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A Spotlight on Emerging Diseases

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A Spotlight on Emerging Diseases FEATURE Powassan virus Powassan virus (POW) is a tickborne fla- vivirus that can cause severe disease in hu- mans. The disease is considered rare, and although human cases have traditionally only been reported sporadically, it is be- coming more common. Most cases report exposure in the northeastern United States and in the upper Midwest. POW typically presents with neurologic symptoms, most commonly encephalitis or meningitis, after an incubation period of one to four weeks. Milder, even subclinical, infections occur, although they are likely underreported. Long-term sequelae after infection occur in approximately 50 percent of cases and 10-15 percent are fatal. THE CHANGING LANDSCAPE OF From 2008 through 2018, Minnesota TICKBORNE DISEASE IN MINNESOTA: reported 37 cases of POW, with an average of three cases per year. Cases were 73 per- cent male and the median age was 60 years A spotlight on (range, 0–75 years). Clinically, 89 percent of cases had meningitis or encephalitis with fever, headache, confusion and weak- emerging diseases ness also commonly reported. Two of Minnesota’s cases were fatal. BY JENNA BJORK, DVM, MPH, AND ELIZABETH SCHIFFMAN, MPH, MA Diagnostic testing for POW is not widely available, and is primarily per- he risk for tickborne disease in Min- More than just a pest, this tick has become formed at public health laboratories or nesota has expanded over the years, a significant disease threat to people living the Centers for Disease Control (CDC). Tnot only geographically, but also in around, working in and enjoying the great Serologic and molecular testing can be or- terms of the number of infections pos- outdoors while in forested areas of the dered through the Minnesota Department sible. Of particular interest are some of the state (Figure 1). In addition to spreading of Health (MDH). There is no vaccine to newer and emerging tickborne diseases Lyme disease, anaplasmosis and babesio- prevent POW and treatment is primarily like Powassan virus, Ehrlichia muris eau- sis, this tick has been shown to be the vec- supportive care. clairensis, Borrelia mayonii and Borrelia tor of several additional diseases over the miyamotoi. In addition to learning how to past 20 years (Figure 2). Powassan virus Ehrlichia muris eauclairensis recognize these infections in patients, pro- was reported in a Minnesota resident in Ehrlichia muris eauclairensis was first viders need to know how to test for them, 2008, and the first case of Ehrlichia muris identified in 2009 by researchers at Mayo offer appropriate and effective treatment eauclairensis in Minnesota was reported in Medical Laboratories, and was initially and help patients reduce or prevent further 2009. The index case of Borrelia mayonii, a referred to as Ehrlichia muris-like agent, exposure to ticks. new form of Lyme disease, was identified or EML. Unlike the more well-known Over the last 30 years, the risk of tick- in a Minnesota child in 2013, and Bor- Ehrlichia chaffeensis, which is transmitted borne diseases has changed. While Lyme relia miyamotoi, also known as hard tick by the lone star tick, E. muris eauclairensis disease is still the most common tickborne relapsing fever, was first identified in Min- is transmitted by the blacklegged tick. The disease, both in Minnesota and nation- nesota in 2016. Much less is known about index patients were from Minnesota and wide, it is now just one of several diseases these new pathogens and the illnesses they Wisconsin and subsequent cases have pri- possible after the bite of an infected tick. cause, but the more cases that are identi- marily occurred in the upper Midwest. The primary vector tick in Minnesota is fied, the more a “typical” clinical course Clinically, illness caused by E. muris Ixodes scapularis, more commonly known emerges. eauclairensis is indistinguishable from the as the blacklegged or deer tick, and as the closely related and much more common distribution of this tick has changed, the illnesses of anaplasmosis or ehrlichiosis picture of disease has changed as well. caused by E. chaffeensis. Patients com- 24 | MINNESOTA MEDICINE | MARCH/APRIL 2020 FEATURE monly report fever, headache, malaise and Currently, testing for B. mayonii is not portant for providers to think broadly myalgia, and laboratory studies often note widely available and is limited to molecu- about tickborne diseases in patients with thrombocytopenia and elevated trans- lar methods. All cases have tested positive compatible symptoms and exposures and aminases. From 2009 through 2018, Min- by PCR for the disease agent. Limited to consider testing with broader disease nesota has reported 60 cases of E. muris information suggests that patients may panels, rather than focusing on specific eauclairensis, 22 percent of which required develop detectable antibodies after infec- tests. The symptoms of tickborne diseases hospitalization. tion with B. mayonii, so infections may can be non-specific and co-infections may Laboratory diagnosis of E. muris eau- be detected on traditional Lyme disease occur. Patients with outdoor occupations clairensis is made by PCR and molecular serology, but serologic testing cannot or recent outdoor activities, either around methods are the only way to reliably dif- distinguish between B. mayonii and B. forested areas at home or away from ferentiate different species. Unlike for burgdorferi. home, are at particular risk. Providers anaplasmosis and ehrlichiosis caused by E. should encourage prevention, like regular chaffeensis, there is no commercially avail- Borrelia miyamotoi use of EPA-registered repellents and daily able serologic test for this bacteria and pe- Borrelia miyamotoi is closely related to tick checks, to reduce risks. ripheral smears are not recommended for the bacteria that cause tickborne relaps- In Minnesota, the highest risk season diagnosis due to insensitivity. As with ana- ing fever. It was first identified as a cause for tickborne diseases is from late spring plasmosis and other rickettsial diseases, of human illness in 2011 in a patient from into mid-summer, coinciding with peak doxycycline is the preferred treatment for Russia and the first case in the United activity of the adult and nymphal stages of infection with E. muris eauclairensis. States was reported in 2013. Since 2016, the blacklegged tick. A smaller, secondary 13 cases have been reported in Minnesota, peak occurs again in the fall when adult Borrelia mayonii with an average of three cases each year. ticks are active again. Routine surveillance Borrelia mayonii is a recently identi- Of the 13 Minnesota cases, 69 percent of ticks in Minnesota has provided data fied bacteria closely related to Borrelia were among males, median patient age since 2005 on six different disease agents burgdorferi. It was first identified in a was 57 years (range, 33–77 years) and 92 (Figure 3). Results have shown that infec- Minnesota resident in 2013. Since then, percent had likely tick exposure a small number of cases have been found in Minnesota or Wisconsin (one in people who have been exposed to ticks case unknown). All patients in Minnesota or Wisconsin. The illness experienced a febrile illness B. mayonii causes is very similar to Lyme with 38 percent of illness onsets disease caused by B. burgdorferi, although occurring in August. Three (23 there are some differences. For instance, percent) cases involved brief nausea and vomiting are associated with hospitalizations. None of those B. mayonii, but are not commonly re- affected experienced a rash. ported symptoms in infections with B. Nationally, the most commonly burgdorferi. reported symptoms are fever, A total of 10 cases have been reported chills and headache, as well as in Minnesota through 2019, with an aver- fatigue, myalgia and arthralgia. age of one to two cases reported each year. Currently, both molecular Of the 10 cases reported, 80 percent were and serologic testing is available among males, the median patient age was for B. miyamotoi at commercial 45 years (range, 6–61 years), and 90 per- laboratories and CDC can as- cent had likely tick exposure in Minnesota sist with diagnostic testing. B. or Wisconsin (one case unknown). All miyamotoi infections have been cases experienced a febrile illness, with 50 successfully treated with a two- percent of illness onsets occurring in July. to four-week course of doxycy- Four cases involved brief hospitalizations. cline. Amoxicillin and ceftriax- Five patients experienced a rash, although one have also been effective. FIGURE 1 only one patient’s rash was described as While these new diseases Minnesota Tickborne erythema migrans. Other common symp- have emerged, the incidence of Disease Risk toms included headache, myalgia and more well-known diseases, like Tickborne disease risk in Minnesota by county, based fatigue. All patients experienced clinical Lyme disease, anaplasmosis and on average incidence (cases/100,000 population) of improvement after treatment with amoxi- babesiosis, has also increased anaplasmosis, babesiosis and Lyme disease, 2007–2018 cillin or doxycycline. over the same period. It is im- (MDH). MARCH/APRIL 2020 | MINNESOTA MEDICINE | 25 FEATURE tion prevalence can vary from site to site FIGURE 2 and year to year but, on average, about one in three adult blacklegged ticks and Timeline of the discovery of the seven human pathogens transmitted by blacklegged ticks (Eisen and Eisen, 2018). one in five blacklegged tick nymphs are infected with B. burgdorferi. Prevalence of other pathogens is considerably lower, with about 6-8 percent of ticks infected with anaplasmosis or babesiosis and only 1-3 percent of ticks infected with E. muris eauclairensis, B. miyamotoi or B. mayonii. While testing of indi- vidual ticks is not gen- FIGURE 3 erally recommended, Average infection prevalence of blacklegged tick adults and nymphs for six tick data collected different pathogens during field studies are useful in under- Based on testing 7,634 ticks from Minnesota, 2005–2019 (MDH). standing the tickborne disease risk from a tick bite in Minnesota.
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