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Tick-Borne Infections
Challenges
Expanding / changing geography of ticks / infections
New infections / newly recognized “old” infections
Newly identified -- new Ehrlichia species 2011
Old infections | new to MN -- Powassan fever, RMSF
Clinical clues that might suggest tick-borne infection
Fever plus [rash, severe headache, mild hepatitis]
low blood cell counts [esp platelets]]
Diagnostic tests -- blood smear, serology, PCR
Daniel J Anderson, MD](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Tick-Borne Infections Guide
- 1. 1 Tick Borne Infections Daniel J Anderson, MD Epidemiology Ecology Clinical Characteristics Diagnosis Treatment Prevention
- 2. 2 Tick-Borne Infections Challenges Expanding / changing geography of ticks / infections New infections / newly recognized “old” infections Newly identified -- new Ehrlichia species 2011 Old infections | new to MN -- Powassan fever, RMSF Clinical clues that might suggest tick-borne infection Fever plus [rash, severe headache, mild hepatitis] low blood cell counts [esp platelets]] Diagnostic tests -- blood smear, serology, PCR Daniel J Anderson, MD
- 4. 4 EPIDEMIOLOGY Tick Borne Infections - MN/WI Daniel J Anderson, MD
- 5. 5 Lyme disease Anaplasmosis Ehrlichiosis Babesiosis Powassan Fever RMSF (Rocky Mountain Spotted Fever) Tick Borne Infections - MN/WI Daniel J Anderson, MD
- 6. 6 Tick Borne Infections - MN Daniel J Anderson, MD Lyme 1,293 cases in 2010 (21 % increase from 2009) Anaplasma 720 cases in 2010 ( > 100 % increase from 2009) Ehrlichia New species of Ehrlichia reported 2011 Babesia 56 cases in 2010 (31 in 2009) Powassan (50 cases in all of US 1958-2009 ) 6 MN cases 2008 - 2010 1 MN death from Powassan 2011 (at ANW) RMSF 2000 cases / year in all of US Sporadic cases in MN 1 death in MN 2009
- 7. 7Daniel J Anderson, MD http://www.health.state.mn.us/divs/idepc/diseases/lyme/highrisk.html Risk of Tick-borne infection is not uniform throughout the state. The highest risk is central and SE sections
- 8. 8Daniel J Anderson, MD More Anaplasma than Lyme in Aitkin, Beltrami, Cass, Crow Wing & Hubbard counties The risk of different tick-borne infections also is not uniform throughout the state
- 9. 9 RMSF annual incidence is increasing Daniel J Anderson, MD
- 10. 10 Ecology Tick Borne Infections - MN/WI Daniel J Anderson, MD
- 11. 11 Ticks <> Diseases Daniel J Anderson, MD TICK Ixodes scapularis Anaplasmosis Lyme disease Babesiosis Powassan Fever Ambyloma americanum Ehrlichiosis RMSF STARI Tularemia Dermacentor variabilis Dermacentor andersoni RMSF Tularemia DISEASE ORIGIN Endogenous “Imported” (returning from travel)
- 12. 12 Comparison of ticks Lyme, Anaplasma, Babesia, Powassan Ehrlichia, STARI, Tularemia, RMSF RMSF, Tularemia Daniel J Anderson, MD
- 13. 13 Blacklegged tick (Deer Tick) Ixodes scapularis Lyme, Anaplasmosis, Babesiosis, & Powassan Daniel J Anderson, MD
- 14. 14 Lone Star tick Amblyoma americanum Ehrlichia, RMSF STARI, Tularemia Daniel J Anderson, MD
- 15. 15 American dog tick Dermacentor variablis RMSF, Tularemia, Human Monocytic Ehrlichiosis Daniel J Anderson, MD
- 16. 16 Brown dog tick Rhipicephalus sanguineus RMSF Daniel J Anderson, MD
- 17. 17 Clinical Tick Borne Infections - MN/WI Daniel J Anderson, MD
- 18. 18 Tick Borne Illnesses Fever, chills, myalgias, arthralgias Fever, chills, rash Fever, chills, CNS findings (encephalitis / paresis / paralysis / focal findings) Hepatitis / transaminitis Leukopenia, thrombocytopenia, anemia Daniel J Anderson, MD
- 19. 19 Diagnostic Clues / Hints Appropriate Exposure Potential Suggestive Symptoms Fever, rash, arthralgias, headache, neurologic findings Exam Rash, splenomegaly Labs Low peripheral blood cell counts (esp thrombocytopenia) Mild transaminitis / hepatitis Blood smear, serologies, nucleic acid based tests (NATs) CSF analysis Daniel J Anderson, MD
- 20. 20 Lyme 3-30 days after tick bite (BEFORE fever) Erythema migrans (EM) 70 - 80 % of patients get rash STARI Very similar to Lyme disease “expanding Bull’s Eye” lesions RMSF 90 % -- usually 2 - 5 days AFTER fever Initially small pink macules on wrists / ankles LATER petchial Tularemia Skin ulcer w regional lymphadenopathy RASH Daniel J Anderson, MD
- 21. 21 Hgb Platelets LFTs WBC Lyme Disease RMSF anemia low platelets transaminitis leukopenia Anaplasmosis Ehrlichiosis Babesiosis Powassan Fever anemia transaminitis leukopenia then leukocytosis Daniel J Anderson, MD
- 22. 22 Lyme Disease Daniel J Anderson, MD
- 23. 23 Lyme Pathogen. Borrelia burgdorferi (spirochete) Clinical EM rash, Bell’s palsy, AV block, CNS, Arthropathy Co-infection -- ~ 5-10 % with Anaplasma || ~ 2 % with Babesia Dx IgM: HGA can cause false + IgM for Lyme IgM can persist for years (even if no clinical disease) After 8 weeks, should always have + IgG Treatment -- no data for prolonged therapy Prevention -- Doxycycline 200 mg if engorged tick < 72 h after bite Daniel J Anderson, MD
- 24. 24 Lyme Diagnosis Clinical diagnosis (ie no serology needed) if exposure to deer tick AND Bilateral Bell’s Palsy III ° AV block or complete heart block [CHB] Characteristic erythema migrans [EM] rash Daniel J Anderson, MD
- 25. 25Daniel J Anderson, MD
- 26. 26 Lyme Serology Criteria for positive Western blot IgG ≥ 5 bands Western blot IgM ≥ 2 bands Chronology Early IgM + After 4-8 weeks nearly all IgG + (regardless of RST test strain used) SO, if IgG still negative > 8 weeks illness, then “+ IgM” is false + IgM HGA can cause false + IgM + IgM can persist for years ... may NOT correlate at all w clinical state Daniel J Anderson, MD
- 27. 27 Lyme Testing: Unvalidated tests with unproven use Test assays whose accuracy and clinical usefulness have not been adequately established. Unvalidated tests available as of 2011 include: • Capture assays for antigens in urine • Culture, immunofluorescence staining, or cell sorting of cell wall- deficient or cystic forms of B. burgdorferi • Lymphocyte transformation tests • Quantitative CD57 lymphocyte assays • “Reverse Western blots” • In-house criteria for interpretation of immunoblots • Measurements of antibodies in joint fluid (synovial fluid) • IgM or IgG tests without a previous ELISA/EIA/IFA Daniel J Anderson, MD
- 28. 28 Lyme PCR Most useful for late arthritis if done on synovial fluid Limited use in CSF Daniel J Anderson, MD
- 29. 29 Lyme Disease Treatment Oral Therapy for all except neurological / late arthritis or initially for high degree AV block IV therapy: for meningitis, late arthritis or initially for high degree AV block Daniel J Anderson, MD
- 30. 30 Lyme Disease Rx Duration 2-3 weeks for most early infections - tho’ some data suggest 10 days sufficient 2-4 weeks for meningitis / arthritis 4-8 weeks for late arthritis Prolonged courses of therapy? . No proven benefit There are proven adverse consequences (C diff, death, IV clots, ...) Daniel J Anderson, MD
- 31. 31 Lyme Disease Treatment Reinfection rate rare (approximately 4 %) Post Exposure Prophylaxis (PEP) - single dose doxycycline 200 mg if < 72 hours Daniel J Anderson, MD
- 33. 33 Human Granulocytic Anaplasomsis [HGA] Pathogen Anaplasma phagocytophilum Clinical up to 35 % coinfected with Lyme and/or Babesia fever, chills, headache, myalgia, and malaise,cough, diarrhea, confusion, and lymphadenopathy, 17 % severe multisystem organ failure / SIRS / even death (Lyme does not do this) rash is not common Data leukopenia, thrombocytopenia, mild hepatitis / transaminitis Daniel J Anderson, MD
- 34. 34 Human Granulocytic Anaplasomsis [HGA] Dx Peripheral blood smear (in WBCs) 30 - 80 % + morulae seen in granulocytes Serology NATs (PCR) Treatment Doxycycline (will also cover potential Lyme coinfection) Daniel J Anderson, MD
- 36. 36 Human Monocytotropic Ehrlichiosis [HME] Pathogens E canis / E chaffeensis / / E muris Clinical < 50 % with rash (but more often than with HGA) More common farther south than Anaplasmosis (HGA) Data -- Lymphopenia, morulae RARE on blood smear (vs HGA) Dx -- Serology, PCR Treatment - doxycycline Daniel J Anderson, MD
- 37. 37Daniel J Anderson, MD Anaplasmosis HGA Ehrlichiosis HME Farther north MN & WI Farther south Iowa & Missouri ~ 50 % morulae on blood smear RARELY see morulae in blood smear rash is RARE rash more common (though still < 50 %) serology / PCR blood smear serology / PCR doxycycline doxycycline
- 39. 39 Babesiosis Pathogen Babesia microtii (MN, WI, East coast), B divergens & B duncani in other locations Clinical fatigue/weakness/malaise followed within days by fever (>38° C) and one or more of the following: shaking chills, sweats, headache, myalgia, arthralgia, and anorexia Malaise, myalgia, arthralgia, and shortness of breath differentiate babesiosis from other febrile illnesses fatigue and malaise persist for several months Daniel J Anderson, MD
- 40. 40 Babesiosis Diagnosis Blood smear (in RBCs) Tetrad of ring forms “Maltese Cross” Serology PCR Treatment Mild: atovaquone + azithromycin Severe: clindamycin + quinine + exchange transfusion Daniel J Anderson, MD
- 41. 41 Less Common Daniel J Anderson, MD
- 42. 42 Powassan Encephalitis Pathogen: Flavivirus Same viral family as Dengue, Yellow Fever, West Nile Clinical 50 % w focal neurologic signs / symptoms Olfactory hallucinations & temporal lobe seizures (DDx Herpes encephalitis) Daniel J Anderson, MD
- 43. 43 Powassan Encephalitis Data Leukopenia first (the high WBC), thrombocytopenia, transaminitis CSF lymphocytosis (usually < 100 cells) MRI => thalamic, basal ganglia lesions Dx => IgM (serum / CSF) /4 x increase serum IgG Treatment => supportive Dx => serologic (some cross reactivity with other flaviviruses (for example Dengue fever) Daniel J Anderson, MD
- 44. 44 RMSF Pathogen Rickettsiae rickettsii Clinical (2 - 14 day [median 7] incubation) fever, headache, nausea / emesis / diarrhea rash usually ~ 3 days AFTER other signs begins wrists / ankles Data thrombocytopenia (sometimes anemia) WBC often nl coagulopathy, DIC, CXR changes Dx serology (? PCR on clinical specimens) Treatment doxycycline early in course illness Daniel J Anderson, MD
- 45. 45 Differential Diagnosis Tick Borne Infections - MN/WI Daniel J Anderson, MD
- 46. 46 Differential Diagnoses Paralytic illnesses Polio, Tick Paralysis, Guillain-Barré, Cervical cord lesion Encephalitidies Herpes simplex encephalitis (HSE) -- critical diagnosis because of the urgent need for intravenous acyclovir for HSE Febrile illnesses with rash Parvovirus B19, Measles, Meningococcal disease, others Fever with transaminitis Lyme, HGA, Babesiosis, Acute hepatitis (HBV, HAV, HCV) Daniel J Anderson, MD
- 48. 48 Diagnosis Clinical Lyme (rash, bilateral Bell’s palsy, III° AV block in o/w healthy pt) Serological Lyme, HGA, RMSF, Powassan Blood / CSF (in CSF only IgM <> indicates local production) NAT (Nucleic Acid based Tests) Powassan Fever, HGA, Babesiosis Blood / CSF Peripheral Blood Smear evaluation Babesiosis, HGA, HGE Daniel J Anderson, MD
- 49. 49 Clinical Summary Daniel J Anderson, MD Lyme Aseptic meningitis Heart Block Rash, Arthritis Anaplasma headache, low platelets, hepatitis, renal failure Ehrlichia Headache, low cell counts, renal failure, hepatitis Babesia fever, headache, pancytopenia Powassan Encephalitis RMSF Fever, severe headache, ... 3 days later rash
- 50. 50 Diagnosis Summary Daniel J Anderson, MD Lyme Clinical (III ° AV block, Bell’s Palsy, EM Rash) Serology, Lumbar puncture Anaplasma Blood smear, PCR, serology Ehrlichia Blood smear, PCR, serology Babesia Blood smear, PCR, serology Powassan Serology supporting evidence by head MRI RMSF Serology
- 51. 51 Treatment Summary Daniel J Anderson, MD Lyme Anaplasma doxycycline/ azithromycin Ehrlichia doxycycline / azithromycin Babesia atovaquone + azithromycin (for severe disease clindamyin + quinine + exchange transfuse) Powassan supportive care RMSF doxycycline PO doxycycline / amoxicillin IV ceftriaxone 2-4 weeks early 4-8 weeks late disease / arthritis no “long term” Rx
- 52. 52 Tick-borne Infections Tick ecology changing (expanding geography of ticks) New / Newly recognized infections Fever, rash, low cell counts (esp thrombocytopenia), transaminitis New diagnostic modalities (esp NAT-based testing) Lyme testing (even western blot IgM) not necessarily definitive Doxycycline -- Rx of choice - Lyme, Anaplasma / Ehrlichia, RMSF Tick avoidance / prevention is the best Daniel J Anderson, MD
- 53. 53 Tick Removal Grab Tick with tweezers close to skin Pull steadily straight up Clean area [alcohol, iodine, soap & H20] Daniel J Anderson, MD
- 54. 54Daniel J Anderson, MD Lyme, Babesia, HGA Powassan Fever RMSF, Tularemia. Human Monocytic Ehrlichiosis Ticks / Illnesses & Geography
- 55. 55 References 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) 43 (9): 1089-1134 http://cid.oxfordjournals.org/content/43/9/1089.full National Institue of Allergy and Infectious Diseases. Tickborne Diseases website. http://www.niaid.nih.gov/topics/tickborne/pages/default.aspx