tick-borne diseases stephen j. gluckman, m.d.. tick-borne diseases lyme disease babesiosis...
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Tick-Borne DiseasesStephen J. Gluckman, M.D.
Tick-Borne DiseasesLyme DiseaseBabesiosisEhrlichiosisTick TyphusRocky Mountain Spotted FeverAfrican Tick TyphusTularemiaRelapsing feverPowassanTick ParalysisSTARI
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 PresentationsA few things to clarifyErythema migransCarditisTransient heart blockMyocarditisNeurologicalVII CN palsyAseptic meningitisRadiculoneuritisLyme EncephalopathyRheumatologicAcute 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 MarsB. Burgdorferi is not from another dimensionB. Burgdorferi is just another bug
How Big is the Ixodes Tick?1-2 mm
Diagnosing Erythema Migrans
ANY LARGE RED PATCH WITHOUT ANOTHER EXPLANATION IS ERYTHEMA MIGRANS
EM or Tick Bite Reaction?
EMTick BiteIncubation7-10 daysHoursLocal SymptomsRarePruritusSize> 5 cmSmallExpandsOver DaysOver HoursResolvesOver WeeksOver DaysSystemic SymptomsCommonRare
Erythema MigransThings to rememberIt is a clinical diagnosis, not a laboratory diagnosisIt is NEVER an emergencyTarget lesion only occurs in 30%
Any big red patch is EM unless you have another explanation
Lyme Disease and VII CN PalsyDifferential DiagnosisHSV (was idiopathic)HIV Herpes ZosterLocal Infection/Trauma/TumorSarcoidosisLymeMore likely with: preceding or present erythema migrans
Lyme Disease and VII CN PalsyShould you treat empirically?Tick time of yearPotential tick exposureBilateralDiagnosisLyme SerologyLumbar Puncture?
Lyme RadiculoneuropathyDifferential DiagnosisDiabetesHerpes zoster (sine herpete)Herniated discCollapsed Vertebral bodySyphilis
Case45 year old who has had several years of low grade fevers, painful lymph nodes, scratchy throat, and mental cloudinessHe has been treated with oral doxycycline, azithromycin, and paromomycin.He has also been treated with three courses of IV ceftriaxone totaling 5 monthsHe has had line related of Staphylococcus aureus bacteremia and ceftriaxone induced acute cholecystitisIs this resistant neuroborreliosis?
LYME ENECEPHALOPATHYTO DIAGNOSE NEED BOTHObjective evidence of neurological diseaseObjective evidence of B. burgdorferi in the CNSLack of response related to:Incorrect diagnosisImpatiencePermanent damage
When Should One Think of Lyme Arthritis?Monoarticular or pauciarticularTypically kneeDifferential Diagnosis: septic, crystal, rheumatoid, ReitersClass II fluidArthralgias can be part of early Lyme Disease, but they are usually associated with EM and do not become chronic
Major Clinical ErrorChronic fatigue, chronic diffuse aching, recurrent sore throats, lymphadynia, and low grade fevers are not symptoms of active Lyme disease.
Lyme SerologyMisunderstandings 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 treatDiseases misdiagnosed as Lyme disease are not
There is NO TEST for Lyme Disease
Interpreting Lyme SerologyWhat is a positive test?Positive screening by ELISA or IFA plus a positive western blotWhat 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 TestsCultureLow sensitivity, high specificityUnapproved testsPCR on blood or urineUrinary Antigen TestingBorreliacidal Antibody Test (Gundersen test)Immune Complex DisruptionT-cell Proliferative Response
Common Testing ErrorsNot establishing a true positive testNot understanding that a positive serology does not mean diseaseTreating to eliminate antibodiesAntibodies persist and vary in titerTreating a positive IgM alone: IgM may persist and is not helpful in disease beyond 1 monthBelieving that a false negative test is frequent: False negatives are very rare other than in EMTreating on the basis of an unestablished test
So, what is the consequence of misunderstanding the serology?THE CREATION OF MYTHSAn 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 TreatmentOralDoxycycline 100 mg BID Amoxicillin 500 mg TIDCefuroxime axetil 500 mg BIDParenteralCeftriaxone 2 gm IV dailyCefotaxime 2 gm IV Q8H
Lyme Disease TreatmentErythema migrans Oral x 10-21 dVII cranial nerve palsyOral x 14-21 dAcute meningitisParenteral x 14-28 d (can finish with oral)Cardiac1st or 2nd degree block: Oral x 14-21 d3rd degree block or myocarditis: parenteral x 14-21 d
Lyme Disease TreatmentArthritisOral x 28 dEncephalopathyParenteral x 28 dNeuropathyParenteral x 28 dPersistent arthritis after two courses of therapy or other chronic symptomsSymptomatic therapy
What About the Newer Antibiotics for Lyme DiseaseThere is no advantage for azithromycin, clarithromycin, cefixime, cefuroxime, etc.Do Not Use Them!
LYME DISEASEConcept Summary23 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 Summary41 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?
LYME DISEASEConcept Summary35 year old who presented several months ago with typical rash of erythema migrans. Treated with 3 weeks of doxycyclineRash resolves after 4 days, but she continues with malaise and diffuse myalgiasRepeat testing:
Lyme serology: EIA (+)Western blot IgG (+)IgM (+)Does this patient need more treatment?
LYME DISEASEConcept Summary31 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?
BabesiosisWhat is it?An intracellular protozoan parasiteWhere is it?Northeast(Northwest)What is the clinical syndrome?FLU like: fever, chills, headache, fatigueHemolytic anemiaSerious especially in asplenic personsRelapses can occur - especially in immunosuppressed persons
BabesiosisDiagnosis and TreatmentDiagnosisPeripheral blood smearPCR on bloodSerology has the same problems as that for Lyme disease. A positive test does not mean disease.Dont treat a positive test; treat a person with a positive test an a compatible clinical syndromeTreatmentQuinine and ClindamycinAtovaquone and azithromycin
Ehrlichiosis and AnaplasmosisWhat are they?Rickettsiaceae family Human Monocytic Ehrlichiosis (HME)Lone star tickHuman Granulocytic Anaplasmosis (HGA)Ixodes ticksWhere is it?Everywhere
Human Monocytic EhrlichiosisE. chaffeensisFirst described in 1987Primarily infects mononuclear cellsReservoir: deer, dogs, goatsVector: Lone star tick (Amblyomma americanum)
Human Granulocytic AnaplasmosisFirst described in 1994Organism recently named Anaplasma phagocytophilum.Reservoir: deer, rodents, elkVector: Ixodes ticks
Ehrlichiosis and AnaplasmosisSIGNS AND SYMPTOMSIncubation period: 5 - 10 daysEarly symptoms are non-specific (flu-like)Fever, headache, myalgiasGI symptoms can occurRash variableLaboratoryLeucopenia, thrombocytopenia, abnormal liver enzymes
Ehrlichiosis and Anaplasmosis
COMPLICATIONSCan be very severeRenal failureARDSDICEncephalitis3% mortalityWorse in patients with impaired host defensesWatch out for dual or triple infections withBorrelia burgdorferi and Babesia
Ehrlichiosis and Anaplasmosis
DIAGNOSISPeripheral smear looking for morulaeSerology PCR (state laboratories)CultureTreat based on epidemiologic and clinical clues. Do not delay while waiting for confirmation.
Ehrlichiosis and AnaplasmosisMorulae
Ehrlichiosis and Anaplasmosis
TREATMENTTreatment should not be delayed until laboratory confirmation is obtainedDoxycycline: 100 mg PO/IVUntil 3 days after fever abatesExpect response in 24 - 72 hoursPregnancy and children ???Rifampin 600 mg IV/PO has been used
Rocky Mountain Spotted FeverClinical Spectrum from mild to fulminantThroughout the Western HemisphereVector: Dermacentor Dog or Wood Ticks
Rocky Mountain Spotted Fever
Rocky Mountain Spotted FeverClinical ManifestationsIncubation Period: 3 - 14 days (ave 5 - 7)Non-specificFeverHeadacheMyalgiasGIRashMortality about 25% if treatment delayed
Rocky Mountain Spotted FeverRashBegins on day 3 - 5Only 15% have a rash on the first day10% never get a rashDo not wait for a rash to initiate therapyStarts on ankles and wristsSpreads centrally and to palms/s