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*

References1. https://www.google.ca/#q=tick+bites. Accessed July 31, 2016.

2. https://www.google.ca/#q=tick+bites. Accessed July 31, 2016.

3. https://www.google.ca/#q=tick+bites. Accessed July 31, 2016.

4. https://www.google.ca/#q=tick+bites. Accessed July 31, 2016.

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.

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.

13. Dantas-Torres, F. (2007). Rocky Mountain spotted fever. The Lancet Infectious Diseases, 7(11), 724-732.

14. Chen, L. F., & Sexton, D. J. (2008). What's new in Rocky Mountain spotted fever? Infectious Disease Clinics of North America, 22 (3), 415-32, vii-viii.

15. Minniear, T. D., & Buckingham, S. C. (2009). Managing Rocky Mountain spotted fever. Expert Review of Anti-Infective Therapy, 7 (9), 1131-1137.

16. Fleming, D. O., Richardson, J. H., Tulis, J. J., & Vesley, D. (Eds.). (1995). Laboratory Safety Principles and Practices (2nd ed.). Washington: American Society for Microbiology.

17. https://www.cdc.gov/ehrlichiosis/stats/index.html. Accessed August 1 2016.

18. http://www.cdc.gov/mmwr/volumes/65/rr/rr6502a1.htm?s_cid=rr6502a1_w. Accessed August 1 2016.

19. Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. 2006 Mar 31. 55:1-27.

20. Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: a 30-year experience with 88 cases. Medicine (Baltimore). 1985 Jul. 64(4):251-69.

21. Finnish Medical Society Duodecim. Tularaemia. EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; Apr 27 2008.

22. Pérez-Castrillón JL, Bachiller-Luque P, Martín-Luquero M, Mena-Martín FJ, Herreros V. Tularemia epidemic in northwestern Spain: clinical description and therapeutic response. Clin Infect Dis. 2001 Aug 15. 33(4):573-6.

23. Wormser GP, Lombardo G, Silverblatt F, El Khoury MY, Prasad A, Yelon JA, et al. Babesiosis as a cause of fever in patients undergoing a splenectomy. Am Surg. 2011 Mar. 77(3):345-7.

24. Krause PJ, Lepore T, Sikand VK, Gadbaw J Jr, Burke G, Telford SR 3rd, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. 2000 Nov 16. 343(20):1454-8.

25. Marrie TJ, Raoult D. Coxiella burnetii (Q fever). Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa: Churchill Livingstone; 2005. 2296-303.

26. Marrie TJ. Q fever pneumonia. Infect Dis Clin North Am. 2010 Mar. 24(1):27-41.

27. Raoult D, Fenollar F, Stein A. Q fever during pregnancy: diagnosis, treatment, and follow-up. Arch Intern Med. 2002 Mar 25. 162(6):701-4.

28. Goodpasture HC, Poland JD, Francy DB, et al. Colorado tick fever: clinical, epidemiologic, and laboratory aspects of 228 cases in Colorado in 1973-1974. Ann Intern Med. 1978 Mar. 88(3):303-10.

29. Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med. 2008 Jul. 75 (7):521-30.

30. Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am. 2008 Sep. 22 (3):449-68.

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.