1Tick BorneInfectionsDaniel J Anderson, MDEpidemiologyEcologyClinical CharacteristicsDiagnosisTreatmentPrevention
2Tick-Borne InfectionsChallengesExpanding / changing geography of ticks / infectionsNew infections / newly recognized “old...
3EpidemiologyEcologyClinicalDiagnosisDifferential DiagnosisDaniel J Anderson, MD
4EPIDEMIOLOGYTick Borne Infections - MN/WIDaniel J Anderson, MD
5Lyme diseaseAnaplasmosisEhrlichiosisBabesiosisPowassan FeverRMSF (Rocky Mountain Spotted Fever)Tick Borne Infections - MN...
6Tick Borne Infections - MNDaniel J Anderson, MDLyme1,293 cases in 2010(21 % increase from 2009)Anaplasma720 cases in 2010...
7Daniel J Anderson, MDhttp://www.health.state.mn.us/divs/idepc/diseases/lyme/highrisk.htmlRisk of Tick-borne infection is ...
8Daniel J Anderson, MDMore Anaplasma than Lyme inAitkin, Beltrami, Cass, Crow Wing& Hubbard countiesThe risk of different ...
9RMSF annualincidence isincreasingDaniel J Anderson, MD
10EcologyTick Borne Infections - MN/WIDaniel J Anderson, MD
11Ticks <> DiseasesDaniel J Anderson, MDTICKIxodes scapularisAnaplasmosisLyme diseaseBabesiosisPowassan FeverAmbyloma amer...
12Comparisonof ticksLyme, Anaplasma, Babesia, PowassanEhrlichia, STARI, Tularemia, RMSFRMSF, TularemiaDaniel J Anderson, MD
13Blacklegged tick (Deer Tick)Ixodes scapularisLyme, Anaplasmosis,Babesiosis,& PowassanDaniel J Anderson, MD
14Lone Star tickAmblyoma americanumEhrlichia, RMSFSTARI, TularemiaDaniel J Anderson, MD
15American dog tickDermacentor variablisRMSF, Tularemia,Human Monocytic EhrlichiosisDaniel J Anderson, MD
16Brown dog tickRhipicephalus sanguineusRMSFDaniel J Anderson, MD
17ClinicalTick Borne Infections - MN/WIDaniel J Anderson, MD
18Tick Borne IllnessesFever, chills, myalgias, arthralgiasFever, chills, rashFever, chills, CNS findings(encephalitis / pa...
19Diagnostic Clues / HintsAppropriate Exposure PotentialSuggestive SymptomsFever, rash, arthralgias, headache, neurologic ...
20Lyme3-30 days after tick bite (BEFORE fever)Erythema migrans (EM)70 - 80 % of patients get rashSTARIVery similar to Lyme...
21Hgb Platelets LFTs WBCLyme DiseaseRMSF anemialowplateletstransaminitis leukopeniaAnaplasmosisEhrlichiosisBabesiosisPowas...
22Lyme DiseaseDaniel J Anderson, MD
23LymePathogen. Borrelia burgdorferi (spirochete)ClinicalEM rash, Bell’s palsy, AV block, CNS, ArthropathyCo-infection -- ...
24Lyme DiagnosisClinical diagnosis (ie no serology needed) if exposure to deer tick ANDBilateral Bell’s PalsyIII ° AV bloc...
25Daniel J Anderson, MD
26Lyme SerologyCriteria for positiveWestern blot IgG ≥ 5 bandsWestern blot IgM ≥ 2 bandsChronologyEarly IgM +After 4-8 wee...
27Lyme Testing:Unvalidated tests with unproven useTest assays whose accuracy and clinical usefulness have not beenadequate...
28Lyme PCRMost useful for late arthritis ifdone on synovial fluidLimited use in CSFDaniel J Anderson, MD
29Lyme Disease TreatmentOral Therapy for all except neurological / latearthritis or initially for high degree AV blockIV t...
30Lyme Disease Rx Duration2-3 weeks for most early infections - tho’some data suggest 10 days sufficient2-4 weeks for meni...
31Lyme DiseaseTreatmentReinfection rate rare (approximately 4 %)Post Exposure Prophylaxis (PEP) -single dose doxycycline 2...
32AnaplasmosisDaniel J Anderson, MD
33Human Granulocytic Anaplasomsis [HGA]Pathogen Anaplasma phagocytophilumClinicalup to 35 % coinfected with Lyme and/or Ba...
34Human Granulocytic Anaplasomsis [HGA]DxPeripheral blood smear (in WBCs)30 - 80 % + morulaeseen in granulocytesSerologyNA...
35EhrlichiosisDaniel J Anderson, MD
36Human Monocytotropic Ehrlichiosis[HME]PathogensE canis / E chaffeensis / / E murisClinical< 50 % with rash (but more oft...
37Daniel J Anderson, MDAnaplasmosisHGAEhrlichiosisHMEFarther northMN & WIFarther southIowa & Missouri~ 50 % morulaeon bloo...
38BabesiosisDaniel J Anderson, MD
39BabesiosisPathogen Babesia microtii (MN, WI, East coast), B divergens & Bduncani in other locationsClinicalfatigue/weakn...
40BabesiosisDiagnosisBlood smear (in RBCs)Tetrad of ring forms“Maltese Cross”SerologyPCRTreatmentMild: atovaquone + azithr...
41Less CommonDaniel J Anderson, MD
42Powassan EncephalitisPathogen: FlavivirusSame viral family as Dengue, Yellow Fever, West NileClinical50 % w focal neurol...
43Powassan EncephalitisDataLeukopenia first (the high WBC), thrombocytopenia,transaminitisCSF lymphocytosis (usually < 100...
44RMSFPathogen Rickettsiae rickettsiiClinical (2 - 14 day [median 7] incubation)fever, headache, nausea / emesis / diarrhe...
45DifferentialDiagnosisTick Borne Infections - MN/WIDaniel J Anderson, MD
46Differential DiagnosesParalytic illnessesPolio, Tick Paralysis, Guillain-Barré, Cervical cord lesionEncephalitidiesHerpe...
47DiagnosisDaniel J Anderson, MD
48DiagnosisClinicalLyme (rash, bilateral Bell’s palsy, III° AV block in o/w healthy pt)SerologicalLyme, HGA, RMSF, Powassa...
49Clinical SummaryDaniel J Anderson, MDLymeAseptic meningitisHeart BlockRash, ArthritisAnaplasma headache, low platelets, ...
50Diagnosis SummaryDaniel J Anderson, MDLymeClinical (III ° AV block, Bell’s Palsy, EM Rash)Serology, Lumbar punctureAnapl...
51Treatment SummaryDaniel J Anderson, MDLymeAnaplasma doxycycline/ azithromycinEhrlichia doxycycline / azithromycinBabesia...
52Tick-borne InfectionsTick ecology changing (expanding geography of ticks)New / Newly recognized infectionsFever, rash, l...
53Tick RemovalGrab Tick with tweezers close to skinPull steadily straight upClean area [alcohol, iodine, soap & H20]Daniel...
54Daniel J Anderson, MDLyme, Babesia, HGAPowassan FeverRMSF, Tularemia.Human Monocytic EhrlichiosisTicks / Illnesses & Geo...
55ReferencesThe Clinical Assessment, Treatment, and Prevention of LymeDisease, Human Granulocytic Anaplasmosis, and Babesi...
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Tick borne infections

  1. 1. 1Tick BorneInfectionsDaniel J Anderson, MDEpidemiologyEcologyClinical CharacteristicsDiagnosisTreatmentPrevention
  2. 2. 2Tick-Borne InfectionsChallengesExpanding / changing geography of ticks / infectionsNew infections / newly recognized “old” infectionsNewly identified -- new Ehrlichia species 2011Old infections | new to MN -- Powassan fever, RMSFClinical clues that might suggest tick-borne infectionFever plus [rash, severe headache, mild hepatitis]low blood cell counts [esp platelets]]Diagnostic tests -- blood smear, serology, PCRDaniel J Anderson, MD
  3. 3. 3EpidemiologyEcologyClinicalDiagnosisDifferential DiagnosisDaniel J Anderson, MD
  4. 4. 4EPIDEMIOLOGYTick Borne Infections - MN/WIDaniel J Anderson, MD
  5. 5. 5Lyme diseaseAnaplasmosisEhrlichiosisBabesiosisPowassan FeverRMSF (Rocky Mountain Spotted Fever)Tick Borne Infections - MN/WIDaniel J Anderson, MD
  6. 6. 6Tick Borne Infections - MNDaniel J Anderson, MDLyme1,293 cases in 2010(21 % increase from 2009)Anaplasma720 cases in 2010( > 100 % increase from 2009)Ehrlichia New species of Ehrlichia reported 2011Babesia 56 cases in 2010 (31 in 2009)Powassan(50 cases in all of US 1958-2009 )6 MN cases 2008 - 20101 MN death from Powassan 2011 (at ANW)RMSF2000 cases / year in all of USSporadic cases in MN1 death in MN 2009
  7. 7. 7Daniel J Anderson, MDhttp://www.health.state.mn.us/divs/idepc/diseases/lyme/highrisk.htmlRisk of Tick-borne infection is notuniform throughout the state.The highest risk is central and SEsections
  8. 8. 8Daniel J Anderson, MDMore Anaplasma than Lyme inAitkin, Beltrami, Cass, Crow Wing& Hubbard countiesThe risk of different tick-borneinfections also is not uniformthroughout the state
  9. 9. 9RMSF annualincidence isincreasingDaniel J Anderson, MD
  10. 10. 10EcologyTick Borne Infections - MN/WIDaniel J Anderson, MD
  11. 11. 11Ticks <> DiseasesDaniel J Anderson, MDTICKIxodes scapularisAnaplasmosisLyme diseaseBabesiosisPowassan FeverAmbyloma americanumEhrlichiosisRMSFSTARITularemiaDermacentor variabilisDermacentor andersoniRMSFTularemiaDISEASEORIGINEndogenous“Imported”(returning from travel)
  12. 12. 12Comparisonof ticksLyme, Anaplasma, Babesia, PowassanEhrlichia, STARI, Tularemia, RMSFRMSF, TularemiaDaniel J Anderson, MD
  13. 13. 13Blacklegged tick (Deer Tick)Ixodes scapularisLyme, Anaplasmosis,Babesiosis,& PowassanDaniel J Anderson, MD
  14. 14. 14Lone Star tickAmblyoma americanumEhrlichia, RMSFSTARI, TularemiaDaniel J Anderson, MD
  15. 15. 15American dog tickDermacentor variablisRMSF, Tularemia,Human Monocytic EhrlichiosisDaniel J Anderson, MD
  16. 16. 16Brown dog tickRhipicephalus sanguineusRMSFDaniel J Anderson, MD
  17. 17. 17ClinicalTick Borne Infections - MN/WIDaniel J Anderson, MD
  18. 18. 18Tick Borne IllnessesFever, chills, myalgias, arthralgiasFever, chills, rashFever, chills, CNS findings(encephalitis / paresis / paralysis / focal findings)Hepatitis / transaminitisLeukopenia, thrombocytopenia, anemiaDaniel J Anderson, MD
  19. 19. 19Diagnostic Clues / HintsAppropriate Exposure PotentialSuggestive SymptomsFever, rash, arthralgias, headache, neurologic findingsExamRash, splenomegalyLabsLow peripheral blood cell counts (esp thrombocytopenia)Mild transaminitis / hepatitisBlood smear, serologies, nucleic acid based tests (NATs)CSF analysisDaniel J Anderson, MD
  20. 20. 20Lyme3-30 days after tick bite (BEFORE fever)Erythema migrans (EM)70 - 80 % of patients get rashSTARIVery similar to Lyme disease“expanding Bull’s Eye” lesionsRMSF90 % -- usually 2 - 5 days AFTER feverInitially small pink macules on wrists /anklesLATER petchialTularemia Skin ulcer w regional lymphadenopathyRASHDaniel J Anderson, MD
  21. 21. 21Hgb Platelets LFTs WBCLyme DiseaseRMSF anemialowplateletstransaminitis leukopeniaAnaplasmosisEhrlichiosisBabesiosisPowassanFeveranemia transaminitisleukopeniathen leukocytosisDaniel J Anderson, MD
  22. 22. 22Lyme DiseaseDaniel J Anderson, MD
  23. 23. 23LymePathogen. Borrelia burgdorferi (spirochete)ClinicalEM rash, Bell’s palsy, AV block, CNS, ArthropathyCo-infection -- ~ 5-10 % with Anaplasma || ~ 2 % with BabesiaDxIgM: HGA can cause false + IgM for LymeIgM can persist for years (even if no clinical disease)After 8 weeks, should always have + IgGTreatment -- no data for prolonged therapyPrevention -- Doxycycline 200 mg if engorged tick < 72 h after biteDaniel J Anderson, MD
  24. 24. 24Lyme DiagnosisClinical diagnosis (ie no serology needed) if exposure to deer tick ANDBilateral Bell’s PalsyIII ° AV block or complete heart block [CHB]Characteristic erythema migrans [EM] rashDaniel J Anderson, MD
  25. 25. 25Daniel J Anderson, MD
  26. 26. 26Lyme SerologyCriteria for positiveWestern blot IgG ≥ 5 bandsWestern blot IgM ≥ 2 bandsChronologyEarly IgM +After 4-8 weeksnearly all IgG + (regardless of RST test strain used)SO, if IgG still negative > 8 weeks illness, then “+ IgM” is false +IgMHGA can cause false + IgM+ IgM can persist for years ... may NOT correlate at all w clinical stateDaniel J Anderson, MD
  27. 27. 27Lyme Testing:Unvalidated tests with unproven useTest assays whose accuracy and clinical usefulness have not beenadequately established. Unvalidated tests available as of 2011include:• 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/IFADaniel J Anderson, MD
  28. 28. 28Lyme PCRMost useful for late arthritis ifdone on synovial fluidLimited use in CSFDaniel J Anderson, MD
  29. 29. 29Lyme Disease TreatmentOral Therapy for all except neurological / latearthritis or initially for high degree AV blockIV therapy: for meningitis, late arthritis or initiallyfor high degree AV blockDaniel J Anderson, MD
  30. 30. 30Lyme Disease Rx Duration2-3 weeks for most early infections - tho’some data suggest 10 days sufficient2-4 weeks for meningitis / arthritis4-8 weeks for late arthritisProlonged courses of therapy? .No proven benefitThere are proven adverse consequences(C diff, death, IV clots, ...)Daniel J Anderson, MD
  31. 31. 31Lyme DiseaseTreatmentReinfection rate rare (approximately 4 %)Post Exposure Prophylaxis (PEP) -single dose doxycycline 200 mg if < 72 hoursDaniel J Anderson, MD
  32. 32. 32AnaplasmosisDaniel J Anderson, MD
  33. 33. 33Human Granulocytic Anaplasomsis [HGA]Pathogen Anaplasma phagocytophilumClinicalup to 35 % coinfected with Lyme and/or Babesiafever, chills, headache, myalgia, and malaise,cough, diarrhea, confusion,and lymphadenopathy,17 % severe multisystem organ failure / SIRS / even death (Lyme does notdo this)rash is not commonDataleukopenia, thrombocytopenia,mild hepatitis / transaminitisDaniel J Anderson, MD
  34. 34. 34Human Granulocytic Anaplasomsis [HGA]DxPeripheral blood smear (in WBCs)30 - 80 % + morulaeseen in granulocytesSerologyNATs (PCR)TreatmentDoxycycline (will also cover potential Lyme coinfection)Daniel J Anderson, MD
  35. 35. 35EhrlichiosisDaniel J Anderson, MD
  36. 36. 36Human Monocytotropic Ehrlichiosis[HME]PathogensE canis / E chaffeensis / / E murisClinical< 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, PCRTreatment - doxycyclineDaniel J Anderson, MD
  37. 37. 37Daniel J Anderson, MDAnaplasmosisHGAEhrlichiosisHMEFarther northMN & WIFarther southIowa & Missouri~ 50 % morulaeon blood smearRARELY seemorulae in blood smearrash is RARErash more common(though still < 50 %)serology / PCRblood smearserology / PCRdoxycycline doxycycline
  38. 38. 38BabesiosisDaniel J Anderson, MD
  39. 39. 39BabesiosisPathogen Babesia microtii (MN, WI, East coast), B divergens & Bduncani in other locationsClinicalfatigue/weakness/malaise followed within days by fever(>38° C) and one or more of the following: shaking chills,sweats, headache, myalgia, arthralgia, and anorexiaMalaise, myalgia, arthralgia, and shortness of breathdifferentiate babesiosis from other febrile illnessesfatigue and malaise persist for several monthsDaniel J Anderson, MD
  40. 40. 40BabesiosisDiagnosisBlood smear (in RBCs)Tetrad of ring forms“Maltese Cross”SerologyPCRTreatmentMild: atovaquone + azithromycinSevere: clindamycin + quinine + exchange transfusionDaniel J Anderson, MD
  41. 41. 41Less CommonDaniel J Anderson, MD
  42. 42. 42Powassan EncephalitisPathogen: FlavivirusSame viral family as Dengue, Yellow Fever, West NileClinical50 % w focal neurologic signs / symptomsOlfactory hallucinations & temporal lobe seizures (DDx Herpesencephalitis)Daniel J Anderson, MD
  43. 43. 43Powassan EncephalitisDataLeukopenia first (the high WBC), thrombocytopenia,transaminitisCSF lymphocytosis (usually < 100 cells)MRI => thalamic, basal ganglia lesionsDx => IgM (serum / CSF) /4 x increase serum IgGTreatment => supportiveDx => serologic (some cross reactivity with other flaviviruses (forexample Dengue fever)Daniel J Anderson, MD
  44. 44. 44RMSFPathogen Rickettsiae rickettsiiClinical (2 - 14 day [median 7] incubation)fever, headache, nausea / emesis / diarrhearash usually ~ 3 days AFTER other signsbegins wrists / anklesDatathrombocytopenia (sometimes anemia) WBC often nlcoagulopathy, DIC, CXR changesDx serology (? PCR on clinical specimens)Treatmentdoxycycline early in course illnessDaniel J Anderson, MD
  45. 45. 45DifferentialDiagnosisTick Borne Infections - MN/WIDaniel J Anderson, MD
  46. 46. 46Differential DiagnosesParalytic illnessesPolio, Tick Paralysis, Guillain-Barré, Cervical cord lesionEncephalitidiesHerpes simplex encephalitis (HSE) -- critical diagnosis becauseof the urgent need for intravenous acyclovir for HSEFebrile illnesses with rashParvovirus B19, Measles, Meningococcal disease, othersFever with transaminitisLyme, HGA, Babesiosis, Acute hepatitis (HBV, HAV, HCV)Daniel J Anderson, MD
  47. 47. 47DiagnosisDaniel J Anderson, MD
  48. 48. 48DiagnosisClinicalLyme (rash, bilateral Bell’s palsy, III° AV block in o/w healthy pt)SerologicalLyme, HGA, RMSF, PowassanBlood / CSF (in CSF only IgM <> indicates local production)NAT (Nucleic Acid based Tests)Powassan Fever, HGA, BabesiosisBlood / CSFPeripheral Blood Smear evaluationBabesiosis, HGA, HGEDaniel J Anderson, MD
  49. 49. 49Clinical SummaryDaniel J Anderson, MDLymeAseptic meningitisHeart BlockRash, ArthritisAnaplasma headache, low platelets, hepatitis, renal failureEhrlichia Headache, low cell counts, renal failure, hepatitisBabesia fever, headache, pancytopeniaPowassan EncephalitisRMSF Fever, severe headache, ... 3 days later rash
  50. 50. 50Diagnosis SummaryDaniel J Anderson, MDLymeClinical (III ° AV block, Bell’s Palsy, EM Rash)Serology, Lumbar punctureAnaplasma Blood smear, PCR, serologyEhrlichia Blood smear, PCR, serologyBabesia Blood smear, PCR, serologyPowassanSerologysupporting evidence by head MRIRMSF Serology
  51. 51. 51Treatment SummaryDaniel J Anderson, MDLymeAnaplasma doxycycline/ azithromycinEhrlichia doxycycline / azithromycinBabesiaatovaquone + azithromycin(for severe disease clindamyin + quinine + exchange transfuse)Powassan supportive careRMSF doxycyclinePO doxycycline / amoxicillinIV ceftriaxone2-4 weeks early4-8 weeks late disease / arthritisno “long term” Rx
  52. 52. 52Tick-borne InfectionsTick ecology changing (expanding geography of ticks)New / Newly recognized infectionsFever, rash, low cell counts (esp thrombocytopenia), transaminitisNew diagnostic modalities (esp NAT-based testing)Lyme testing (even western blot IgM) not necessarily definitiveDoxycycline -- Rx of choice - Lyme, Anaplasma / Ehrlichia, RMSFTick avoidance / prevention is the bestDaniel J Anderson, MD
  53. 53. 53Tick RemovalGrab Tick with tweezers close to skinPull steadily straight upClean area [alcohol, iodine, soap & H20]Daniel J Anderson, MD
  54. 54. 54Daniel J Anderson, MDLyme, Babesia, HGAPowassan FeverRMSF, Tularemia.Human Monocytic EhrlichiosisTicks / Illnesses & Geography
  55. 55. 55ReferencesThe Clinical Assessment, Treatment, and Prevention of LymeDisease, Human Granulocytic Anaplasmosis, and Babesiosis:Clinical Practice Guidelines by the Infectious Diseases Society ofAmerica. Clin Infect Dis. (2006) 43 (9): 1089-1134http://cid.oxfordjournals.org/content/43/9/1089.fullNational Institue of Allergy and Infectious Diseases. TickborneDiseases website.http://www.niaid.nih.gov/topics/tickborne/pages/default.aspx
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