Of 1770 children undergoing emergency department evaluation for Lyme disease, 362 (20.5%) children had Lyme disease. Of those with an available tick bite history, only a minority of those with Lyme disease had a recognized tick bite (60/325; 18.5%, 95% confidence interval 14.6–23.0%). Lack of a tick bite history does not reliably exclude Lyme disease.

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**Comment**

While this information isn’t shocking to me in the least, what does concern me is that only about 20% were found to have Lyme.  The abstract does not give the diagnostic criteria; however, it is typically the 2-tiered CDC serological (blood) testing which misses over half of all cases.  

So many of these children have Lyme and are now undiagnosed and will go on to develop chronic/persistent symptoms.

While I’m thankful the authors conclude that lack of recollection of a tick bite does not exclude infection, I’m highly concerned for those that perhaps are infected but couldn’t mount an appropriate immune response to show antibodies.