Transcript Tick-Borne Disease - MCE Conferences Inc.

Tick-Borne Diseases
Stephen J. Gluckman, M.D.
Tick-Borne Diseases
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Lyme Disease
Babesiosis
Ehrlichiosis
“Tick Typhus”
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Rocky Mountain Spotted
Fever
African Tick Typhus
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Tularemia
Relapsing fever
Powassan
Tick Paralysis
STARI
An adult female Ixodes scapularis (blacklegged tick)
An adult female Dermacentor variabilis
(American dog tick)
An adult female Amblyomma americanum
(lone star tick)
Lyme Disease
Clinical Presentations
A few things to clarify
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Erythema migrans
Carditis
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Neurological
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Transient heart block
Myocarditis
VII CN palsy
Aseptic meningitis
Radiculoneuritis
Lyme Encephalopathy
Rheumatologic
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Acute pauci-articular arthritis
Where Do You See
Lyme Disease?
Throughout the world
National Lyme Disease Risk
Map with Four Categories of
Risk
(CDC)
BORELLIA
BorreliaBURGDORFERI
Burgdorferi
B. burgdorferi is not from Mars
B. Burgdorferi is not from another dimension
B. Burgdorferi is just another bug
How Big is the
Ixodes Tick?
1-2 mm
Ixodes Ticks
Diagnosing Erythema Migrans
ANY LARGE RED PATCH WITHOUT
ANOTHER EXPLANATION IS ERYTHEMA
MIGRANS
EM or Tick Bite Reaction?
EM
7-10 days
Tick Bite
Hours
Rare
Pruritus
> 5 cm
Small
Expands
Over Days
Over Hours
Resolves
Over Weeks
Over Days
Common
Rare
Incubation
Local Symptoms
Size
Systemic
Symptoms
Erythema Migrans
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Things to remember
It is a clinical diagnosis, not a laboratory
diagnosis
 It is NEVER an emergency
 “Target” lesion only occurs in 30%
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Any big red patch is EM unless you have
another explanation
Lyme Disease and VII CN
Palsy
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Differential Diagnosis
HSV (was idiopathic)
 HIV
 Herpes Zoster
 Local Infection/Trauma/Tumor
 Sarcoidosis
 Lyme
 More likely with: preceding or present
erythema migrans
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Lyme Disease and VII CN
Palsy
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Should you treat empirically?
Tick time of year
 Potential tick exposure
 Bilateral
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“Diagnosis”
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Lyme Serology
Lumbar Puncture?
Lyme Radiculoneuropathy
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Differential Diagnosis
Diabetes
 Herpes zoster (sine herpete)
 Herniated disc
 Collapsed Vertebral body
 Syphilis
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Case
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45 year old who has had several years of
“low grade” fevers, painful lymph nodes,
scratchy throat, and mental cloudiness
He has been treated with oral doxycycline,
azithromycin, and paromomycin.
He has also been treated with three
courses of IV ceftriaxone totaling 5 months
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He has had line related of Staphylococcus
aureus bacteremia and ceftriaxone induced
acute cholecystitis
Is this resistant neuroborreliosis?
LYME ENECEPHALOPATHY
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TO DIAGNOSE NEED BOTH
Objective evidence of neurological disease
 Objective evidence of B. burgdorferi in the
CNS
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Lack of response related to:
Incorrect diagnosis
 Impatience
 Permanent damage
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When Should One Think of
Lyme Arthritis?
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Monoarticular or pauciarticular
Typically knee
Differential Diagnosis: septic, crystal,
rheumatoid, Reiter’s
Class II fluid
Arthralgias can be part of early Lyme
Disease, but they are usually associated
with EM and do not become chronic
Major Clinical Error
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Chronic fatigue, chronic diffuse
aching, recurrent sore throats,
lymphadynia, and “low grade”
fevers are not symptoms of
active Lyme disease.
Lyme Serology
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Misunderstandings about the use of
serological testing for Lyme disease is the
primary reason for the misunderstanding of
this relatively uncomplicated infectious
disease.
“Real” Lyme disease is generally easy to
diagnose and treat
 Diseases misdiagnosed as Lyme disease are not
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There is NO TEST
for Lyme Disease
Interpreting Lyme Serology
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What is a positive test?
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Positive screening by ELISA or IFA plus a
positive western blot
What is a negative test?
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Negative screening or positive screening with
a negative Western Blot
(2nd National Conf. on Serol Dx of LD MMWR 1995;4:590)
What is a positive western
blot?
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An IGM Western Blot is considered positive
if 2 of 3 specific bands are present.
An IGG Western Blot is considered positive
if 5 of 10 specific bands are present.
Otherwise they are negative AND a positive
screening serology with a negative WB is a
negative test.
Other Diagnostic Tests
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Culture
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Low sensitivity, high specificity
Unapproved tests
PCR on blood or urine
 Urinary Antigen Testing
 Borreliacidal Antibody Test (Gundersen test)
 Immune Complex Disruption
 T-cell Proliferative Response
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Common Testing Errors
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Not establishing a true positive test
Not understanding that a positive serology does
not mean disease
Treating to eliminate antibodies
 Antibodies persist and vary in titer
Treating a positive IgM alone: IgM may persist
and is not helpful in disease beyond 1 month
Believing that a false negative test is frequent:
False negatives are very rare other than in EM
Treating on the basis of an unestablished test
So, what is the consequence of
misunderstanding the serology?
THE CREATION OF MYTHS
 An entire syndrome (disease?) has been
created that does not exist
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A belief that the serology is not good.
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A belief that Lyme disease is difficult to treat.
How Good is the Treatment of
Lyme Disease?
VERY GOOD
There Rarely is a Reason to Retreat a
Patient
Lyme Disease Treatment
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Oral
Doxycycline 100 mg BID
 Amoxicillin 500 mg TID
 Cefuroxime axetil 500 mg BID
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Parenteral
Ceftriaxone 2 gm IV daily
 Cefotaxime 2 gm IV Q8H
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Lyme Disease Treatment
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Erythema migrans
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VII cranial nerve palsy
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Oral x 14-21 d
Acute meningitis
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Oral x 10-21 d
Parenteral x 14-28 d (can finish with oral)
Cardiac
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1st or 2nd degree block: Oral x 14-21 d
3rd degree block or myocarditis: parenteral x 14-21 d
Lyme Disease Treatment
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Arthritis
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Encephalopathy
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Parenteral x 28 d
Neuropathy
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Oral x 28 d
Parenteral x 28 d
Persistent arthritis after two courses of
therapy or other chronic symptoms
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Symptomatic therapy
What About the Newer
Antibiotics for Lyme Disease
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There is no advantage for
azithromycin, clarithromycin,
cefixime, cefuroxime, etc….
Do Not Use Them!
LYME DISEASE
Concept Summary
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23 year old with 4 months of diffuse aching and
fatigue.
Lyme serology: EIA (+)
IgG Western Blot: 2 bands
IgM Western Blot: 1 band
Is this Lyme disease?
NO
LYME DISEASE
Concept Summary
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41 year old who has had difficulty remembering
names for the past several years.
Lyme serology: EIA: (-)
Western blot IgG (-)
Western blot IgM (+)
Is this Lyme disease?
NO
LYME DISEASE
Concept Summary
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35 year old who presented several months ago with typical rash of
erythema migrans.
Treated with 3 weeks of doxycycline
Rash resolves after 4 days, but she continues with malaise and
diffuse myalgias
Repeat testing:
Lyme serology: EIA (+)
Western blot IgG (+)
IgM (+)
Does this patient need more treatment?
NO
LYME DISEASE
Concept Summary
31 year old with the non-pruritic, nonpainful skin lesions seen on the following
slide.
Lyme serology:
EIA (-)
Western blot IgG (-)
Western blot IgM (-)
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Does this patient have Lyme disease?
YOU
BETCHA
Babesiosis
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What is it?
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Where is it?
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An intracellular protozoan parasite
Northeast
(Northwest)
What is the clinical syndrome?
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“FLU” – like: fever, chills, headache, fatigue
 Hemolytic anemia
Serious especially in asplenic persons
Relapses can occur - especially in immunosuppressed
persons
Babesiosis
Diagnosis and Treatment
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Diagnosis
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Peripheral blood smear
PCR on blood
Serology has the same problems as that for Lyme
disease. A positive test does not mean disease.
 Don’t treat a positive test; treat a person with a
positive test an a compatible clinical syndrome
Treatment
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Quinine and Clindamycin
Atovaquone and azithromycin
Babesiosis
Ehrlichiosis and Anaplasmosis
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What are they?
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Rickettsiaceae family
 Human Monocytic Ehrlichiosis (HME)
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Lone star tick
 Human
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Granulocytic Anaplasmosis (HGA)
Ixodes ticks
Where is it?
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Everywhere
Human Monocytic
Ehrlichiosis
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E. chaffeensis
First described in 1987
Primarily infects mononuclear cells
Reservoir: deer, dogs, goats
Vector: Lone star tick (Amblyomma americanum)
Human Granulocytic
Anaplasmosis
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First described in 1994
Organism recently named Anaplasma
phagocytophilum.
Reservoir: deer, rodents, elk
Vector: Ixodes ticks
Ehrlichiosis and Anaplasmosis
SIGNS AND SYMPTOMS
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Incubation period: 5 - 10 days
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Early symptoms are non-specific (“flu-like”)
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Fever, headache, myalgias
GI symptoms can occur
Rash variable
Laboratory
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Leucopenia, thrombocytopenia, abnormal
liver enzymes
Ehrlichiosis and Anaplasmosis
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COMPLICATIONS
Can be very severe
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Renal failure
ARDS
DIC
Encephalitis
3% mortality
Worse in patients with impaired host defenses
Watch out for dual or triple infections with
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Borrelia burgdorferi and Babesia
Ehrlichiosis and Anaplasmosis
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DIAGNOSIS
Peripheral smear looking for morulae
Serology
PCR (state laboratories)
Culture
Treat based on epidemiologic and clinical
clues. Do not delay while waiting for
confirmation.
Ehrlichiosis and Anaplasmosis
Morulae
Ehrlichiosis and Anaplasmosis
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TREATMENT
Treatment should not be delayed until
laboratory confirmation is obtained
Doxycycline: 100 mg PO/IV
Until 3 days after fever abates
 Expect response in 24 - 72 hours
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Pregnancy and children ???
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Rifampin 600 mg IV/PO has been used
Rocky Mountain Spotted
Fever
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Clinical Spectrum from mild to fulminant
Throughout the Western Hemisphere
Vector: Dermacentor
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Dog or Wood Ticks
Rocky Mountain Spotted Fever
Rocky Mountain Spotted Fever
Clinical Manifestations
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Incubation Period: 3 - 14 days (ave 5 - 7)
Non-specific
Fever
 Headache
 Myalgias
 GI
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Rash
Mortality about 25% if treatment delayed
Rocky Mountain Spotted Fever
Rash
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Begins on day 3 - 5
Only 15% have a rash on the first day
 10% never get a rash
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Do not wait for a rash to initiate therapy
Starts on ankles and wrists
Spreads centrally and to palms/soles
Rocky Mountain Spotted Fever
Diagnosis
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Initially made clinically on suspicion and
epidemiology
Serology
Used to confirm diagnosis
 Takes at least 10-14 days to seroconvert
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Skin biopsy
Rapid, if available (requires special stains)
 70% sensitive
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Rocky Mountain Spotted Fever
Treatment
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Can not overstress the importance of early
therapy
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Mortality related to when treatment initiated
 < 5 days 6.5%
 > 5 days 22.9% (most saw a physician within
the first five days)
Doxycycline for adults and children
Chloramphenicol is the alternative
Tick Typhus
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Throughout the world
All have rashes
Typically on trunk
 Most with tick bite site eschar
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All diagnosed serologically
All treated with doxycycline
Consider the diagnosis in a febrile returning
traveler
Tick Typhus
STARI
“Southern Tick-Associated Rash Illness”
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Rash similar to erythema migrans in
persons living in the SE USA
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First reported in 1996 and organism identified
in 2001
Different vector than Lyme disease
Amblyomma rather than Ixodes
 Same life cycle and ecology
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Different pathogen
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Borrelia lonestari (?)
Amblyomma americanum
“Lone Star” Tick
STARI
“Southern Tick-Associated Rash Illness”
Distribution of Lone Star Ticks in the USA
STARI
“Southern Tick-Associated Rash Illness”
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Diagnosis
Unable to culture at this time
 PCR on biopsy of rash
 Lyme disease serology is negative
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Treatment
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? Doxycycline
Sequellae
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None known to date
Managing a Tick Bite
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You get a phone call at 5:30 on a Friday
evening from a patient who says that he
just found a tick behind the ear of his wife.
They ask:
How should they remove it?
 Should she get antibiotics?
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Removing a Tick
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Do not use Vaseline, kerosene, matches,
gasoline
Use a hemostat or forceps and grasp tick
as close to the skin as possible
Pull back gently and firmly perpendicular
to the skin
Don’t squeeze or crush
Don’t worry about residual mouth parts
Antibiotic ?
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Need to address three questions
Type of tick?
 Attached or engorged?
 Duration of attachment?
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Prophylactic antibiotics generally
not indicated
SINGLE DOSE DOXYCYCLINE?
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If:
> 8 years old
 Attached tick was nymph or adult Ixodes
scapularis
 Attached for at least 36 hours
 Prophylaxis can be started within 72 hours of tick
removal
 Local prevalence of Lyme disease is > 20%
 No contraindication to doxy
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Otherwise observation alone is recommended
Questions?