Tick-Borne Diseases
Stephen J. Gluckman, M.D.
Tick-Borne Diseases
Lyme Disease Babesiosis Ehrlichiosis “Tick Typhus”
Rocky Mountain Spotted Fever
African Tick Typhus
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 DiseaseClinical Presentations
A few things to clarify Erythema migrans Carditis
Transient heart block Myocarditis
Neurological VII CN palsy Aseptic meningitis Radiculoneuritis Lyme Encephalopathy
Rheumatologic Acute pauci-articular arthritis
Where Do You See Lyme Disease?
Throughout the world
National Lyme Disease Risk Map with Four Categories of
Risk
(CDC)
Borrelia BurgdorferiB. 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 Tick Bite
Incubation 7-10 days Hours
Local Symptoms Rare Pruritus
Size > 5 cm Small
Expands Over Days Over Hours
Resolves Over Weeks Over Days
Systemic Symptoms
Common Rare
Erythema Migrans
Things to remember It is a clinical diagnosis, not a laboratory
diagnosis It is NEVER an emergency “Target” lesion only occurs in 30%
Any big red patch is EM unless you have another explanation
Lyme Disease and VII CN Palsy
Differential Diagnosis HSV (was idiopathic) HIV Herpes Zoster Local Infection/Trauma/Tumor Sarcoidosis Lyme
More likely with: preceding or present erythema migrans
Lyme Disease and VII CN Palsy
Should you treat empirically? Tick time of year Potential tick exposure Bilateral
“Diagnosis” Lyme Serology
Lumbar Puncture?
Lyme Radiculoneuropathy
Differential Diagnosis Diabetes Herpes zoster (sine herpete) Herniated disc Collapsed Vertebral body Syphilis
Case 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 He has had line related of Staphylococcus
aureus bacteremia and ceftriaxone induced acute cholecystitis
Is this resistant neuroborreliosis?
LYME ENECEPHALOPATHY
TO DIAGNOSE NEED BOTH Objective evidence of neurological disease Objective evidence of B. burgdorferi in the
CNS Lack of response related to:
Incorrect diagnosis Impatience Permanent damage
When Should One Think of Lyme Arthritis?
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
Chronic fatigue, chronic diffuse aching, recurrent sore throats, lymphadynia, and “low grade” fevers are not symptoms of active Lyme disease.
Lyme Serology
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
There is NO TEST for Lyme Disease
Interpreting Lyme Serology
What is a positive test? Positive screening by ELISA or IFA plus a
positive western blot What is a negative test?
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?
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
Culture 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
Common Testing Errors
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
A belief that the serology is not good.
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
Oral Doxycycline 100 mg BID Amoxicillin 500 mg TID Cefuroxime axetil 500 mg BID
Parenteral Ceftriaxone 2 gm IV daily Cefotaxime 2 gm IV Q8H
Lyme Disease Treatment
Erythema migrans Oral x 10-21 d
VII cranial nerve palsy Oral x 14-21 d
Acute meningitis Parenteral x 14-28 d (can finish with oral)
Cardiac 1st or 2nd degree block: Oral x 14-21 d 3rd degree block or myocarditis: parenteral x 14-21 d
Lyme Disease Treatment
Arthritis Oral x 28 d
Encephalopathy Parenteral x 28 d
Neuropathy Parenteral x 28 d
Persistent arthritis after two courses of therapy or other chronic symptoms Symptomatic therapy
What About the Newer Antibiotics for Lyme Disease
There is no advantage for azithromycin, clarithromycin, cefixime, cefuroxime, etc….
Do Not Use Them!
LYME DISEASEConcept Summary
23 year old with 4 months of diffuse aching and fatigue.
Lyme serology: EIA (+)IgG Western Blot: 2 bandsIgM Western Blot: 1 band
Is this Lyme disease?
NO
LYME DISEASEConcept Summary
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 DISEASEConcept Summary
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 DISEASEConcept Summary
31 year old with the non-pruritic, non-painful skin lesions seen on the following slide.
Lyme serology: EIA (-)Western blot IgG (-)Western blot IgM (-)
Does this patient have Lyme disease?
YOU BETCH
A
Babesiosis What is it?
An intracellular protozoan parasite Where is it?
Northeast (Northwest)
What is the clinical syndrome? “FLU” – like: fever, chills, headache, fatigue
Hemolytic anemia Serious especially in asplenic persons Relapses can occur - especially in immunosuppressed
persons
BabesiosisDiagnosis and Treatment
Diagnosis 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 Quinine and Clindamycin Atovaquone and azithromycin
Babesiosis
Ehrlichiosis and Anaplasmosis
What are they? Rickettsiaceae family
Human Monocytic Ehrlichiosis (HME) Lone star tick
Human Granulocytic Anaplasmosis (HGA) Ixodes ticks
Where is it? Everywhere
Human Monocytic Ehrlichiosis
E. chaffeensis First described in 1987 Primarily infects mononuclear cells Reservoir: deer, dogs, goats Vector: Lone star tick (Amblyomma americanum)
Human Granulocytic Anaplasmosis
First described in 1994 Organism recently named Anaplasma
phagocytophilum. Reservoir: deer, rodents, elk Vector: Ixodes ticks
Ehrlichiosis and Anaplasmosis
SIGNS AND SYMPTOMS Incubation period: 5 - 10 days Early symptoms are non-specific (“flu-like”)
Fever, headache, myalgias GI symptoms can occur Rash variable
Laboratory Leucopenia, thrombocytopenia, abnormal
liver enzymes
Ehrlichiosis and Anaplasmosis
COMPLICATIONS Can be very severe
Renal failure ARDS DIC Encephalitis
3% mortality Worse in patients with impaired host defenses Watch out for dual or triple infections with
Borrelia burgdorferi and Babesia
Ehrlichiosis and Anaplasmosis
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
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
Pregnancy and children ??? Rifampin 600 mg IV/PO has been used
Rocky Mountain Spotted Fever
Clinical Spectrum from mild to fulminant Throughout the Western Hemisphere Vector: Dermacentor
Dog or Wood Ticks
Rocky Mountain Spotted Fever
Rocky Mountain Spotted FeverClinical Manifestations
Incubation Period: 3 - 14 days (ave 5 - 7) Non-specific
Fever Headache Myalgias GI
Rash Mortality about 25% if treatment delayed
Rocky Mountain Spotted FeverRash
Begins on day 3 - 5 Only 15% have a rash on the first day 10% never get a rash
Do not wait for a rash to initiate therapy Starts on ankles and wrists Spreads centrally and to palms/soles
Rocky Mountain Spotted FeverDiagnosis
Initially made clinically on suspicion and epidemiology
Serology Used to confirm diagnosis Takes at least 10-14 days to seroconvert
Skin biopsy Rapid, if available (requires special stains) 70% sensitive
Rocky Mountain Spotted FeverTreatment
Can not overstress the importance of early therapy 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
Throughout the world All have rashes
Typically on trunk Most with tick bite site eschar
All diagnosed serologically All treated with doxycycline Consider the diagnosis in a febrile returning
traveler
Tick Typhus
STARI“Southern Tick-Associated Rash Illness”
Rash similar to erythema migrans in persons living in the SE USA First reported in 1996 and organism identified
in 2001 Different vector than Lyme disease
Amblyomma rather than Ixodes Same life cycle and ecology
Different pathogen 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”
Diagnosis Unable to culture at this time PCR on biopsy of rash Lyme disease serology is negative
Treatment ? Doxycycline
Sequellae None known to date
Managing a Tick Bite
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?
Removing a Tick
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 ?
Need to address three questions Type of tick? Attached or engorged? Duration of attachment?
Prophylactic antibiotics generally not indicated
SINGLE DOSE DOXYCYCLINE? 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
Otherwise observation alone is recommended
Questions?