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CHAPTER 129
CHAPTER 132

RABIES
TICK-BORNE
ILLNESSES

29 JANUARY 2014
1. Which of the following is true?
A. Worldwide, dogs are the most commonly rabiesinfected animals.
B. Despite similaritie...
2. Regarding clinical rabies:
A. There are three distinct stages: prodrome, acute
neurological illness, death.
B. The incu...
3. Post-exposure rabies prophylaxis
A. Includes gentle wound irrigation with saline only, so as not to
irritate tissues an...
4. Which of the following is not commonly seen
with encephalitic, or “furious” rabies?
A.
B.
C.
D.
E.

Hydrophobia – the f...
5. Which is true in making the diagnosis of lyme disease?
A. Erythema chronicum migrans (ECM) is always a macular
rash wit...
6. Which of the following is the correct pair?
A.
B.
C.
D.
E.

Lyme disease – caused by a virus
Rocky Mountain Spotted Fev...
7. You suspect tick paralysis (TP) in an 8-year-old boy.
A. Treatment of choice is doxycycline for 3 weeks.
B. TP is an as...
8. A 35-year-old “outdoorsy” male presents to your
ED in upstate NY after syncope. You see a HR of
40-bpm with occasional ...
9. Which of the following is true regarding Lyme disease?
A.
B.
C.
D.
E.

Cattle are the preferred hosts of Ixodes scapula...
10. Regarding Rocky Mountain spotted fever (RMSF):
A. A maculopapular rash is the most common symptom.
B. It is most commo...
1. Which of the following is true?
A. Worldwide, dogs are the most commonly rabiesinfected animals.
B. Despite similaritie...
2. Regarding clinical rabies:
A. There are three distinct stages: prodrome, acute
neurological illness, death.
B. The incu...
3. Post-exposure rabies prophylaxis
A. Includes gentle wound irrigation with saline only, so as not to
irritate tissues an...
4. Which of the following is not commonly seen
with encephalitic, or “furious” rabies?
A.
B.
C.
D.
E.

Hydrophobia – the f...
5. Which is true in making the diagnosis of lyme disease?
A. Erythema chronicum migrans (ECM) is always a macular
rash wit...
6. Which of the following is the correct pair?
A.
B.
C.
D.
E.

Lyme disease – caused by a virus
Rocky Mountain Spotted Fev...
7. You suspect tick paralysis (TP) in an 8-year-old boy.
A. Treatment of choice is doxycycline for 3 weeks.
B. TP is an as...
8. A 35-year-old “outdoorsy” male presents to your
ED in upstate NY after syncope. You see a HR of
40-bpm with occasional ...
9. Which of the following is true regarding Lyme disease?
A.
B.
C.
D.
E.

Cattle are the preferred hosts of Ixodes scapula...
10. Regarding Rocky Mountain spotted fever (RMSF):
A. A maculopapular rash is the most common symptom.
B. It is most commo...
RABIES
• Lyssavirus (rhabdoviridae) – RNA
• Preference for CNS tissue
• In US:
•
•

Raccoons most common carrier
Bats most...
RABIES SYNDROME
• 5 stages of rabies infection:
• Incubation (30-90) days
• Prodrome – flu-like syndrome
• Acute neurologi...
RABIES TREATMENT
• Aggressive wound washing
•

Virucidal agent

•

HRIG 20 IU/kg (local if poss)

• Human rabies immune gl...
TICK-BORNE ILLNESS
Lyme Disease:
• Borrelia burgdorferi
• Ixodes ticks (white tailed deer)
• 3 stages of disease:
1. Local...
TICK-BORNE ILLNESS
Lyme Disease:
• 3 stages of disease:
1. Localized – rash
2. Disseminated – neuro / cardiac
Neuro: CN VI...
TICK-BORNE ILLNESS
Lyme Disease:
• 3 stages of disease:
1. Localized – rash
2. Disseminated – neuro / cardiac
3. Persisten...
TICK-BORNE ILLNESS
Lyme Disease:
• Diagnosis – ELISA for screening
• Treatment
•
•
•
•

Western Blot to confirm

doxycycli...
TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:
• Rickettsia rickettsii
• Multiple tick species
• Southeastern US
• April...
TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:
• Flu-like syndrome – fever, HA, myalgias
• Rash – begins distal, spreads...
TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:
• Diagnosis – clinical!
• Complications (vasculitis)

Confusion / sz / de...
TICK-BORNE ILLNESS
Ehrlichiosis:
• Similar syndrome to RMSF
• Two types: HME: human monocytic
HGE: human granulocytic

•
•...
TICK-BORNE ILLNESS
Babesiosis:
• Malaria-like hemolytic disease
• Intra-erythrocyte protozoa
• Sx: often asx, fevers, mala...
TICK-BORNE ILLNESS
Tularemia:
• Gram- coccobacillus Francisella tularensis
• Lagomorph resevoir

RABIES
TICK ILLNESS

Lyme...
TICK-BORNE ILLNESS
Tularemia:
• Gram- coccobacillus
• Lagomorph resevoir
• Sx: 1. ulceroglandular
2. glandular
3. orophary...
ACES: Rabies / Tick Illness
ACES: Rabies / Tick Illness
ACES: Rabies / Tick Illness
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  • A. B. Foxes commonly carry rabies.C. Raccoons are the most common source of rabies in the US.D. Estimated 55,000 cases/year worldwide.E. Lagomorphs can carry rabies.
  • A. 5 stages: incubation, prodrome, acute neurological illness, coma, deathB. Incubation period 30-90 days although 7yrs has been describedC. Hydrophobia = laryngospasm/diaphargm in response to trying to drink. Leads to overwhelming “terror” of water.D. Only 8 cases of survivors ever.E.
  • A. Aggressive wound scrubbing with virucidal agent.B.C. HRIG is injected IM.D. Regimen varies in different countries. Antigenically distinct viruses.E.
  • A.B.C.D.E.
  • A. There are multiple variations of ECM including linear/triangular.B. 2/3C. D.E. 90%
  • A. BorreliaburgdorferiB. Rickettsia rickettsii – Dermacentor ticksC. D. TP – neurotoxin – Dermacentor ticksE. Borreliahermsii
  • A. Treatment is removal of the tick.B. C. Commonly seen in SE and NWD. No abx neededE. Prevents Ach release
  • A. Carditis occurs 3-5 weeks after infection – ECM often goneB. No indication for aspirinC. NoD.E. Unstable pts require IV ceftriaxone or PCN
  • A. White tailed deer and white field mouseB. Serology is gold standard. Cx rarely positive.C.D. Palms and soles often sparedE. Antibiotics are indicated in all phases of disease
  • A. Fever is the most common Sx (99%) rash in 88%B. Most common in SEC. Platelets aren’t cells. The vasculitis is what leads to thrombocytopenia and petechiaeD. E. Triad only seen in 3%
  • Spares face
  • Spares face
  • Obligate intracellular bacteria that attack and kill white blood cells. Ehrlichiosis refers to 3 species of bacteria.
  • Northeastern US. Maltese cross formation.
  • Pneumonic can be weaponized.
  • Pneumonic can be weaponized.
  • Transcript of "ACES: Rabies / Tick Illness"

    1. 1. CHAPTER 129 CHAPTER 132 RABIES TICK-BORNE ILLNESSES 29 JANUARY 2014
    2. 2. 1. Which of the following is true? A. Worldwide, dogs are the most commonly rabiesinfected animals. B. Despite similarities to dogs, foxes rarely carry rabies. C. Skunks are the most common source of rabies in the US. D. Due to efforts by the WHO, deaths from rabies have dropped to less than 5000 cases/year. E. Rabbits and other langomorphs almost never carry rabies because they are herbivores.
    3. 3. 2. Regarding clinical rabies: A. There are three distinct stages: prodrome, acute neurological illness, death. B. The incubation period is typically < 72 hours. C. Hydrophobia is largely mythical and is almost never seen. D. One-quarter of patients with clinically-evident rabies will survive, although with neurologic sequelae. E. The duration of the incubation period depends on the severity of the bite.
    4. 4. 3. Post-exposure rabies prophylaxis A. Includes gentle wound irrigation with saline only, so as not to irritate tissues and increase the risk of viremia. B. Should include immunoprophylaxis for a pt who awakens to find a bat in her tent, even without a known bite. C. Should include human rabies immunoglobin (HRIG) applied topically to the wound. D. Involves the same regimen worldwide regardless of the type of exposure or country of origin.
    5. 5. 4. Which of the following is not commonly seen with encephalitic, or “furious” rabies? A. B. C. D. E. Hydrophobia – the fear of being in contact with water Aerophobia – the fear of air in motion Hyperactivity in response to light exposure Seizures Excessive salivation
    6. 6. 5. Which is true in making the diagnosis of lyme disease? A. Erythema chronicum migrans (ECM) is always a macular rash with central clearing. B. 10% of patients cannot recall the tick bite. C. Arthritis of early Lyme disease is episodic, symmetrical, polyarticular and attacks small joints. D. Common sites for ECM include ankles and skin folds. E. ECM is seen in 50% of early Lyme disease.
    7. 7. 6. Which of the following is the correct pair? A. B. C. D. E. Lyme disease – caused by a virus Rocky Mountain Spotted Fever – Ixodes sp. ticks Tularemia – lagomorph reservoir Tick paralysis – Rickettsia rickettsii Relapsing fever – parasitic (protozoal)
    8. 8. 7. You suspect tick paralysis (TP) in an 8-year-old boy. A. Treatment of choice is doxycycline for 3 weeks. B. TP is an ascending flaccid paralysis 4-7 days after tick attachment. C. TP is commonly seen in the southwest, distinguishing it from other tick-borne illnesses. D. A single dose of antibiotics is needed to kill the bacteria that produce the neurotoxin. E. The neurotoxin prevents acetylcholine breakdown.
    9. 9. 8. A 35-year-old “outdoorsy” male presents to your ED in upstate NY after syncope. You see a HR of 40-bpm with occasional p-waves. You realize: A. B. C. D. E. This cannot be due to Lyme disease as you see no ECM rash. You should administer aspirin immediately. This conduction abnormality can be managed outpatient. This patient needs a temporary cardiac pacemaker. The treatment of choice is still oral doxycycline.
    10. 10. 9. Which of the following is true regarding Lyme disease? A. B. C. D. E. Cattle are the preferred hosts of Ixodes scapularis Culture of blood/tissue is the gold standard for diagnosis Borrelia burgdorferi, a spirochete, spreads to all tissues Skin lesions on the palms and soles are common Once chronic symptoms develop, antibiotics are no longer useful
    11. 11. 10. Regarding Rocky Mountain spotted fever (RMSF): A. A maculopapular rash is the most common symptom. B. It is most commonly seen in Montana, Idaho, Colorado and Utah. C. Rickettsia rickettsii are obligate intracellular bacteria that live in platelets. This leads to thrombocytopenia / petechiae. D. Early RMSF mimics any self-limited febrile viral illnesses. E. A triad of fever, rash and tick bite is seen in 33% of cases.
    12. 12. 1. Which of the following is true? A. Worldwide, dogs are the most commonly rabiesinfected animals. B. Despite similarities to dogs, foxes rarely carry rabies. C. Skunks are the most common source of rabies in the US. D. Due to efforts by the WHO, deaths from rabies have dropped to less than 5000 cases/year. E. Rabbits and other lagomorphs almost never carry rabies because they are herbivores.
    13. 13. 2. Regarding clinical rabies: A. There are three distinct stages: prodrome, acute neurological illness, death. B. The incubation period is typically < 72 hours. C. Hydrophobia is largely mythical and is almost never seen. D. One-quarter of patients with clinically-evident rabies will survive, although with neurologic sequelae. E. The duration of the incubation period depends on the severity of the bite.
    14. 14. 3. Post-exposure rabies prophylaxis A. Includes gentle wound irrigation with saline only, so as not to irritate tissues and increase the risk of viremia. B. Should include immunoprophylaxis for a pt who awakens to find a bat in her tent, even without a known bite. C. Should include human rabies immunoglobin (HRIG) applied topically to the wound. D. Involves the same regimen worldwide regardless of the type of exposure or country of origin.
    15. 15. 4. Which of the following is not commonly seen with encephalitic, or “furious” rabies? A. B. C. D. E. Hydrophobia – the fear of being in contact with water Aerophobia – the fear of air in motion Hyperactivity in response to light exposure Seizures Excessive salivation
    16. 16. 5. Which is true in making the diagnosis of lyme disease? A. Erythema chronicum migrans (ECM) is always a macular rash with central clearing. B. 10% of patients cannot recall the tick bite. C. Arthritis of early Lyme disease is episodic, symmetrical, polyarticular and attacks small joints. D. Common sites for ECM include ankles and skin folds. E. ECM is seen in 50% of early Lyme disease.
    17. 17. 6. Which of the following is the correct pair? A. B. C. D. E. Lyme disease – caused by a virus Rocky Mountain Spotted Fever – Ixodes sp. ticks Tularemia – lagomorph reservoir Tick paralysis – Rickettsia rickettsii Relapsing fever – parasitic (protozoal)
    18. 18. 7. You suspect tick paralysis (TP) in an 8-year-old boy. A. Treatment of choice is doxycycline for 3 weeks. B. TP is an ascending flaccid paralysis 4-7 days after tick attachment. C. TP is commonly seen in the southwest, distinguishing it from other tick-borne illnesses. D. A single dose of antibiotics is needed to kill the bacteria that produce the neurotoxin. E. The neurotoxin prevents acetylcholine breakdown.
    19. 19. 8. A 35-year-old “outdoorsy” male presents to your ED in upstate NY after syncope. You see a HR of 40-bpm with occasional p-waves. You realize: A. B. C. D. E. This cannot be due to Lyme disease as you see no ECM rash. You should administer aspirin immediately. This conduction abnormality can be managed outpatient. This patient needs a temporary cardiac pacemaker. The treatment of choice is still oral doxycycline.
    20. 20. 9. Which of the following is true regarding Lyme disease? A. B. C. D. E. Cattle are the preferred hosts of Ixodes scapularis Culture of blood/tissue is the gold standard for diagnosis Borrelia burgdorferi, a spirochete, spreads to all tissues Skin lesions on the palms and soles are common Once chronic symptoms develop, antibiotics are no longer useful
    21. 21. 10. Regarding Rocky Mountain spotted fever (RMSF): A. A maculopapular rash is the most common symptom. B. It is most commonly seen in Montana, Idaho, Colorado and Utah. C. Rickettsia rickettsii are obligate intracellular bacteria that live in platelets. This leads to thrombocytopenia / petechiae. D. Early RMSF mimics any self-limited febrile viral illnesses. E. A triad of fever, rash and tick bite is seen in 33% of cases.
    22. 22. RABIES • Lyssavirus (rhabdoviridae) – RNA • Preference for CNS tissue • In US: • • Raccoons most common carrier Bats most common infector • Worldwide: Dogs most common RABIES Background Clinical Treatment TICK ILLNESS
    23. 23. RABIES SYNDROME • 5 stages of rabies infection: • Incubation (30-90) days • Prodrome – flu-like syndrome • Acute neurological illness • • • • Excitement Opisthotonus Hydrophobia Salivation, lacrimation, unste ady gait • Coma • Death RABIES Background Clinical Treatment TICK ILLNESS
    24. 24. RABIES TREATMENT • Aggressive wound washing • Virucidal agent • HRIG 20 IU/kg (local if poss) • Human rabies immune globulin • Human diploid cell vaccine • HDCV days 0, 3, 7, 14, 28 • In US treat: • skunk, raccoon, fox, bat RABIES Background Clinical Treatment TICK ILLNESS
    25. 25. TICK-BORNE ILLNESS Lyme Disease: • Borrelia burgdorferi • Ixodes ticks (white tailed deer) • 3 stages of disease: 1. Localized – rash Erythema migrans: annular, expanding erythematous lesion with central clearing (spares palms, soles) RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    26. 26. TICK-BORNE ILLNESS Lyme Disease: • 3 stages of disease: 1. Localized – rash 2. Disseminated – neuro / cardiac Neuro: CN VII palsy, meningitis, peripheral neuropathy Cardiac: myocarditis, pericarditis, heart block RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    27. 27. TICK-BORNE ILLNESS Lyme Disease: • 3 stages of disease: 1. Localized – rash 2. Disseminated – neuro / cardiac 3. Persistent – arthritis RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    28. 28. TICK-BORNE ILLNESS Lyme Disease: • Diagnosis – ELISA for screening • Treatment • • • • Western Blot to confirm doxycycline erythromycin amoxicillin ceftriaxone if unstable / ill RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    29. 29. TICK-BORNE ILLNESS Rocky Mountain Spotted Fever: • Rickettsia rickettsii • Multiple tick species • Southeastern US • April – September RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    30. 30. TICK-BORNE ILLNESS Rocky Mountain Spotted Fever: • Flu-like syndrome – fever, HA, myalgias • Rash – begins distal, spreads proximal macules  petechiae  purpura (d/t vasculitis) RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    31. 31. TICK-BORNE ILLNESS Rocky Mountain Spotted Fever: • Diagnosis – clinical! • Complications (vasculitis) Confusion / sz / delirium DIC Heart failure / ARDS Renal failure Loss of digits / limbs • Treatment – doxycycline, chloramphenicol RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    32. 32. TICK-BORNE ILLNESS Ehrlichiosis: • Similar syndrome to RMSF • Two types: HME: human monocytic HGE: human granulocytic • • • • Pancytopenia, hypoNa++,↑ LFTs Dx: clinical suspicion Tx: doxy, tetracycline, chloramphenicol Complications: DIC, renal failure, coma, death RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    33. 33. TICK-BORNE ILLNESS Babesiosis: • Malaria-like hemolytic disease • Intra-erythrocyte protozoa • Sx: often asx, fevers, malaise hepatosplenomegaly, jaundice • Dx: peripheral smear • Tx: only immunocomp, quinine + clinda or atovaquone + azithro RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    34. 34. TICK-BORNE ILLNESS Tularemia: • Gram- coccobacillus Francisella tularensis • Lagomorph resevoir RABIES TICK ILLNESS Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
    35. 35. TICK-BORNE ILLNESS Tularemia: • Gram- coccobacillus • Lagomorph resevoir • Sx: 1. ulceroglandular 2. glandular 3. oropharyngeal 4. pneumonic 5. oculoglandular 6. typhoidal RABIES TICK ILLNESS Tx: doxy, gent Dx: clinical, serology Lyme Dis. RMSF Ehrlichiosis Babesiosis Tularemia
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