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Tick Borne IllnessesDr. Constance LeBlanc
No affiliations (research grants, speaker bureaus, or other) with industry
DOHW Nova Scotia funding
DEANS grants
CADTH funding
TVN grant
Dalhousie FoM Living Lab grants
NSHRF grants
CPSNS funding
DoctorsNS funding and grant
Health Canada grant
Disclosures
Potential symptoms of tick-borne diseases include:
• red spot or rash near the bite site
• neck stiffness
• headache or nausea
• weakness
• muscle or joint pain or achiness
• fever or chills
• swollen lymph nodes
Dr. Google1
1- https://www.google.ca/#q=tick+bites. Accessed July 31, 2016.
Lyme3 Borrelia burgdorferi
FOCAL
Erythema migrans
Fever
Myalgias
Malaise
Arthralgia
Headache
Adenopathy
DISEMINATED
EM
Headache
Fever
Adenopathy
Heart Block (carditis)
Meningismus
Cranioneuropathy(VII, Bell)
3- van Nunen S. Tick-induced allergies: mammalian meat allergy, tick anaphylaxis and their significance. Asia Pac Allergy. 2015 Jan. 5 (1):3-16.
Lyme disease became nationally notifiable in 20094
4- http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/lyme/surveillance-eng.php. Accessed July 31 2016.
Exposure
24 hours of attachment5,6
Testing for epidemiologic reasons
Risk of acquiring Lyme disease from an infected tick is < 1% to 6%6
5- De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol. 1993 Jul. 30(4):748-52.6- Huegli D, Moret J, Rais O, Moosmann Y, Erard P, Malinverni R, et al. Prospective study on the incidence of infection by Borrelia burgdorferi sensu lato after a tick bite in a highly endemic area of Switzerland. Ticks Tick Borne Dis. 2011;2:129-36.
Tick Removal
No contraindications
• Gloves
• Isopropyl alcohol
• Needle nose forceps
• NO XYLOCAINE7
7- Needham GR. Evaluation of five popular methods for tick removal. Pediatrics. 1985 Jun. 75(6):997-100.
• Queen’s
• Yarmouth
• Shelburne
• Lunenburg
• Halifax
• Pictou
Endemic Area
1. Test in the absence of symptoms or signs consistent with Lyme disease
2. Test in asymptomatic patients who have had a blacklegged tick bite: antibodies to B. burgdorferi are not detected until a few weeks after infection
3. Test in patients with the typical EM rash (>5cm) during Lyme season
4. Repeat testing after treatment
5. Send specimens to laboratories that use interpretive criteria that are different from the CDC
6. Bypass the ELISA and using Western Blots alone: Western Blots done in the absence of preceding ELISA testing have been associated with a reduction in specificity and are NOT recommended
7. Use of PCR on blood, serum or plasma or the use of urinary antigen as a diagnostic test: these tests have not been validated
Don’t
1. The attached tick is estimated to have been attached for ≥36 h based on the degree of engorgement or by certainty about the time of tick acquisition
2. Prophylaxis can be started within 72 h of tick removal
3. Ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi is ≥20%. There is insufficient information to provide a list of all counties in NS that meet this criterion.
4. Doxycycline is not contraindicated.
Do Prophylax
• Adults and children > 8 years of age: single dose doxycycline 200 mg po (4.4mg/kg for patients < 45kg)
There is no effective antibiotic for prophylaxis in children ≤8 years of age
What to give
Who needs Prophylaxis?8
8- Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Nov 1;43:1089-134.
Who needs Treatment?9,10,11
9-Hengge UR, Tannapfel A, Tyring SK, Erbel R, Arendt G, Ruzicka T. Lyme borreliosis. Lancet Infect Dis. 2003;3:489-500.10- Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S.11- Hatchette, Todd F., et al. "Epidemiology of Lyme Disease, Nova Scotia, Canada, 2002–2013." Emerging infectious diseases 21.10 (2015): 1751.
Serological tests IgG• not a test of cure• not be used to measure treatment
The EIA test• low specificity (may yield false-positive results stand-
alone)
• cross-reacts with antibodies to commensal or pathogenic spirochetes and some conditions (varicella, Epstein-Barr, lupus)
Canadian laboratory diagnostics for Lyme disease meet international standards12
12- http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/lyme/professionals-professionnels/index-eng.php#a5. Accessed August 1, 2016.
A woman presents to the ED with a swollen hand. She is otherwise well.
Her hand has been increasingly sore for 2 days and today she noticed some erythema so is seeking care.
Case 1
Rare
Young girls
2-6 days post tick attachment
Differential GBS, myasthenia gravis, botulism, west Nile virus myelitis
Tick Paralysis31,32
31-Grattan-Smith PJ, Morris JG, Johnston HM, et al. Clinical and neurophysiological features of tick paralysis. Brain 1997; 120:1975-1987. 32- Edlow JA, McGillicuddy DC: Tick paralysis. Inf Dis Clin North Am. 2008, 22, 397-414.
Prodromal phase: paraesthesias, restlessness, irritability, fatigue, and myalgias
Neurological symptoms: Acute ascending paralysis a few days after tick attachment. Deep tendon reflexes are weak or absent. Children may present with ataxia. Over12 to 24 hours the muscles innervated by facial nerves become weak
Death: the respiratory muscles will fail and the patient will die of respiratory failure
Presentation
Lone star tick produces galactose-alpha-1,3-galactose (“Alpha-Gal”)
Injects during bite
This sugar is found in red meat (eg., beef, pork, venison, rabbit) and in some dairy products
Red Meat Allergy*
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6. Huegli D, Moret J, Rais O, Moosmann Y, Erard P, Malinverni R, et al. Prospective study on the incidence of infection by Borrelia burgdorferi sensu lato after a tick bite in a highly endemic area of Switzerland. Ticks Tick Borne Dis. 2011;2:129-36.
7. Needham GR. Evaluation of five popular methods for tick removal. Pediatrics. 1985 Jun. 75(6):997-100.
8. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Nov 1;43:1089-134
9. Hengge UR, Tannapfel A, Tyring SK, Erbel R, Arendt G, Ruzicka T. Lyme borreliosis. Lancet Infect Dis. 2003;3:489-500.
10. Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S.
11. Hatchette, Todd F., et al. "Epidemiology of Lyme Disease, Nova Scotia, Canada, 2002–2013." Emerging infectious diseases 21.10 (2015): 1751.
12. http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/lyme/professionals-professionnels/index-eng.php#a5. Accessed August 1, 2016.
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31. Grattan-Smith PJ, Morris JG, Johnston HM, et al. Clinical and neurophysiological features of tick paralysis. Brain 1997; 120:1975-1987.
32. Edlow JA, McGillicuddy DC: Tick paralysis. Inf Dis Clin North Am. 2008, 22, 397-414.