Creepy, Crawly Killers Tick-Borne Illnesses - PowerPoint Presentation

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Creepy, Crawly Killers

Tick-Borne Illnesses

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Tick Identification

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Lyme Disease

Transmitted by Ixodes scapularis “deer tick”

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Borrelia burgdorferi

Most common vector-borne zoonotic infection in the United States

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Seasonal Variation

Most cases occur in the warmer

months

Outdoor

activity is highest

Nymph

activity is at its peak

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Stages: Primary

Symptoms: 7-10 days after biteErythema migrans: 80% of patientsBelt line, axillary, inguinal, or popliteal25% report bite

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Stages: Primary

Flu-Like Symptoms

Fatigue

(54

%)

Anorexia

(26

%)

Myalgias

(44%) and

arthralgias

(44%)

Fever (16%)

Regional

lymphadenopathy

(23%)

Headache

(42%), neck stiffness (35

%)

Meningeal

findings

absent

,

CSF

studies

normal

 

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Stages: Secondary

Rash can evolve

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Stages: Secondary

Cranial neuropathy

Meningoencephalitis

Meningeal

signs typically absent

CSF studies may be positive

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Stages: Secondary

Myopericarditis

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Stages: Secondary

Atrioventricular block

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Stages: Secondary

RarelyConjunctivitisKeratitisUveitisOptic neuritisBlindness

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Stages: Tertiary

Months - Years after bite

Joint complaints (usually larger joints)

60% of untreated patients:

monoarticular

or

oligoarticular

arthritis

Exacerbations less frequent over years

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Stages: Tertiary

“Lyme encephalopathy”

Mood, memory, cognition, and sleep changes

Polyneuropathy

Both have abnormal CSF studies

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Diagnosis

Skin findings in endemic area

ELISA

IgG

and

IgM

against

Borrelia

(sensitivity of 89% and specificity of 72%)

Many false-positives

Positive or equivocal ELISA tests may be confirmed with western blot

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Treatment

Tick removed within 72 hours: low likelihood of infectionTick attached for at least 36 hours: consider treatment

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Treatment: Primary + Secondary Stages

Doxycycline Adults: 100 mg BID for 14-21 daysChildren > 8 years: 1-2 mg/kg BID AmoxicillinPregnant or lactating: 500 mg TID for 14-21 days Children < 8 years: amoxicillin 50 mg/kg/day, divided TID (max dose of 500mg/dose)

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Treatment Exceptions

Ceftriaxone

Lyme Meningitis

Severe cardiac disease

Second or third degree heart block

PR > 300

msec

Symptomatic patients

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Co-Infections

Babesiosis

2-40% of

lyme

patients

Human granulocytic

anaplasmosis

(HGA).

2-12% of

lyme

patients

Doxycycline

does not treat

babesiosis

Amoxicillin does not treat HGA or

babesiosis

Fever persists past 6 days: suspect co-infection

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Babesiosis

Babesia

species (especially

microti

)

Transmitted by deer tick

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Clinical Presentation

Flu-like illness: fever, chills, headache, fatigue, and anorexia

Splenomegaly

More severe in

splenectomized

Severe hemolytic anemia,

hemoglobinuria

, jaundice

MOD: renal insufficiency, ARDS, and DIC

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Diagnosis

Microscopy of thick and thin

Giemsa

stains

Antibody detection through IFA staining

PCR

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Treatment

With spleen: generally recover without treatment

Severe disease,

splenectomized

Clindamycin

+ quinine x 7-10 days OR

Atovaquone

+

azithromycin

x 7-10 days

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Ehrlichioses

Human granulocytic

anaplasmosis

(HGA)

Anaplasma

phagocytophilum

Black-legged tick

Upper Midwest, New England, parts of the mid-Atlantic states, northern California

Human

monocytic

ehrlichiosis

(HME)

Ehrlichia

chaffeensis

Lone Star tick

South central and South east

Ehrlichia

ewingii

South central

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Clinical Presentation

Abrupt onset of flu symptoms: fever, headache, myalgia, and shaking chillsCan see GI: N/V, diarrhea, abdominal painRashes (HME>HGA)MeningitisCarditisMODRenal failureDIC ARDS

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Diagnosis

Clinical

Leukopenia

, thrombocytopenia

Elevated LFTs

Acute and convalescent antibodies

Enzyme immunoassay and Western blot

PCR

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Treatment

Doxycycline

or tetracycline x 7–14 days

Rifampin

in children if concern for tooth staining

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Rocky Mountain Spotted Fever

Rickettsia

rickettsii

Southeastern United States

American dog tick

,

Rocky Mountain wood tick, common brown dog tick, Lone star tick

Frequently transmitted to humans by dogs

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Infection Cycle

Infect vascular endothelial cells and vascular smooth muscleCell-to-cell transfer via actin-based motilityDamaged endothelium with exposed subendothelium, tissue plasminogen activator, and von Willebrand's factor

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Clinical Presentation

Vasculitis

and thrombocytopenia

Early rash

Petechial

and hemorrhagic lesions

Microinfarcts

Small-vessel permeability

Hypotension, edema, and increased

extravascular

fluid

Acute renal failure and

hypovolemic

shock

Direct lung invasion: interstitial

pneumonitis

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Diagnosis

Clinical

Immunofluorescent

assay and

immunoperoxidase

staining of

R.

rickettsii

in rash biopsies

Serum antibody titer

PCR

Cell culture

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Treatment

Doxycycline

Including children!

Chloramphenicol

Pregnant women (except those near term)

For significant contraindication to

tetracyclines

High-dose steroids in critically ill

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Relapsing Fever

Epidemic (louse-borne)

Borrelia

recurrentis

Endemic (tick-borne)

Borrelia

hermsii

Borrelia

turicatae

Borrelia

parkeri

Mountain and Pacific states

Elevations 2,000-7,000 ft with coniferous forest

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Relapsing Fever

Rodent-Tick/Rodent-Louse life cycleTransmitted in infected saliva

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Clinical Presentation

Febrile episode: ~ 3 daysAsymptomatic period: ~7 daysRelapse Antigenic variationCycle repeats itself three to five times Successive relapses usually less severe

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Diagnosis

Spirochetes on peripheral smearGenus-specific PCR tests from CDCDifferentialmalaria, typhus, dengue, yellow fever, Colorado tick fever, and tularemia

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Treatment

Tetracycline or erythromycin

33% have

Jarisch-Herxheimer

Approx. 4 hours after treatment

Flu-like illness: fever, chills, headache,

myalgia

, flushing

Skin lesions

Hypotension

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Tularemia

Francisella

tularensis

Most common in Southwest

Rodents, rabbits,

prarie

dogs

Deer tick, the Lone Star tick, and the dog tick

Horse fly, and deer fly

Infected food or water

Inhalation of dust or water aerosol

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Seasonal Variation

May to August: ticks

December to January: hunting/skinning of infected animals

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Clinical Presentation

Ulceroglandular Most common form Inoculation site erythematous papule  ulcerates 2 to 3 days laterRegional lymphadenopathy and fever

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Clinical Presentation

GlandularLAD (usually cervical) without skin ulcer.Oropharyngeal tularemia exudative pharyngitis with associated cervical lymphadenitisOculoglandular Unilateral conjunctivitis with regional adenopathy of pre-auricular lymph nodes

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Clinical Presentation

Typhoidal

: systemic form with no obvious entry site

Fever, chills, constipation/diarrhea, abdominal pain, and weight loss

30 to 60% mortality

Pulmonary

Direct inhalation of aerosolized organisms or

bacteremic

spread from another site

Fever, chills, cough,

substernal

burning,

dyspnea

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Bioterrorism

Category ARelease of aerosolized particles3 to 5 days after exposureAcute feverPneumoniaPleuritisHilar lymphadenopathy

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Diagnosis

PCR

Do not culture bubo

Notify lab personnel if you do

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Treatment

Do not need patient isolation

Streptomycin

I&D residual sterile buboes after completion of antibiotics

Prophylaxis with

doxycycline

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Q Fever

Coxiella

burnetii

Cattle, sheep, goats

Rocky Mountain wood tick

Midwest states and California

80% of cases in males

Extremely resistant

One organism can cause infection

Category B biologic warfare agent

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Clinical Presentation (Acute)

Fever (often 40° C or higher),

myalgia

Chest pain

Atypical PNA

Retrobulbar

headache

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Chronic

Granulomatous

hepatitis

Culture-negative

endocarditis

Up to 68% of patients with chronic Q fever

Up to 25% mortality rate

Usually a history of

valvular

heart disease

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Diagnosis

Do not culture (risk to lab workers)

ELISA assays

Takes 2 - 3 weeks

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Treatment

Uncomplicated acute

Doxycycline

Acute disease with

valvular

disease

Doxycycline

+

Hydroxychloroquine

x 1 year

Chronic

Doxycycline

+

Hydroxychloroquine

x 1.5 to 3 years

Pregnant

Long-term TMP/SMX

Prophylaxis

Doxycyline

x 5-7 days

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Colorado Tick Fever

ColtivirusRocky Mountain areaRocky Mountain wood tick

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Clinical Presentation

Flu-like: fever, chills, headache, myalgia, lethargy, anorexia, and nauseaRetrobulbar painBiphasic course : “saddleback” fever curveSick for 2 - 3 daysWell for 1 - 2 daysSick 2 - 4 days

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Diagnosis

Immunofluoroescence

PCR

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Treatment

Almost always self-limited

Supportive treatment

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Tick Paralysis

Adult female tick

Releases a neurotoxin that causes

cerebellar

dysfunction, ascending paralysis

Southeastern and northwestern regions of the United States

47 tick species: most common Rocky Mountain wood tick and American dog tick

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Mechanism

Ixobotoxin

stops sodium flux across axonal membranes  loss of acetyl choline release at neuromuscular junction

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Clinical Presentation

Restlessness and irritability

Ascending flaccid paralysis +/- acute ataxia



bulbar involvement, respiratory paralysis,

https://www.youtube.com/watch?v=24DZEaUN7cc

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Treatment

Tick removalImprovement in hours

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References

http://www.cdc.gov/ticks/diseases/

Cline D, Ma OJ, et al.

Tintinalli’s

Emergency Medicine: A Comprehensive Study Guide, 6

th

edition. McGraw-Hill, 2004

Dudley, J P (2010), “Tularemia: A Case Study In Medical Surveillance And Bioterrorism Preparedness”,

JMedCBR

8, 17 September 2010, http://www.jmedcbr.org/issue_0801/Dudley/Dudley_09_10.html.

Halperin

JJ. Prolonged Lyme disease treatment: enough is enough. Neurology 2008;70:986

http://www.michigan.gov/emergingdiseases/0,4579,7-186-25890-75870--,00.html

. Accessed 9/27/15.

Nadelman

RB,

Nowakowski

J,

Forseter

G, et al. The clinical spectrum of early Lyme

borreliosis

in patients with culture-confirmed

erythema

migrans

. Am J Med 1996; 100:502

Rosen's emergency medicine: concepts and clinical practice 7th edition. Philadelphia, PA: Mosby/Elsevier; 2010.

Steere

AC,

Schoe

RT, Taylor E. The clinical evolution of Lyme arthritis. Ann Intern Med 1987; 107:725

Wolfson

A,

Hendey

GW, et al. Harwood-

Nuss

’ Clinical Practice of Emergency Medicine, 5

th

edition. Philadelphia: Lippincott Williams & Wilkins and

Wolters

Kluwer

Business, 2010.

Wormser

GP. Clinical Practice Early Lyme Disease. N

Engl

J Med 1996; 354:2794.