had no recent respiratory or gastrointestinal illness, sick contacts, or recent travel. Initial physical exam revealed abnormal gait with limp of left lower extremity and pain with movement of left ankle. Our initial differentials included septic joint, toxic synovitis, myositis, meningitis, encephalitis and possible lower extremity fracture. CBC, CMP, Respiratory Viral Panel, CRP, ESR, CPK, U/A, and GI panel were all within normal limits. X-ray bilateral lower extremities was negative.

After initial improvement in activity level following intravenous fluids administration, the patient woke the next morning with increasing fussiness, along with decreased tone and reflexes in both lower extremities. She additionally began having difficulty speaking and swallowing. At this point, we were concerned about Guillain Barre syndrome and acute disseminated encephalomyelitis. MRI brain and cervical, thoracic, and lumbar spine were negative. CSF analysis with 5 WBCs, 0 RBCs, 20 protein, and 59 glucose. Urine culture and CSF culture negative. A thorough post procedure physical exam revealed a tick attached to the left posterior occipital scalp.

Final Diagnosis: Tick borne paralysis

Outcome and Follow-up: The patient steadily improved after removal of the tick. She regained all motor and cognitive function within 24 hours and was back to her neurological baseline. She was discharged home with close follow up with Neurology.