Tick-borne rash at the surgical site prior to lung cancer resection: a diagnostic and surgical dilemma case report

Introduction

Surgical management of infections is a well-documented concern in clinical guidelines. Yet, there is a significant gap in the literature regarding the presence and implications of vector-borne pathogens discovered at or near surgical sites. This gap is particularly relevant for patients undergoing time-sensitive procedures, such as oncologic surgeries. Despite the increasing incidence of vector-borne diseases in endemic areas, few documented cases exist to guide surgical teams when such exposures are discovered preoperatively. This case study explores one such scenario and reviews its implications for surgical planning and preoperative care.

Lyme disease is a spirochetal infection caused by Borrelia burgdorferi and is transmitted by Ixodes ticks. This disease typically presents with nonspecific symptoms, including fever, fatigue, and erythema migrans—a large expanding rash. If untreated, it can progress to serious complications as the infection spreads to the heart, joints, and nervous system (1). This case explores an unusual presentation in which a patient scheduled for lung resection for lung cancer had a large erythematous rash, erythema migrans, accompanied by a live tick embedded directly over the planned surgical site. This unexpected finding represents a rare clinical intersection between vector-borne diseases and thoracic surgical planning—a scenario not previously reported in literature. As a result, the surgical team faced a dilemma on whether to proceed with oncologic resection through a potentially infected and inflamed field. With no precedent or established guidelines to inform decisions, clinical reasoning and multidisciplinary consultation were crucial in justifying the surgical course. Ultimately, this case emphasizes the need to manage unforeseen infectious exposures during preoperative assessment, particularly in endemic regions, and has broader implications for surgical practices when confronted with similar circumstances. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-162/rc).

Case presentation

A 69-year-old female patient with a history of hypertension, chronic pain, multiple sclerosis, and a past smoking history was found to have a right lower lobe (RLL) pulmonary nodule. The nodule was incidentally discovered during a computed tomography (CT) scan performed for transient encephalopathy in August 2024 (Figure 1). Initial imaging revealed a 5 mm spiculated lesion in the right upper lobe (RUL) and an 11 mm spiculated lesion in the RLL (Figure 2A,2B). A second CT in November 2024 showed no change in this nodule. A positron emission tomography (PET)-CT in December 2024 showed elevated uptake in the RLL relative to the surrounding tissue (Figure 2C). Initial navigational bronchoscopy and endobronchial ultrasound (EBUS) of mediastinal lymph nodes in January 2025 yielded inconclusive results for the RLL nodule (benign lung with fibrosis) and were negative for mediastinal staging. Subsequent interventional radiology RLL biopsy confirmed lung adenocarcinoma, mucinous type. Brain magnetic resonance imaging (MRI) was negative. Pulmonary function testing was within normal limits [forced expiratory volume in 1 s (FEV1), 100%; diffusion capacity of the lungs for carbon monoxide (DLCO), 112%].

Figure 1 Timeline of a case of a 69-year-old female undergoing evaluation and treatment for pulmonary adenocarcinoma undergoing VATS surgery. CT, computed tomography; EBUS, endobronchial ultrasound; PET, positron emission tomography; RLL, right lower lobe; VATS, video-assisted thoracic surgery.

Figure 2 Preoperative imaging. (A) CT scan showing an 11 mm spiculated nodule in the patient’s RLL. (B) CT scan showing a 5 mm spiculated lesion in the patient’s RUL. (C) PET/CT scan showing PET avidity in the 11 mm right lower lobe nodule. CT, computed tomography; PET, positron emission tomography; RLL, right lower lobe; RUL, right upper lobe.

The patient was then referred for thoracic surgery for resection and was scheduled for right video-assisted thoracic surgery (VATS) lobectomy, thoracoscopic lung wedge resection, and mediastinal node dissection, all of which would be on the right chest. On the day of the surgery, during standard preoperative skin examination, a live tick was discovered embedded in the patient’s right flank, directly over the planned incision site (Figure 3A,3B). The duration of the bite was unknown. Surrounding the tick was a large, erythematous rash suggestive of erythema migrans. The tick was removed intact and sent for parasitic identification, which later confirmed an Ixodes species. The area over the tick was prepped with standard chlorhexidine. An elliptical incision was made circumferentially around the tick down to the subcutaneous tissue to fully resect the entire head and body of the tick. The incision was closed with interrupted nylon suture. The patient was then re-prepped with Betadine and underwent RUL wedge resection of the 5 mm ground glass opacity, RLL lobectomy of the known central adenocarcinoma, and mediastinal lymph node dissection of stations 4 and 7–12. The wound was classified as class 4 according to the current Centers for Disease Control and Prevention (CDC) surgical wound classification system given the active rash and potential parasitic infection (2). The patient remained asymptomatic for Lyme disease, with no fever, neurologic symptoms, or malaise. CDC guidelines recommend prophylactic antibiotics only in certain high-risk cases, such as when the tick is confirmed to be Ixodes scapularis, the patient is from a Lyme-endemic area, and the tick has been attached for more than 36 hours (3,4). The Infectious Diseases Society of America (IDSA) guidelines are also in line with these recommendations. In patients with potential tick exposure in a Lyme disease-endemic area who have one or more skin lesions compatible with erythema migrans, they recommend clinical diagnosis rather than laboratory testing. They recommend against testing asymptomatic patients for exposure to B. burgdorferi following a tick bite, as serologic testing in such cases does not influence treatment decisions and may lead to unnecessary interventions (3). Based on CDC and IDSA guidelines and following consultation with infectious disease specialists, the surgical team proceeded with surgery.

Figure 3 Embedded tick over surgical site. (A) Preoperative photograph of the patient’s right flank showing an embedded live Ixodes tick surrounded by a large rash suggestive of erythema migrans. (B) Close-up image of the tick with ruler for scale.

The patient underwent successful right VATS lobectomy, thoracoscopic lung wedge resection, and mediastinal node dissection. Her postoperative course was uneventful. She was discharged home on postoperative day one in stable condition with appropriate follow-up instructions. At the time of her discharge, infectious disease specialists continued to recommend that no antibiotics be administered until speciation was available. Speciation later confirmed an Ixodes tick. Although the result was initially concerning, infectious disease specialists continued to recommend no antibiotics based on the patient’s asymptomatic status and the fact that Lyme disease was not highly endemic to the area. No additional analyses were performed on the tick itself.

On pathology, she was found to have synchronous primaries adenocarcinomas (T1aN0, RUL wedge; T1bN0, RLL lobectomy) and the patient was seen in follow-up without any wound complications. The patient is currently on routine surveillance CT scan imaging as indicated by the National Comprehensive Cancer Network (NCCN).

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case presents a rare but significant clinical challenge. The discovery of an Ixodes tick and associated erythema migrans directly over the surgical site suggested early localized Lyme disease, yet the patient was asymptomatic. Erythema migrans is a possible early sign of Lyme disease, usually appearing 3–32 days after a tick bite, and does not always display a classic bull’s-eye appearance (5). While erythema migrans is suggestive of early localized Lyme disease, asymptomatic presentation with no systemic signs or symptoms meant that laboratory testing and treatment were not indicated according to CDC and IDSA guidelines.

These guidelines recommend prophylactic antibiotic treatment only under specific conditions: if the tick is confirmed to be Ixodes scapularis, has been attached for more than 36 hours, and the patient resides or has traveled to a Lyme-endemic region. A single 200 mg dose of doxycycline can reduce the likelihood of contracting Lyme disease after a bite from an Ixodes scapularis tick. However, it is not typically advised for routine use, as the chance of infection from a tick bite remains low even in regions where Lyme disease is prevalent (5). In asymptomatic patients who do not meet this criterion, antibiotics are not recommended, and serologic testing is discouraged. Moreover, the risk of transmission from a recognized tick bite is estimated at just 1–3%, particularly if the tick has been attached for less than 36–48 hours. Ixodes ticks may also carry other pathogens, including Anaplasma and Babesia, which can complicate the clinical picture. Only 25–40% of early Lyme cases test positive serologically, making testing in early localized disease both low-yield and potentially misleading (5-7).

In this case, although the tick species was identified as Ixodes, the patient’s lack of symptoms and the uncertain duration of tick attachment made the decision less clear, especially given the site’s location. Some guidelines suggest tick engorgement as a proxy for duration of attachment (1). Had the patient demonstrated symptoms of more advanced Lyme disease, such as fever, malaise, or neurologic findings, delaying the surgery and antibiotic administration would have been warranted. Had the local prevalence of Lyme disease been higher (i.e., in the Northeast, mid-Atlantic, and upper Midwest regions of the United States), proceeding with prophylaxis regardless of symptoms would have also been prudent (8). Doxycycline, amoxicillin, and cefuroxime axetil are effective first-line treatments, with cure rates near 90% for early localized Lyme disease (9,10), with relatively modest side effects (e.g., gastrointestinal upset) (1).

The urgency of the patient’s lung cancer resection further complicated the matter. Proceeding through a potentially infected field raises concerns about wound healing and surgical site infection. It also raises issues regarding distinguishing between a typical surgical site infection and one from the erythema migrans rash associated with Lyme disease. In contrast, delaying surgery in lung cancer treatment can result in tumor progression, missed treatment windows, and poorer outcomes (11).

Although the cancer in this case was early stage, the decision to proceed with surgery rather than delay was guided by both oncologic urgency and multidisciplinary input. Even in early-stage non-small cell lung cancer, delays in surgical resection have proved to be associated with worsened outcomes, including increased mortality rates. Evidence shows that exceeding an 8-week interval between the initial CT scan and surgery is linked to significantly worse survival. Beyond this point, the 5-year adjusted mortality risk rises with each additional 2-week delay, and the 1-year risk of recurrence also increases (12). In this patient’s case, we were nearing the 8-week mark, and delaying surgery further could have compromised the patient’s outcome.

The patient was asymptomatic, the tick wound was not actively infected, and infectious disease specialists were consulted. Based on CDC and IDSA guidelines, as well as the clinical judgment of the surgical team, it was considered safe to proceed without prophylactic antibiotics (3). The tick was resected in full, and the surgical site was managed with appropriate antiseptic preparation. Postoperatively, the patient had no wound complications and did not require antibiotics, further supporting the safety of our approach.

While surgical site infections are most often caused by Staphylococcus aureus, E. coli, and Pseudomonas, rare pathogens like Borrelia burgdorferi can mimic or exacerbate typical infections (13,14). Notably, surgical site infections often develop within 30 days of surgery—an interval that overlaps with the incubation periods of many tick-borne diseases such as Lyme disease (3–30 days) and anaplasmosis (5–14 days) (15-17). This introduces additional challenges in postoperative surveillance.

While literature exists on tick-borne pathogens causing complications such as prosthetic joint infections, there are no established protocols for managing suspected Lyme disease at active surgical sites (18). Given these considerations, the multidisciplinary team, including infectious disease specialists, opted to proceed with the surgery with standard surgical prophylactic antibiotics (i.e., cefazolin). This decision aligned with existing guidelines but was influenced by clinical judgement, the patient’s optimal functional status, oncologic surgery, and the absence of systemic signs of illness or infection.

Beyond thoracic surgery, vector-borne pathogens have posed diagnostic and management challenges in other surgical specialties. In orthopedic surgery, Borrelia burgdorferi has been implicated in culture-negative periprosthetic joint infections, often mimicking typical bacterial infections and delaying appropriate treatment. A case of Lyme arthritis masquerading as prosthetic joint infection ultimately required revision arthroplasty and targeted antimicrobial therapy (18). Similarly, a fatal case of human granulocytic anaplasmosis following spinal fusion surgery, where the tick-borne illness was only diagnosed postmortem through polymerase chain reaction (PCR) after the patient developed acute respiratory distress syndrome (19). These cases highlight the broader relevance of vector-borne illnesses in surgical care and underscore the importance of maintaining a high index of suspicion, especially in endemic regions. They also reinforce the need for interdisciplinary collaboration and clearer perioperative guidelines when atypical infectious exposures intersect with surgical planning.

However, if this had been an elective procedure—for example, a hernia surgery or plastic surgery—postponing surgery might have been the more appropriate choice, allowing time for pathogen analysis and treatment. While there are inherent limitations with generalizing from a singular case, the positive outcome in this case supports the safety of our approach in similar low-risk, time-sensitive scenarios. This case also underscores the need for more guidelines in similar situations.

To our knowledge, this is the first reported case of a live tick and suspected erythema migrans discovered at a planned thoracic surgical site. This case highlights the importance of integrating infectious disease awareness into preoperative assessment, particularly in endemic areas. It also demonstrates the value of collaboration when clinical decisions fall into zones outside the scope of standardized protocols.

Conclusions

This rare case presents an important clinical scenario at the intersection of infectious disease and cancer surgery. It highlights the challenge of managing emerging infectious exposures in the context of urgent surgical intervention, where standard guidelines may not provide direct answers. It challenges clinicians to balance the risk of infectious complications with the urgency of oncologic intervention, especially when current guidelines are not directly applicable. This case report demonstrated a multidisciplinary team-based approach to patient care by integrating infectious disease and surgical decision-making to manage a rare preoperative infectious risk. This outcome supports the safety of proceeding with surgery in asymptomatic patients, provided that multidisciplinary evaluation is conducted and current best practices are followed. The need for surgical protocols that account for potential vector-borne exposure is increasingly relevant as endemic disease patterns shift and surgical care grows more complex. Incorporating infectious disease guidance into preoperative workflows may help identify rare but clinically significant findings, reducing uncertainty in similar future cases. This case serves as an example of how adaptability, collaboration, and guideline-informed reasoning can successfully guide care in such unprecedented scenarios.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-162/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-162/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-162/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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