Tick Borne Illness

 

 

 

 

Lyme

Borrelia Burgdorferi (spirochete), Ixodes Tick

Bull’s Eye rash-erythema migrans (usually 7-10 days post bite, but up to 30 days), though classic rash is described as red area with central clearing (15%), just the opposite can be present (32%) or homogenous erythema (53%) or vesicles/ulcerations (7%)  (Ann Intern Med 136(6):421, 2002)

 

Chronic arthritis, tropism for heart skin and CNS

Stage I:          Rash, malaise, arthralgias

II:       Meningoencephalitis, neuropathies (Bell’s)

LP-lymphocytes, increased protein

Lyme Carditis-AV BlockConduction abnormalities, especially varying degrees of atrio-ventricular (AV) block, are the most common cardiac manifestations, with complete, transient heart block occurring in about 50% of patients with cardiac involvement.53,55 Myocarditis, pericarditis, and myopericarditis also occur, and there is a single case report of pericarditis with tamponade

Opthamalogic involvement

III:  monoarticular arthritis and possible neurologic c/o for years

RX:  Doxycycline 100 mg BID x 21 days

Should present c low grade fever, if high, reconsider dx

1 dose of doxy post exposure has shown to reduce risk of Lyme 3.2 to .4%

In one European study of 231 culture-confirmed cases of EM, data were reported on those 34 patients who specifically recalled not only the tick bite but also the duration of attachment. In nine of the 34, the duration of attachment was less than six hours, and in an additional 16 of the 34, it was less than 24 hours.(Clin Infect Dis 1996;23)

Moreover, clinical LD has also been documented after as little as six hours of attachment in North America. (J Spirochet Tick-Borne Dis 1994;1:77-78)

Relapsing Fever

Borrelia spirochete from ticks

3 days fever, 1 week asymp, then relapse x 3-5

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Tularemia

Francisella tularemis-hard tick

Rabbits

Ulcerative skin lesion c lymphadenopathy

Alert lab, as it can be infectious to personnel

Rx c streptomycin 1 g BID x 14 days.

Typhoidal form

occurs in 10-15%

Ulcers and lymphadenopathy will be absent.

 

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Erlichiosis

From deer tick

Incubation of 1-60 days following bite, usually 1 week

Rash present only 10% of time

2 Forms:

Human Monocytic (HME)

ehrlichia chaffeensis

found is southern states and

fever, malaise, rigors, and headache.  Half will have rash.

Focal liver necrosis, with spleen, bone marrow, and LN involvement.

Human Granulocytic (HGE)

e. equi and phagocytophila

distribution similar to Lyme

Similar symptoms to HME, but rarely presents with rash

 

Leukopenia, thrombocytopenia, increased LFTs, anemia, hyponatremia

Rx c doxy, should see very rapid response

Also co-treat for Lyme

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Rocky Mountain Spotted Fever

Rickettsia Rickettsii-dog tip (dermacenter tick)

April to Sept is the most common time.

Fever/Rash/Tick Exposure (Can also present as nonspotted fever or it may actually be Erlichosis)

Rash usually begins on the fourth day after the bite (1-15 days)  erupting first on the ankles and wrists.  Rash then spreads to the extremities and trunk.  Starts as reddish macules that blanch with pressure, eventually advancing to petechiae/purpura.  Patients will also have fever, headache, myalgias, and malaise.  Abd pain and calf pain is also common.

Skin-vasculitis-arms, ankles, soles.  Irregular macules to maculopapular palpable generalized rash

Cor-myocarditis

Neuro-meningitis and HA, encephalitis and meningoencephalitis secondary to vascular injury

Pulmonary involvement leads to noncardiogenic pulmonary edema,

interstitial pneumonia, and adult respiratory distress syndrome (ARDS),

Renal manifestations: decreased glomerular filtration rates (GFRs) and

prerenal azotemia from hypovolemia.

Gastrointestinal (GI) endothelial cell injury leads to abdominal pain, nausea,

vomiting, and diarrhea. Many patients have guaiac positive stools.

Thirty percent of patients are anemic, and death has been reported from massive GI

bleeding.

 

Fever greater than 102 degrees F – 94% of reported cases

Fever within 3 days after tick bite – 66% of reported cases

Headache, frequently severe – 86% of reported cases

Myalgias – 85% of reported cases

CNS – 25% of patients develop signs of encephalitis (ie, confusion, lethargy).

GI – some patients present with anorexia, nausea, vomiting, diarrhea, and abdominal pain.

Approximately 10–15% of patients have Rocky Mountain spotless fever. This

more often is reported in older patients and African American patients.

Spotless fever is not synonymous with mild or early illness because

substantial proportions of the deaths occur in patients without a rash.

Classic distribution of RMSF rash on palms and soles occurs relatively late  in the course, in 43% of patients only after the fifth day of symptoms.  Some reports have observed 36–80% of RMSF patients without the classic distribution of rash on palms and soles. Four percent have skin necrosis or gangrene secondary to hypoperfusion.

Jaundice occurs in 8–9% of patients.

 

Dx:  Skin Biopsy or Ab

Rx:  Preferred treatment is Doxy 100 mg BID PO or IV for 7 days.  tetracycline,chloramphenicol

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Q Fever

Coxiella Burnetii

caused by aerosol, usually livestock, Australian slaughterhouse fever

Fever and Retrobulbar headache.

Myo and Pericarditis

Culture negative endocarditis (Vegetations are often absent on echo)

Doxycycline 200 mg loading then 100 mg BID

Chronic form requires months of treatment, the acute form two weeks.

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Babesiosis

Babesia Microti in the Northeast, B. Equi in the West

Protozoan-malaria like infection from ixodes tick

No rash

Presents very similarly to Erlichiosis but with a more predominant anemia

DIC and Jaundice

Lyme may be a coninfection

Quinine 650 mg PO TID

Clindamycin 600 mg IV Q8 or 300 mg PO Q8

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Colorado Tick Fever

Viral tick-borne illness

Coltivirus is a RNA virus of reoviridae family

Rapid fever 3-6 days after infection.  Fever can be biphasic, saddleback, with the intial fever abating and then returning 1-3 days later.

May see a relative leukopenia

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Tick Paralysis

Neurotoxin mediated.  Ascending paralysis cured by tick removal

Scrub Typhus

Ricketssial from chigger mites

Rx c tetracyclines

 

 

 

The author notes that prompt suffocation of ticks with application of chemicals is unlikely, given their extremely low respiratory rate (3-15 breaths per hour). A mechanical removal technique that utilizes a straight, slow pull appears to be least likely to result in retained mouth parts.

 

 

 

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Bites, Stings, Etc.

• Diethyltoluamide: repels biting insects, eg, mosquitoes, ticks, fleas; does not repel stinging insects, eg, bees, wasps; maximum protection with 35% to 40% concentration for adults; do not use >10% to 15% concentration on children (do not place on their hands or face); 100% DEET can be put on cotton, wool, or nylon clothing, but not skin; 100% concentration flammable, damages spandex, rayon, acetate, pigmented leather, and can dissolve plastic, vinyl, paint, and linoleum; needs to be applied only once daily; DEET in sunscreen reduces SPF by approximately 30%
• Permethrin: do not put on skin; repels and kills ticks, mosquitoes, and other arthropods; put on clothing, shoes, netting; lasts even after washing
• Items that do not work: sonic devices—“it will repel your friends but it doesn’t do much for insects”; bug zappers—kill bugs that eat mosquitoes; mosquitoes not attracted by light; citronella candle—works for 10 to 15 min; must sit right by it; “not so great”; Skin-So-Soft—“of limited value, but provokes intense loyalty”; works on gnats because thought it gets their feet oily so they cannot fly as well; not repellent

 

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