# Forehead Erythematous Rash: A Rare Manifestation of Tick-Borne Lymphadenopathy (TIBOLA)

## TL;DR

A rare forehead rash was observed in a case of TIBOLA, a tick-borne infection, highlighting the need for better recognition of this disease in Portugal.

## Contribution

This is the first reported case of TIBOLA presenting with an erythematous forehead rash.

## Key findings

- The patient developed a forehead rash three days after a tick bite and retroauricular swelling.
- Seroconversion for spotted fever group rickettsia confirmed the TIBOLA diagnosis six weeks later.
- Symptoms resolved without antibiotic treatment, and no eschar was observed.

## Abstract

Tick-borne lymphadenopathy (TIBOLA) is a rickettsial infection caused by Rickettsia slovaca. It has been increasingly identified across Europe. We present the case of TIBOLA with a unique erythematous forehead rash, which hasn't been described before. Four days after a tick bite on the scalp, a woman presented to the emergency department with a painful swelling in the right retroauricular area and a headache. Examination revealed a palpable lymph node and fever. No eschar was observed. Initial serology for common tick-borne infections was negative. Three days later, she returned to the hospital with an erythematous rash on her forehead. Despite not receiving antibiotic treatment, the symptoms resolved spontaneously. A follow-up serum sample, taken six weeks later, showed seroconversion for spotted fever group rickettsia, leading to the diagnosis of TIBOLA. TIBOLA often goes unrecognized due to nonspecific symptoms and the hidden location of eschars. This case emphasizes the importance of considering TIBOLA in tick-borne illness diagnoses in Portugal.