Tick Borne Illnesses. Dr. Constance LeBlanc

Transcription

1 Tick Borne Illnesses Dr. Constance LeBlanc

2 Disclosures No affiliations (research grants, speaker bureaus, or other) with industry DOHW Nova Scotia funding DEANS grants CADTH funding TVN grant Dalhousie FoM Living Lab grants NSHRF grants CPSNS funding DoctorsNS funding and grant Health Canada grant

3 Dr. Google 1 Potential symptoms of tick-borne diseases include: red spot or rash near the bite site neck stiffness headache or nausea weakness muscle or joint pain or achiness fever or chills swollen lymph nodes 1- Accessed July 31, 2016.

4 Lyme 3 Borrelia burgdorferi FOCAL Erythema migrans Fever Myalgias Malaise Arthralgia Headache Adenopathy DISEMINATED EM Headache Fever Adenopathy Heart Block (carditis) Meningismus Cranioneuropathy(VII, Bell) 3- van Nunen S. Tick-induced allergies: mammalian meat allergy, tick anaphylaxis and their significance. Asia Pac Allergy Jan. 5 (1):3-16.

5 Lyme disease became nationally notifiable in Accessed July

6 Exposure 24 hours of attachment 5,6 Testing for epidemiologic reasons Risk of acquiring Lyme disease from an infected tick is < 1% to 6% 6 5- De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol Jul. 30(4): Huegli D, Moret J, Rais O, Moosmann Y, Erard P, Malinverni R, et al. Prospective study on the incidence of infection by Borrelia burgdorferi sensu lato after a tick bite in a highly endemic area of Switzerland. Ticks Tick Borne Dis. 2011;2:

7 Tick Removal No contraindications Gloves Isopropyl alcohol Needle nose forceps NO XYLOCAINE 7 7- Needham GR. Evaluation of five popular methods for tick removal. Pediatrics Jun. 75(6):

8 Endemic Area Queen s Yarmouth Shelburne Lunenburg Halifax Pictou

9 Don t 1. Test in the absence of symptoms or signs consistent with Lyme disease 2. Test in asymptomatic patients who have had a blacklegged tick bite: antibodies to B. burgdorferi are not detected until a few weeks after infection 3. Test in patients with the typical EM rash (>5cm) during Lyme season 4. Repeat testing after treatment 5. Send specimens to laboratories that use interpretive criteria that are different from the CDC 6. Bypass the ELISA and using Western Blots alone: Western Blots done in the absence of preceding ELISA testing have been associated with a reduction in specificity and are NOT recommended 7. Use of PCR on blood, serum or plasma or the use of urinary antigen as a diagnostic test: these tests have not been validated

10 Do Prophylax 1. The attached tick is estimated to have been attached for 36 h based on the degree of engorgement or by certainty about the time of tick acquisition 2. Prophylaxis can be started within 72 h of tick removal 3. Ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi is 20%. There is insufficient information to provide a list of all counties in NS that meet this criterion. 4. Doxycycline is not contraindicated.

11 What to give Adults and children > 8 years of age: single dose doxycycline 200 mg po (4.4mg/kg for patients < 45kg) There is no effective antibiotic for prophylaxis in children 8 years of age

12 Who needs Prophylaxis? 8 8- Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. 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 Nov 1;43:

13 Who needs Treatment? 9,10,11 9-Hengge UR, Tannapfel A, Tyring SK, Erbel R, Arendt G, Ruzicka T. Lyme borreliosis. Lancet Infect Dis. 2003;3: Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S. 11- Hatchette, Todd F., et al. "Epidemiology of Lyme Disease, Nova Scotia, Canada, " Emerging infectious diseases (2015): 1751.

14 Canadian laboratory diagnostics for Lyme disease meet international standards 12 Serological tests IgG not a test of cure not be used to measure treatment The EIA test low specificity (may yield false-positive results standalone) cross-reacts with antibodies to commensal or pathogenic spirochetes and some conditions (varicella, Epstein-Barr, lupus) Accessed August 1, 2016.

15 Case 1 A woman presents to the ED with a swollen hand. She is otherwise well. Her hand has been increasingly sore for 2 days and today she noticed some erythema so is seeking care.

16 Tick Paralysis 31,32 Rare Young girls 2-6 days post tick attachment Differential GBS, myasthenia gravis, botulism, west Nile virus myelitis 31-Grattan-Smith PJ, Morris JG, Johnston HM, et al. Clinical and neurophysiological features of tick paralysis. Brain 1997; 120: Edlow JA, McGillicuddy DC: Tick paralysis. Inf Dis Clin North Am. 2008, 22,

17 Presentation Prodromal phase: paraesthesias, restlessness, irritability, fatigue, and myalgias Neurological symptoms: Acute ascending paralysis a few days after tick attachment. Deep tendon reflexes are weak or absent. Children may present with ataxia. Over12 to 24 hours the muscles innervated by facial nerves become weak Death: the respiratory muscles will fail and the patient will die of respiratory failure

18 Red Meat Allergy* Lone star tick produces galactose-alpha-1,3- galactose ( Alpha-Gal ) Injects during bite This sugar is found in red meat (eg., beef, pork, venison, rabbit) and in some dairy products

19 References 1. Accessed July 31, Accessed July 31, Accessed July 31, Accessed July 31, De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol Jul. 30(4): Huegli D, Moret J, Rais O, Moosmann Y, Erard P, Malinverni R, et al. Prospective study on the incidence of infection by Borrelia burgdorferi sensu lato after a tick bite in a highly endemic area of Switzerland. Ticks Tick Borne Dis. 2011;2: Needham GR. Evaluation of five popular methods for tick removal. Pediatrics Jun. 75(6): Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, et al. 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 Nov 1;43: Hengge UR, Tannapfel A, Tyring SK, Erbel R, Arendt G, Ruzicka T. Lyme borreliosis. Lancet Infect Dis. 2003;3: Sigal LH. Early disseminated Lyme disease: cardiac manifestations. Am J Med. 1995;98:25S-28S. 11. Hatchette, Todd F., et al. "Epidemiology of Lyme Disease, Nova Scotia, Canada, " Emerging infectious diseases (2015): Accessed August 1, Dantas-Torres, F. (2007). Rocky Mountain spotted fever. The Lancet Infectious Diseases, 7(11), Chen, L. F., & Sexton, D. J. (2008). What's new in Rocky Mountain spotted fever? Infectious Disease Clinics of North America, 22 (3), , vii-viii. 15. Minniear, T. D., & Buckingham, S. C. (2009). Managing Rocky Mountain spotted fever. Expert Review of Anti-Infective Therapy, 7 (9), Fleming, D. O., Richardson, J. H., Tulis, J. J., & Vesley, D. (Eds.). (1995). Laboratory Safety Principles and Practices (2nd ed.). Washington: American Society for Microbiology.

20 17. Accessed August Accessed August Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--united States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep Mar : Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: a 30-year experience with 88 cases. Medicine (Baltimore) Jul. 64(4): Finnish Medical Society Duodecim. Tularaemia. EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; Apr Pérez-Castrillón JL, Bachiller-Luque P, Martín-Luquero M, Mena-Martín FJ, Herreros V. Tularemia epidemic in northwestern Spain: clinical description and therapeutic response. Clin Infect Dis Aug (4): Wormser GP, Lombardo G, Silverblatt F, El Khoury MY, Prasad A, Yelon JA, et al. Babesiosis as a cause of fever in patients undergoing a splenectomy. Am Surg Mar. 77(3): Krause PJ, Lepore T, Sikand VK, Gadbaw J Jr, Burke G, Telford SR 3rd, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med Nov (20): Marrie TJ, Raoult D. Coxiella burnetii (Q fever). Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa: Churchill Livingstone; Marrie TJ. Q fever pneumonia. Infect Dis Clin North Am Mar. 24(1): Raoult D, Fenollar F, Stein A. Q fever during pregnancy: diagnosis, treatment, and follow-up. Arch Intern Med Mar (6): Goodpasture HC, Poland JD, Francy DB, et al. Colorado tick fever: clinical, epidemiologic, and laboratory aspects of 228 cases in Colorado in Ann Intern Med Mar. 88(3): Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med Jul. 75 (7): Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am Sep. 22 (3): Grattan-Smith PJ, Morris JG, Johnston HM, et al. Clinical and neurophysiological features of tick paralysis. Brain 1997; 120: Edlow JA, McGillicuddy DC: Tick paralysis. Inf Dis Clin North Am. 2008, 22,