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.

1. 2013 ID Board Review Part 3
Greg Fenati DO
ARMC EM

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

13. ???????????

14. Small Pox (Variola)



Eradicated in 1980, last natural
1977
Untreated mortality 30%
Airborne pathogen which is
concerning for bioterrorism

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????

19. Malaria


Plasmodium falciparum, ovale,
vivax, malariae
Falciparum is the most leathal (foul)

20. Malaria Signs/Symptoms/Hx




Recent Travel
Irregular Fevers (intermittent very
high imposed on a low level
background) Q48hrs
Hepatosplenomegally
Blackwater fever secondary to
severe hemolysis

21. Malaria Complications

Cerebral



Anemia




Mostly falciprum
AMS, sz, coma
Immune related hemolysis from RBC surface
antigen
Thrombocytopenia
Think G6PD deficiency in primaquine tx
Pulmonary


Mostly falciprum -- fever/cough
May develop ARDS

22. Malaria Dx



Peripheral blood smears
Hemolytic anemia commonly with
thrombocytopenia
False 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

24. Gardener / Landscaper ?????

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


30. Fevers, myalgias, dark urine
traveled to the northeast?

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

33. Babesiosis Management



Most patients have spontaneous
remission
Can be deadly s/p splenectomy
If ill appearing quinine with
clyndamycin

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

37. ????

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)

45. Erlichiosis Signs/ Sympt


Abrupt fever, h/a, myalgias, chills,
occaisional AGE symptoms
Complications: Optic Neuritis, ,
ARDS, Meningitis, Pericarditis, Renal
Failure, DIC

46. Erlichiosis Dx/Management

DX




Leukopenia
Thrombocytopenia
Incresed LFTs
Peripheral smear
showing morula
clusters

MANAGEMENT



Doxy or
Tetracycline for 12wks
Rifampin
Most recover
without residual

47. Went hiking next day severe h/a, calf
tenderness and a rash???

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

50. RMSF Complications







Gangreen
Myocarditis
Interstitial pneumonitis / ARDS
Rickettsial encephalitis, meningitis,
focal neuro deficits, sz, coma
ARF
Hypovolemic Shock
DIC

51. RMSF Dx/Management

Dx:



Serology (start tx
prior to results)
Thrombocytopenia,
hyponatremia,
anemia, azotemia,
hyperbilirubinemia
ECG conduction
abnormalities

Management:





If suspected tx
Doxy 100 BID 1-2wks
Chloramphenicol 50
mg/kg/day (max 1
G)
Supportive care
No steroids unless:



Extensive vasculitis
Encephalitis
Cerebral edema

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

55. We skinned up these rabbits good!!

56. Now I have this and belly pain.. What’s
up?

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

60. Infectious Control Standard
Precautions


Yeah Gown, Glove, blah, blah…
For the test it is always hand wash,
hand wash, hand wash

61. Infectious Control Airborne





Particles <5 microns
Patients need to be in negative
pressure rooms
Keep door shut
N-95
Rubeola, Vericella (including
desseminated zoster), TB

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


67. Good luck on your boards!!