6030 Exam 4 mod 10 ticks.pdf

6030 Exam 4 Ticks and Vector Borne Diseases • • • Definition and Epidemiology o Vector-borne Illnesses § Tick-borne diseases are most common• o Risk Factors § Living in a rural area (suburban area or farm) § Having indoor/outdoor pets (especially a dog) § The presence of a bird feeder in the yar...

6030 Exam 4 Ticks and Vector Borne Diseases • • • Definition and Epidemiology o Vector-borne Illnesses § Tick-borne diseases are most common• o Risk Factors § Living in a rural area (suburban area or farm) § Having indoor/outdoor pets (especially a dog) § The presence of a bird feeder in the yard § The presence of an outdoor dining area Tick Borne Diseases in the United States o Rocky Mountain Spotted Fever o Lyme o Ehrlichiosis Transmission = bites, transfusion, congenital o Tularemia Incubation periods = days to weeks o Babesiosis o Colorado Tick Fever Can be confused as viral syndrome When in o Relapsing fever doubt, treat with Doxycycline! o + More LYME DISEASE o Pathophysiology § Transmission requires 36 hours of attachment § Local and systemic symptoms • Influenced by the initial spread of bacteria o Lyme Disease Overview § ‘Borrelia burgdorferi’ • Upper Midwestern and Northeastern US; Summer • Most commonly reported in Summer o Consider if pt has traveled to this ara § Diagnosis based upon: • Symptoms • Physical findings (e.g., rash) • Exposure § Treat with appropriate antibiotic treatment • DOXYCYCLINE o Untreated can spread to heart, nerves, joints o Clinical Presentation § Stage I: Acute (Localized) • Incubation of 1- 30 days• • Erythema Migrans à Bulls-eye Rash § § § • • Generalized, flu-like symptoms Stage II: Subacute (Disseminated) • Incubation of days – 10 months • Secondary annular rashes • Increase in generalized symptoms Stage III (Chronic) • Incubation of months to years Potential manifestations of: • Neurological • Rheumatological • Cardiac• Musculoskeletal • Vision• Integumentary• Gastrointestinal • Memory loss Headache Bell’s Palsy Meningitis Radiculopathy Mood changes Joint arthritis Joint effusions Muscle pain Bone pain • Conduction abnormalities (e.g. atrioventricular node block, myocarditis, pericarditis)Myocardial Infarction • Conjunctivitis, keratitis, Uveitis, mild hepatitis, Splenomegaly o Tick Bite can present with an ALLERGIC REACTION § Allergic relations typically appear within the first 48 hours of tick attachment and are usually <5cm in diameter § DO not treat with Doxycycline à Not LYME o DX: § § Serology (IgM, IgG) • False negatives in acute phase of illness Screening Criteria • Recent history of having resided in or travled to an endermic area • Risk Factors for exposure to ticks • Symptoms consistant with early disseminated disease or late Lyme disease Two-Tiered Testing for Lyme Disease (CDC) • First Test o Enzyme Immunoassay (EIA) o Or o Immunofluorescence Assay (IFA) • Positive Result o S/S <30 days à IgM & IgG Western Blot o S/S >30days à IgG Western Blot ONLY • Negative result o Consider alt. dx o If patient with s/s consistent with Lyme <30days, consider obtaining a convalescent serum § 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 o Differential Diagnosis § Bacterial cellulitis § Facial palsies § Herpes Simplex or Zoster § Meningitis § Reactive Arthritis § Chronic Fatigue Syndrome § o Interprofessional Collab § Centers for Disease Control à REPORT § UpToDate § Local Health Department à REPORT § Infectious Disease Specialist § Rheumatologist/Orthopedist o Management of LYME § Pharmacological Management • Treat Empirically if Erythema Migrans with viral s/sx o Endemic Area o Rash and Flu like sym o Tick attachment >36hr • DOXYCYCLINE 100mg BID – 10-21days § § § § § • Pharmacological Management - IDSA – updated guidelines • For recognized tick bite = 200 mg single dose doxycycline • Suspect Lyme = Doxycycline 100 mg PO BID x 10-21 days (~14 days) • Low risk of disease if tick attached <36 hours • Doxycycline 100 mg twice per day x 10-21 days • Amoxicillin 500 mg 3 times per day x 14-21 days • Cefuroxime 500 mg twice per day x 14-21 days Alternative Pharmacologic Management – Macrolides • Azithromycin 500 mg orally per day for 7–10 days • Peds:10 mg/kg per day (maximum of 500 mg per day) • • Clarithromycin 500 mg orally twice per day for 14–21 days Peds:7.5 mg/kg twice per day (maximum of 500 mg per dose • • Erythromycin 500 mg orally 4 times per day for 14–21 days 12.5 mg/kg 4 times per day (maximum of 500 mg per dose) Symptomatic Treatment • Take an antihistamine medicine to help relieve itching, redness, and swelling. • Use a spray of local anesthetic that contains benzocaine, such as Solarcaine. It may help relieve pain. ... • Put calamine lotion on the skin. It may help relieve itching. ROCKY MOUNTAIN SPOTTED FEVER o Spotted Fever Rickettsiosis’ § Most prevalent in SE US • North Carolina, Oklahoma, Arkansas, Tennesse, Miisouri § Diagnosis • Rare, less common than Lyme • Infection transmitted after several hrs of feeding • Muscle Ache, 102-103F, Vomit, HA § Curable, potentially lethal • *** most severe, lethal tick bite o Pathophysiology § Transmission requires 2 to 20 hours of attachment • Horizontal transmission § Local and systemic symptoms • Influenced by the initial spread of bacteria o Salivary Gland à to epithelial cells of vessel causing systemic vasculitis à Severe Illness o Clinical Presentation § Onset within 3 to 12 days § A rash MAY be present à Tx not based on rash • Early Rash: Maculopapular Rash o Wrist forearm ankle • Late State: Petechial Rash o Sign of progression § TX before develop = GOAL § Late Manifestations • Signs and symptoms occur 5-7 days post-inoculation • Signals progression to severe disease o Severe Disease: cerebral edema, renal failure, necrosis, coma o Differential Diagnosis § Influenza vs. Tick-borne Disease § Meningococcemia § Vasculitis § Missed Dx • 90% patients saw MD in 1st 5 days, but only 50% were treated. § Independent Predictors of Failure to Treat: • No rash • Presentation within 1st 3 days o Diagnostics § Serology (IgM, IgG) • False Negatives in acute phase of illness § Refer to confirm à serology or biopsy of lesion • Expensive test – offered by local health departments • Results take > 5 days – missed treatment window o Management § Non-pharm Management: • Symptomatic treatment for generalized symptoms § Treat or Refer • Treat = If febrile in endemic area with known bite, Summer/Spring • Refer/Long-Term F/U = If severe disease suspected § Pharmacologic Management *** Treat within 5 days – don’t wait on rash • Suspect RMSF = Doxycycline 100 mg po bid x 7-14 days • Admit/refer = 200 mg single dose doxycycline § § • Special Populations • Pregnant women = chloramphenicol 50 mg/kg in 4 divided doses per day • Children <45kg = 2.2mg/kg doxy per dose q 12hr o No DOXY bc SE in pregnancy and children § Discoloration of teeth, ulcer, thrombocytopenia, skin hyperpig Pharm Mang • Empiric – based on clinical judgment • <1% of ticks in endemic area infected • Consider area/incidence • May watch and advised patient to report any fever or HA WEST NILE o Overview § Flavivirus • Continental United States • Likely from Israel or Middle East • Risk for >60 years, chronic disease § Transmission • Mosquitoes à BITE • Reservoir - Birds o Mosquitos get from feeding on infected birds § ***NOT spread by handle infected animals or birds or eating them • Also get from: o Organ Transplant, Blood Transfusion o Labs o Mother Baby à BF, Preg, Delivery § Lifelong immunity w recovery o Clinical Presentation § Incubation of 2-14 days • 1 in 5 infected develop symptoms § Febrile Illness • Self-limiting generalized symptoms for 3-6 days • Fatigue may be long-lasting § Severe Illness • Maculopapular Rash on chest, back, arms in 25-50% o Rash à pustules à 50% of severe sym • High fever, possible neurological manifestations in 1% o Neck stiffness, disorientation, MSK prob, HA, eye pain § > 60 or Immunocompromised are at increased risk o DX: Timing/Location/Risk Profile • Confirmed endemic area • S/sx during mosquito season w febrile illness or acute neuro sx • Temperate and tropical climate- Year round risk § Risk in elderly/immunocompromised • Febrile Illness: fever, headache, malaise, back pain, myalgias, and anorexia § Serology (IgM) and or CSF o Interprofesional Collaborative Management § REFER to local health department à REFER ALL VECTOR DISEASES § Severe case require hospitalization o Management: § Nonpharmacologic Management • Supportive Treatment for generalized symptoms § Pharmacologic Management • OTC pain relievers § • ALL VECTOR DISEASES:: o INDICATIONS to Hospitalize Vector Diseases § Heart Block with Lyme Carditis § Petechial Rash with RMSF § Maculopapular Rash with WNV o Health Promo: § There is no vaccine avaiavle § Prevention is key o Patient and Family Education § Tick Removal • Remove the tick as soon as possible • Cover tick with a tissue or gauze pad • Wait until it releases the victim • Clean the bite area and your hands • Observe for local reaction § Inflammatory reactions • May not have a rash § Medication administration • TAKE WITHH FOOD! § Personal protective measures • Physical barriers à Clothes, long sleeves, tucked in, light colors • Chemical barriers à Off, Repel, Bug Spray o DEET à chemical product § Also lemon, eucalyptus, soybean, citronella oil • Avoid exposure • § Inspection Environmental Disease from Animal Bites o Localized Infections and Rabies § Wildlife*** § Canine § Feline o Refer to local government health services § Health Department § Agricultural Extension o ALL unprovoked bites in carrying/pet animals require treatment for rabies.