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Tick-Borne Diseases in Maine a Physician’S Reference Manual Deer Tick Dog Tick Lonestar Tick (CDC Photo)

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Tick-Borne Diseases in Maine a Physician’S Reference Manual Deer Tick Dog Tick Lonestar Tick (CDC Photo) tick-borne diseases in Maine A Physician’s Reference Manual Deer Tick Dog Tick Lonestar Tick (CDC PHOTO) Nymph Nymph Nymph Adult Male Adult Male Adult Male Adult Female Adult Female Adult Female images not to scale know your ticks Ticks are generally found in brushy or wooded areas, near the DEER TICK DOG TICK LONESTAR TICK Ixodes scapularis Dermacentor variabilis Amblyomma americanum ground; they cannot jump or fly. Ticks are attracted to a variety (also called blacklegged tick) (also called wood tick) of host factors including body heat and carbon dioxide. They will Diseases Diseases Diseases transfer to a potential host when one brushes directly against Lyme disease, Rocky Mountain spotted Ehrlichiosis anaplasmosis, babesiosis fever and tularemia them and then seek a site for attachment. What bites What bites What bites Nymph and adult females Nymph and adult females Adult females When When When April through September in Anytime temperatures are April through August New England, year-round in above freezing, greatest Southern U.S. Coloring risk is spring through fall Adult females have a dark Coloring Coloring brown body with whitish Adult females have a brown Adult females have a markings on its hood body with a white spot on reddish-brown tear shaped the hood Size: body with dark brown hood Unfed Adults: Size: Size: Watermelon seed Nymphs: Poppy seed Nymphs: Poppy seed Unfed Adults: Sesame seed Unfed Adults: Sesame seed suMMer fever algorithM ALGORITHM FOR DIFFERENTIATING TICK-BORNE DISEASES IN MAINE Patient resides, works, or recreates in an area likely to have ticks and is exhibiting fever, This algorithm is intended for use as a general guide when pursuing a diagnosis. headache, malaise and/or lymphadenopathy It does not replace the physician’s clinical judgment or the need for definitive laboratory testing. Does the patient have a rash? YES NO OTHER CONSIDERATIONS • Rash occurs in 70-80% of Lyme disease patients. Blood smear review Complete • Rash occurs in less than 10% of blood count (CBC) anaplasma patients. • Rash occurs in less than 40% of adult Erythema migrans (single or Parasites in RBC* Normal CBC Ehrlichia patients, and less than 60% multiple lesions) Babesiosis May be Anaplasma, RMSF,* of children. Lyme disease *If patient has an international tularemia** travel history, malaria should or Lyme disease, further • Rash occurs in 70-80% of RMSF patients be ruled out tests needed but only appears several days after onset Maculopapular * RMSF—thrombocytopenia of febrile illness. May be anaplasmosis (rash is may be observed very uncommon), further tests Morulae in WBC ** tularemia—WBC normal or • Hyponatremia may occur with RMSF needed May be anaplasmosis (seen elevated, thrombocytopenia or tularemia. in less than 50% of serious may be observed cases), further tests needed • Lyme disease can present as Bell’s palsy, further tests needed. • Ulceroglandular tularemia usually presents as regional lymphadenopathy with a small Cutaneous ulcer WBC low or normal, ulceration distally, further tests needed. May be tularemia thrombocytopenia, (ulceroglandular), further tests low hematocrit, • Coinfections involving Lyme disease, needed elevated reticulocytes babesiosis, and/or anaplasmosis may occur May be anaplasmosis or because a single deer tick may carry babesiosis, further tests multiple pathogens. Maculopapular to Petechial* needed May be RMSF, or ehrlichiosis, • Consider pneumonic tularemia in any further tests needed patient presenting with community- *If petechial rash of palm and Normal hematocrit, sole (characteristic of RMSF) thrombocytopenia, leukopenia acquired pneumonia who resides on, is present, treat immediately May be anaplasmosis or or has recently visited, Martha’s Vineyard, ehrlichiosis, further tests Massachusetts. needed anaPLASMosis (AKA HUMAN GRANULOCYTIC ANAPLASMOSIS) AGENT SIGNS/SYMPTOMS LABS Bacteria: Anaplasma phagocytophilum [Incubation Period 1-2 weeks] Common Findings on Routine NOTES (formerly Ehrlichia phagocytophilum) • Fever, chills Laboratory Tests • Visualization of morulae in the Generally observed during the first week cytoplasm of neutrophils or eosinophils Tick: Ixodes scapularis • Severe headache of clinical disease during examination of blood smears • Malaise • Mild anemia is highly suggestive of a diagnosis; • Myalgia however, blood smear examination is • Thrombocytopenia • Gastrointestinal symptoms (nausea, insensitive and should never be relied • Leukopenia (characterized by relative vomiting, diarrhea, anorexia) upon solely to rule anaplamsa in or out. and absolute lymphopenia and a • Cough left shift) • Confirmation of the diagnosis is based • Arthralgia • Modest elevations in hepatic on laboratory testing, but antibiotic ther- • Stiff neck transaminases apy should not be delayed in a patient with a suggestive clinical presentation. • Confusion Diagnostic Laboratory Criteria • Clinical signs of anaplasmosis and • Detection of DNA by PCR assay ehrlichiosis are similar, and testing (preferred method); or for both species is indicated due to • Demonstration of a four-fold change presence of both tick vectors. Also in IgG-specific antibody titer by IFA consider the possibility of coinfection in paired serum samples; or with B. microti and/or B. burgdorferi. • Immunohistochemistry (IHC) staining of organism; or • Isolation of organism from a clinical specimen in cell culture. anaPLASMosis TREATMENT REFERENCES The regimens listed below are guidelines only and may need to be adjusted depend- American Academy of Pediatrics. Ehrlichia and Anaplasma In: Pickering LK, Baker CJ, Long SS, ing on a patient’s age, medical history, underlying health conditions, pregnancy McMillan JA, eds. Red Book: 2009 Report of the status or allergies. Consult an infectious disease specialist for the most current Committee on Infectious Diseases. 28th ed. Elk † treatment guidelines or for individual patient treatment decisions. Grove Village, IL: American Academy of Pediatrics; 2009: 284-287. AGE CATEGORY DRUG DOSAGE MAXIMUM DURATION Bakken JS, Aguero-Rosenfeld ME, Tilden RL, et (DAYS) NOTES al. Serial Measurements of Hematologic Counts during the Active Phase of Human Granulocytic Adults Doxycycline 100 mg twice N/A 10 • Patients with mild illness for whom Ehrlichiosis. Clinical Infectious Diseases. 2001; per day orally doxycycline treatment is contraindicated or IV 32: 862-870. may be treated with rifampin for 7-10 days Centers for Disease Control and Prevention. Children Doxycycline 4 mg/kg 100 mg 10 using a dosage regimen of 300 mg twice Diagnosis and Management of Tick-borne 8 years of age or older per day orally per dose per day by mouth for adults and 10 mg/kg Rickettsial Diseases: Rocky Mountain Spotted moderate illness or IV in twice per day for children (maximum, 2 divided doses Fever, Ehrlichiosis, and Anaplasmosis—United 300 mg per dose). States: A Practical Guide for Physicians and Children Doxycycline 4 mg/kg 100 mg 4-5 Other Health-care and Public Health professionals. • Because anaplasmosis can be life-threaten- less than 8 years of age per day orally per dose OR approx. MMWR 2006; 55 (No. RR-4). severe illness or IV in 3 days after ing and limited courses of therapy do not without Lyme disease 2 divided doses resolution of pose a substantial risk for tooth staining, Centers for Disease Control and Prevention. Case fever the American Academy of Pediatrics Definitions for Infectious Conditions Under Public has identified doxycycline as the drug Health Surveillance. http://www.cdc.gov/ncphi/ Children Doxycycline 4 mg/kg 100 mg 4-5 disss/nndss/casedef/case_definitions.htm. of choice for treating anaplasmosis in less than 8 years of age per day given per dose Accessed 12/10/2009. severe illness orally or IV in children of any age. with Lyme disease 2 divided doses Dumler JS, Walker DH. Ehrlichia chaffeensis • Treatment response is expected within (human monocytotropic ehrlichiosis), Anaplasma FOLLOWED BY 48 hours. Failure to respond in 3 days phagocytophilum (human granulocytotropic suggests infection with a different agent. anaplasmosis) and Other Ehrlichiae. In: Mandell Amoxicillin 50 mg/kg 500 mg to complete GL, Bennett JE, Dolin R, editors. Manell, Douglas, per day in per dose a 14 day • Treatment is not recommended for asymp- 3 divided doses total course and Bennett’s Principles and Practice of Infectious of antibiotic tomatic individuals who are seropositive Diseases. 7th ed. Philadelphia, PA: Churchill therapy for antibodies to A. phagocytophilum. Livingstone; 2010. p. 2531-2538. †Wormser GP, Dattwyler RJ, Shapiro ED, et al. The OR Clinical Assessment, Treatment and Prevention of Cefuroxime axetil 30 mg/kg 500 mg to complete Lyme Disease, Human Granulocytic Anaplasmosis, per day in per dose a 14 day and Babesiosis. Clinical Practice Guidelines by the 2 divided doses total course Infectious Diseases Society of America. Clinical of antibiotic Infectious Diseases. 2006; 43: 1089-1134. therapy BABESIOSIS AGENT SIGNS/SYMPTOMS LABS Parasite: Babesia microti [incubation period: 1-6 weeks] Common Findings on Routine Diagnostic Laboratory Criteria Tick: Ixodes scapularis • Malaise, fatigue Laboratory Tests • Positive PCR assay (preferred method); • • Sustained or intermittent fever, chills Decreased hematocrit secondary to or hemolytic anemia • • Gastrointestinal symptoms (anorexia, Identification of intraerythrocytic nausea, abdominal pain, vomiting) • Elevated reticulocyte counts Babesia parasites in a peripheral blood • smear or • Myalgia Elevated erythrocyte sedimentation rate • Isolation
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