The patient recently went hiking and has developed leg paralysis. This is likely due to tick paralysis caused by a toxin secreted by certain tick species that blocks acetylcholine during feeding. Tick paralysis is most common in the Southeast in spring and summer. Removing the attached tick promptly can reverse the paralysis, so the doctor should conduct an examination to look for any remaining ticks and ensure removal of the culprit.
2. Just got back from Africa…
Flu like symptoms
Bleeding
??????
3. Marburg and Ebola Viruses
What to look for…
Recent travel (specifically Africa)
Hemorrhagic fever 7-10 days after
exposure
Head ache, fever, myalgias,
arthralgias, lethargy
GI – N/V/D
Bleeding from the nose, mouth,
rectum, eyes and ears
4. Marburg and Ebola Viruses
Labs – Thrombocytopenia,
Hemorrhagic anemia (specifically
GI med student finger positive)
ELISA and PCR for confirmation
Management Supportive (death
is common)
5. Parents find a bat in an infants
room when they wake up in the
AM.
What are you worried about?
6. Rabies
Roughly 3 cases per year in the US
however 40,000 deaths / yr
worldwide
Most common bites for Dogs and
Bats
7. Rabies
HIGH RISK
Raccoon
Skunk (not spray)
Fox
Bats
Coyote
Bite from larger
carnivore in endemic
area
LOW RISK
Domestic animals
Small rodents
Lagomorphs
Groundhogs /
Woodchucks based on
if area is endemic
SMALL ANIMALS ARE
KILLED WHEN BITTEN
8. Rabies
Rhabdovirus transmitted though saliva
into wound or mucous membrane
Replicates in muscle cells near bite site
and stays at site during incubation period
for 30 TO 90 DAYS. Head or neck is
shorter
Tracks through peripheral nerves to brain
stem, replicates, then enters salivary
glands
9. Rabies Symptoms
Prodrome ->URI / GI viral like
symptoms
Rabies Fury (encephalitis)->
agitation, irritable, hallucinations,
ataxia, weakness, sz
Aerophobia then Hydrophabia
Coma after one week followed
quickly by death
10. Rabies Dx
History, History, History
Bite or exposure to suspected animal
Animal should be observed for 10 DAYS
with animal vaccination hx obtained
Travel to endemic area South West
(SoCal spared), NorCal, Midwest, East
Brain Biopsy
11. Rabies Management
Clinical Rabies? – Sorry! Otherwise,
Post Exposure Prophylaxis!!!
PEP for bats with no history or signs
if in room while sleeping or
unattended child or someone with
dementia
12. Rabies PEP
Scrubbing with soap within 3 hours nearly
100% effective (Benzalkonium chloride,
povidone-iodide)
Passive immunity Human Rabies
Immunoglobulin (HRIG) 20 IU/kg as much as
possible in and arround wound, the rest at distant
site IM (must be 2 sites)
Active immunity Human diploid cell
vaccine (HDCV)
If no previous vacc then 1ml IM deltoid on days
0,3,7,14,28
If previously vacc then days 0,3
15. Small Pox (Variola) Sympt
Prodrome fever, malaise, back
pain, myalgias
Rash was often confused with
varicella
Macules
/ Papules that progress to
pustules over 1 to 2 days
Uniform progression (unlike vericalla)
Centerfugal distribution usually face
and oral mucosa first
16. Small Pox (Variola) Dx
If clinically suspected..
Viral swab of oral mucosa or open
pustule
Then call CDC and authorities for
suspected terrorist attack
17. Small Pox (Variola) Management
Contact and droplet iso
Iso family and close contacts
Vaccination and immunoglobulin
Supportive once rash appears
18. Pt returned from (insert 3rd world
country) now low grade fever
which has been spiking high, flu
like symptoms and very dark urine
with a positive VDRL????
23. Malaria Management
Uncomplicated Chloroquine (Haiti,
Dominican Rep, Central America parts of
Middle East)
Chloroquine Resistance? Quinine +
Doxy
P. Falciparum? IV quinine or quinidine
(causes profound hypoglycemia and
dysrythmias)
Primaquine? hepatic phases of P. ovale
and vivax – after testing for G6PD
25. Sporotrichosis Etiology
Fungal infection by Sporothrix
scheenckii
Mold
on plants– Roses
Cats, Armidillos
Inoculation into skin
Farmers, gardeners, forestry
workers
26. Sporotrichosis Hx/Symptoms
Acute:
Painless red papule
or papules
Lesions can be
delayed up to a
month post
exposure
Lymphocutaneous
spread
Chronic:
Skin leasions may
persist
intermittently for
years
Pulm involvement
with cough, fever,
and weight loss
Osteomylitis,
tenosynovitis,
osteomyelitis
CNS unlikely
27. Sporotrichosis Dx/Management
Organisms found in skin bx or body
fluid (blood, sputum, joint fluid)
MANAGEMENT
CUTANEOUS
ONLY months of azole tx
DISSIMINATED
Itraconazole if well appearing
Amphotericin if sick
31. Babesiosis
THE MALARIA OF NORTH EAST USA
Protazoan Maria-like parasite
Babesia
Multiplies in RBC’s resulting in
hemolysis then microvasculature
has sludging effect
Vector Ixodes (dammini, scapularis,
pacificus) with primary reservoir
white footed mouse
32. Babesiosis Symptoms/Signs/Dx
Fevers, myalgias, dark urine, headache,
fatigue
Hepatospleenomegally, anemia,
thrombocytopenia, increased LFT’s and
LDH
Giemsa and Wright stains on peripheral
smears reveal rings
Tetrad forms on smear is pathognomonic
34. I went hiking and got a tick bite. A
few days later I got a fever. A few
days after that it went away. A few
days after that it came back and
now I feel like crap. What do I
have??
35. Colorado Tick Fever
Western US and Germany
Dermacentor Andersoni (wood tick)
Can get with concurrent Rocky
Mountain Spotted Fever
Incubation of 3-6 days after tick
bite
36. Colorado Tick Fever
Symptoms/Signs:
1
Acute chills,
lethargy, H/A,
photophobia, abd
pain, severe
myalgias
2
Fever breaks
after 2-3 days
3
Recurs for
another 3 days
Management:
Supportive
38. Lyme Disease
Most common tick disease
North central to Northeastern and
Mid Atlantic areas --- also global
Spirochete – Borrelia Burgdorferi
Tick – Ixodes dammini
Primary reservoir is field mouse
Transmission 2 days after tick
attachment
39. Lyme Disease
Early:
Erythema Migrans
Secondary spread to
palms and soles
H/A (meningeal
irritation)
Hepatitis / Pharyngitis
Acute Disseminated:
Neuro findings (4
wks)
Meningeoencephalitis,
cranial neuropathy
(Bells) which can be
bilateral, extremity
radiculopathy with
assymetric
pain/weakness
Cardiac (3-5 wks)AV
block is most common
with gradual resolution
Arthritis (wksmonths)mono or
polyarticular
asymmetric arthritis
Late: (>1 yr)
10% chronic arthritis
Neuro fatigue
syndromes, chronic
encephalopathy
(memory impairment,
hypersomnolence, mild
psych)
40. Lyme Disease Dx
Only some pts report tick bite <50%
EM is diagostic
IgM peaks at 3-6 weeks then
nondiagnostic
IgG dectable at 2mo, peaks at 12 mo
ELISA, Western blot, PCR for confirmation
Lumbar puncture if neuro Lyme
41. Lyme Disease Management
Vaccination and Doxy
prophylax single dose
(72 hours after finding
an engorged tick) only
in high risk areas
Early Lyme Dz Doxy
100 Bid X 3wks
If Preg or Peds
amoxicillin
Jarish-Herxhiemer
rxn fever,
tachycardia, mylaise,
h/a (ASA/Rest for tx)
Early Disseminated
Doxy or amox X 1
month and no steroids
for Bells
Meningitis/Enceph –
IV Ceftriaxone or PCN
Cardiac first degree –
doxy or amox for 2130 days
Cardiac high degreeAdmit to tele, IV
Ceftriaxone or PCN
42. Lyme Disease Management
Late Dz:
Arthritis
Doxy or Amox for 30 days if
persistant 2nd course OR 2-4wks IV
Ceftriaxone
Neuro
Ceftriaxone 2 G daily for 2 -4
wks often with no complete resolution
of symptoms
43. WUZ GATOR HUNTIN WITH MY
CUZ/WIFE AND I SAW A TICK ON
ME!! NOW I’M SICK!! WHAT IS
IT DOC??? (in July)
44. Erlichiosis
Spotless RMSF
Summer Dz
Endemic South Central and South
Atlantic
Tick Ixodes scapularis
Gram neg coccbacilli -- Organisms
live in the leukocytes
Onset 9 days after bite (most pts
90% report bite)
48. Rocky Mountain Spotted Fever
5% mortality
Endemic in 48 contiguous states except
Maine– Most prevalent in Southeast
Ricketia Rickettsii–
Obligate intracellular gram neg coccobacillus
Orginisms multiply in vascular endothelium
and smooth muscle
Cause tPA and VWF release
Ticks – Dermacentor anderosi and
variabilis (wood tick and dog tick). All
warm blooded animals are resevoir
49. RMSF signs/symptoms
Tick bite history in most
Abrupt onset of symptoms:
h/a,
myalgias, N/V, abd mm myositis,
calf tenderness
Rumple-Leede phenom– petechiae
after BP cuff
Centripital Rash – initial pink/red
blanchable macules, may involve palms
and soles
52. Went hiking a week ago and now I
can’t move my legs. What do I
have and can you fix me?
53. TICK PARALYSIS
Most common in Southeast in spring
and summer
Dermacentor Species – toxin
secreted in salivary glands during
blood meal blocks acetylcholine
release
54. TICK PARALYSIS
Signs Symptoms:
Restlessness and
irritability 4-7 days
Then ascending
flacid paralysis +/ataxia
Loss of DTRs,
bulbar involvement
then resp paralysis
Management
Remove Tick
Improvement in a
few hours and
recovery within 48
hours
57. Tularemia
Most common in southwest
Untreated mortality 5-30%
Treated <1%
Francisella tularenis Gram neg
pleomorphic bacillus
Reservoirs RABITS, domestic cat, Tick
(Amblyomma Americanum and
Dermacento Variabilis)
Mode of transmission dictates illness
58. Tularemia Manifestations
Ulceroglandular
Most common
Ulceration of papules 2
days after tick innoculation
Glandular
2nd most common
Lymphadenopathy without
ulceration
Unilateral conjunctivitis
with regional adenopathy
Systemic dz without
identified entry site
f/c/abd pain/ night sweats
Pulmonary
Oculoglandular
Typhoidal
Direct inhalation
Similar to bacterial
pneumonia
Concern for bio warfare
Oropharyngeal
Least Common
Undercooked rabbit meat
Nonspecific GI issues… may
progress to GI bleed
59. Tularemia Dx/ Management
Dx:
Clinical history
Bubos
Seerologic testing
Do not aspirate LN
due to risk of
transmission to
health care worker
MaInagement:
Isolation not
required
Streptomysin for
active dz
PEP Doxy 100 BID
X 14 days
62. Infectious Control Droplet
Particles > 5 microns
Neg pressure not required
Doors may be open
Standard precautions with mask when
within
3FT of pt
Meningitis, diptheria, pertussis, plague,
bacterial pneumonia, scarlet fever,
adenovirus, mumps, parvovirus
63. Occupational Exposure
Hep B blood exposure
Consider booster if >10 yrs if prior
immunization and > 10mIU/ml 3 months after
3rd dose
If Prior immunization but non responder HBIG
and Vaccine concurrently or HBIG at injury and
again 1 month later
Unkown titers then draw and treat depending
on results if lab results > 48 hours then treat
No prior immunization same options as
nonresponder
64. Occupational Exposure
Hep C blood exposure
Transmission
is approximately 2-7%
Good Luck!! No treatment or
vaccination exists
65. Occupational Exposure
HIV blood exposure
Risk of all percutaneous exposure 0.3% if
source is HIV positive
Viral load of source makes a difference
Mucous memb exposure with blood risk 0.1%
PEP Recommend only for high risk exposure
including
Pt with AIDS plus mucous memb or skin
compramise
Patients with symptomatic HIV
Acute seroconversion
High Viral load >1500 copies/ml
66. Occupational Exposure
HIV blood exposure
Regimen:
Zidovudine and Lamivudine X 1 month
Administer as soon as possible
May be ineffective if started > 24 hours