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Home , Anaplasmosis, Babesia microti, Dermacentor variabilis, Ixodes scapularis, Lyme disease, Lymphadenopathy

tick-borne in Maine A Physician’s Reference Manual Deer Dog Tick Lonestar Tick (CDC photo)

Nymph Nymph Nymph

Adult Male Adult Male Adult Male

Adult Female Adult Female Adult Female

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Ticks are generally found in brushy or wooded areas, near the Deer Tick Dog Tick lonestar Tick scapularis variabilis americanum ground; they cannot jump or fly. Ticks are attracted to a variety (also called blacklegged tick) (also called wood tick) of factors including body heat and carbon dioxide. They will Diseases Diseases Diseases transfer to a potential host when one brushes directly against Lyme , Rocky Mountain spotted , and 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 , 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. , and/or It does not replace the physician’s clinical judgment or the need for definitive laboratory testing. Does the patient have a ?

YES NO Other Considerations

• Rash occurs in 70-80% of patients. Blood smear review Complete • Rash occurs in less than 10% of blood count (CBC) patients.

• Rash occurs in less than 40% of adult migrans (single or Parasites in RBC* Normal CBC patients, and less than 60% multiple lesions) Babesiosis May be Anaplasma, RMSF,* of children. Lyme disease *If patient has an international tularemia** travel history, 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— 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 WBC low or normal, ulceration distally, further tests needed. May be tularemia thrombocytopenia, (ulceroglandular), further tests low hematocrit, • 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, acquired who resides on, is present, treat immediately May be anaplasmosis or or has recently visited, Martha’s Vineyard, ehrlichiosis, further tests . needed ANAPLASMOSIS (AKA HUMAN GRANULOCYTIC ANAPLASMOSIS)

AGENT Signs/Symptoms Labs : Anaplasma phagocytophilum [ 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 or eosinophils Tick: • Severe headache of clinical disease during examination of blood smears • Malaise • Mild is highly suggestive of a diagnosis; • however, blood smear examination is • Thrombocytopenia • Gastrointestinal symptoms (nausea, insensitive and should never be relied • Leukopenia (characterized by relative vomiting, , ) upon solely to rule anaplamsa in or out. and absolute lymphopenia and a • Cough left shift) • Confirmation of the diagnosis is based • • Modest elevations in hepatic on laboratory testing, but ther- • Stiff transaminases apy should not be delayed in a patient with a suggestive clinical presentation. •

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 titer by IFA consider the possibility of in paired 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 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. • Treatment response is expected within (human monocytotropic ehrlichiosis), Anaplasma Followed by 48 hours. Failure to respond in 3 days phagocytophilum (human granulocytotropic suggests with a different agent. anaplasmosis) and Other Ehrlichiae. In: Mandell 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 to A. phagocytophilum. Livingstone; 2010. p. 2531-2538.

†Wormser GP, Dattwyler RJ, Shapiro ED, et al. The OR Clinical Assessment, Treatment and Prevention of 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: microti [incubation period: 1-6 weeks] Common Findings on Routine Diagnostic Laboratory Criteria Tick: Ixodes scapularis • Malaise, Laboratory Tests • Positive PCR assay (preferred method); • • Sustained or , chills Decreased hematocrit secondary to or hemolytic anemia • • Gastrointestinal symptoms (anorexia, Identification of intraerythrocytic nausea, , vomiting) • Elevated reticulocyte counts Babesia parasites in a peripheral blood • smear or • Myalgia Elevated erythrocyte sedimentation rate • Isolation of the parasite from a whole • Arthralgia • Thrombocytopenia blood specimen by . • , emotional lability • WBC count may be normal or mildly • decreased NOTE: Due to the sparse parasitemia • Conjunctival injection • Decreased serum haptoglobin typical of most , • Dark urine • Elevated serum BUN and creatinine additional diagnostic tests should be • Petechiae, splinter hemorrhages, performed in suspect patients if the initial • Mildly elevated hepatic transaminases ecchymoses blood smear is negative. • Proteinuria • Mild and/or hepatomegaly • Hemoglobinuria • • Cough Direct Coombs’ test may react Supportive Laboratory Criteria positively • Sore throat • Demonstration of a Babesia-specific antibody titer by Immunoflourescent Antibody (IFA) test for IgG. In general, higher cutoff titers (> 1:256) are associated with greater diagnostic specificity. BABESIOSIS

treatment REFERENCES The regimens listed below are guidelines only and may need to be adjusted depend- American Academy of Pediatrics. Babesiosis In: Pickering LK, Baker CJ, Long SS, McMillan JA, ing on a patient’s age, medical history, underlying health conditions, pregnancy eds. Red Book: 2009 Report of the Committee on status or allergies. Consult an infectious disease specialist for the most current Infectious Diseases. 28th ed. Elk Grove Village, IL: † treatment guidelines or for individual patient treatment decisions. American Academy of Pediatrics; 2009: 226-227.

Gelfand JA, Vannier E. Babesia Species. In: age category drug dosage maximum duration Mandell GL, Bennett JE, Dolin R, editors. Mandell, (days) notes Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Adults Atovaquone 750 mg orally N/A 7-10 • For adult patients who are immunocom- Churchill Livingstone; 2010. p. 3539-3545. every 12 hours promised, higher doses of , plus 600-1000 mg per day, may be used. Homer MJ, et al. Babesiosis. Clinical Microbiology Reviews. 2000; 13(3): 451-469. Azithromycin 500-1000 mg 100 mg 7-10 • The recommended treatment for patients on day 1 and per dose Krause PJ. Babesiosis Diagnosis and Treatment. 250 mg orally with severe babesiosis, as indicated -borne and Zoonotic Diseases. once per day by high-grade parasitemia (=> 10%), 2003; 3(1): 45-51. thereafter significant , or renal, hepatic or OR pulmonary compromise, is quinine and IV Krause PJ, et al. Comparison of PCR with Blood Clindamycin 300-600 mg N/A 7-10 clindamycin, and the patient should be Smear and Inoculation of Small for Diag- nosis of Babesia microti Parasitemia. Journal of IV every considered for partial or complete RBC 6 hours OR Clinical Microbiology. 1996; 34(11): 2791-2794. exchange transfusion 600 mg orally every 8 hours Persing DH, et al. Detection of Babesia microti • Consider the possibility of coinfection with by Polymerase Chain Reaction. Journal of Clinical plus B. burgdorferi and/or A. phagocytophilum Microbiology. 1992: 30(8): 2097-2103. Quinine 650 mg orally 100 mg 7-10 in patients with especially severe or every 6-8 hours per dose Ruebush TK, Juranek DD, Spielman A, Piesman J, persistent symptoms, despite appropriate Healy G. Epidemiology of Human Babesiosis Children Atovaquone 20 mg/kg 750 mg 7-10 antibabesial therapy. on Nantucket Island. Am. J. Trop. Med. Hyg. per dose every 12 hours 1981; 30 (5): 937-941. • patients with a positive plus babesial smear and/or PCR results should Thompson C, Spielman A, Krause PJ. Coinfecting Azithromycin 10 mg/kg once 500 mg 7-10 have these studies repeated. Treatment Deer-Associated Zoonoses: Lyme Disease, per day on per dose on Babesiosis, and Ehrlichiosis. Clinical Infectious day 1 and day 1 and should be considered if parasitemia per- 5 mg/kg 250 mg sists for more than three months. Diseases. 2001; 33: 676-685. once per day per dose thereafter orally thereafter †Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment and Prevention of OR Lyme Disease, Human Granulocytic Anaplasmosis, Clindamycin 7-10 mg/kg IV 600 mg 7-10 and Babesiosis. Clinical Practice Guidelines by the or orally every per dose Infectious Diseases Society of America. Clinical 6-8 hours Infectious Diseases. 2006; 43: 1089-1134. plus Quinine 8 mg/kg orally 650 mg per 7-10 every 8 hours dose EHRLICHIOSIS (AKA HUMAN MONOCYTIC EHRLICHIOSIS)

AGENT Signs/Symptoms Labs Bacteria: Ehrlichia chaffeensis [Incubation period 7-10 days] Common Findings on Routine notes Laboratory Tests Tick: Ambylomma americanum • Fever, chills • Confirmation of the diagnosis is based Generally observed during the first on laboratory testing, but antibiotic ther- • Severe headache week of clinical disease apy should not be delayed in a patient • Malaise • Thrombocytopenia with a suggestive clinical presentation. • Myalgia • Mild to moderate leukopenia • Clinical signs of anaplasmosis and ehrli- • Gastrointestinal symptoms (nausea, • chiosis are similar, and testing for both vomiting, diarrhea, anorexia) Modest elevations in hepatic transaminases species are indicated due to presence • Cough of both tick vectors. Also consider the • Arthralgia Diagnostic Laboratory Criteria possibility of coinfection with B. microti • Stiff neck • Detection of DNA by PCR assay and/or B. burgdorferi. • Confusion (preferred method); or • Demonstration of a four-fold change in IgG-specific antibody titer by IFA in paired serum samples; or • Immunohistochemistry (IHC) staining of organism; or • Isolation of organism from a clinical specimen in cell culture. EHRLICHIOSIS

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 Centers for Disease Control and Prevention. (days) notes Diagnosis and Management of Tick-borne Rickettsial Diseases: Rocky Mountain Spotted Adults Doxycycline 100 mg N/A 10 • Patients with mild illness for whom Fever, Ehrlichiosis, and Anaplasmosis—United twice per day doxycycline treatment is contraindicated orally or IV States: A Practical Guide for Physicians and may be treated with rifampin for 7-10 days Other Health-care and Public Health professionals. Children Doxycycline 4 mg/kg 100 mg 10 using a dosage regimen of 300 mg twice MMWR 2006; 55 (No. RR-4). 8 years of age or older per day orally per dose per day by mouth for adults and 10 mg/kg Centers for Disease Control and Prevention. Case moderate illness or IV in twice per day for children (maximum, 2 divided doses Definitions for Infectious Conditions Under Public 300 mg per dose). Health Surveillance. http://www.cdc.gov/ncphi/ Children Doxycycline 4 mg/kg 100 mg 4-5 disss/nndss/casedef/case_definitions.htm. Accessed • Because ehrlichiosis can be life-threaten- less than 8 years of age per day orally per dose OR approx. 12/10/2009. 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, Dumler JS, Walker DH. Ehrlichia chaffeensis fever the American Academy of Pediatrics has (human monocytotropic ehrlichiosis), Anaplasma phagocytophilum (human granulocytotropic Children Doxycycline 4 mg/kg 100 mg 4-5 identified doxycycline as the drug of anaplasmosis) and other ehrlichiae. In: Mandell less than 8 years of age per day given per dose choice for treating ehrichiosis in children GL, Bennett JE, Dolin R, editors. Manell, Douglas, severe illness orally or IV in of any age. with Lyme disease 2 divided doses and Bennett’s Principles and Practice of Infec- tious Diseases. 7th ed. Philadelphia, PA: Churchill • Treatment response is expected within Followed by Livingstone; 2010. p. 2531-2538. 48 hours. Failure to respond in 3 days Amoxicillin 50 mg/kg 500 mg to complete suggests infection with a different agent. †Wormser GP, Dattwyler RJ, Shapiro ED, et al. The per day in per dose a 14 day Clinical Assessment, Treatment and Prevention of 3 divided doses total course • Treatment is not recommended for asymp- Lyme Disease, Human Granulocytic Anaplasmosis, of antibiotic tomatic individuals who are seropositive and Babesiosis. Clinical Practice Guidelines by the therapy for antibodies to E. chaffeensis. Infectious Diseases Society of America. Clinical Infectious Diseases. 2006; 43: 1089-1134. OR

Cefuroxime axetil 30 mg/kg 500 mg to complete per day in per dose a 14 day 2 divided doses total course of antibiotic therapy Lyme disease

AGENT Labs Bacteria: burgdorferi Late disseminated stage (within months Common Findings on Routine Limitations to Serologic Tests for Tick: Ixodes scapularis post-exposure) Laboratory Tests Lyme Disease: • Prolonged episodes of • Elevated sedimentation rate (generally • Serologic tests are insensitive during with localized or early disseminated the first few weeks of infection. Signs/Symptoms • Peripheral enthesopathy disease) • In persons with illness > than 1 month, Early localized stage (within 3-30 days • Chronic axonal polyradiculopathy post-exposure) • For cases of Lyme disease , a positive IgM test alone is not • Spastic parapareses CSF typically has a lymphocytic recommended for determining current • (EM)—red ring-like • Ataxic gait pleocytosis with slightly elevated disease or homogenous expanding rash (this is protein levels and normal glucose a sign) • Chronic • Due to antibody persistence, single levels • Subtle mental disorders positive serologic test results can not • Flu-like symptoms including malaise, distinguish between active and past fatigue, headache, fever, chills, myal- • Keratitis Diagnostic Laboratory Criteria infection and serologic tests can not be gia, regional lymphadenopathy • Fatigue • Demonstration of diagnostic IgM (in used to measure treatment response. first 6 weeks ONLY) or IgG antibodies • Due to their high sensitivity and low Early disseminated stage (within days in serum or . Due specificity, EIA and IFA tests may yield to weeks post-exposure) to high false-positive rates in both false-positive results due to cross- • Severe malaise and fatigue enzyme immunoassay (EIA) and reactivity with antibodies to commensal immunoflourescence assay (IFA) • Multiple secondary annular or pathogenic spirochetes, certain viral tests, a two-tier testing protocol is infections (e.g., varicella, Epstein-Barr • Regional or generalized recommended; a positive or equivocal lymphadenopathy ), or certain autoimmune diseases EIA or IFA should be followed by (e.g., systemic erythematosus). • Migratory pain in joints, tendons, a (preferred method) bursae, muscle and bone • Transient, migratory arthritis NOTE: Coinfection with B. microti and/or • Atrioventricular nodal block A. phagocytophilum should be considered in patients who present with initial symp- • toms that are more severe than are com- • Meningitis, motor and sensory monly observed with Lyme disease alone, radiculoneuritis, subtle , especially in those who have high-grade mononeuritis multiplex, pseudotumor fever for more than 48 hours despite cerebri appropriate antibiotic therapy or who have • Bell’s palsy or other cranial nerve unexplained leucopenia, thrombocytopenia, or anemia. Coinfection might also be • Splenomegaly considered in patients whose erythema migrans skin lesion has resolved but have • Microsopic or proteinuria persistent viral infection-like symptoms.

Lyme disease

treatment REFERENCES The regimens listed below are guidelines only and may need to be adjusted depend- American Academy of Pediatrics. Lyme disease (Lyme borreliosis, infection). ing on a patient’s age, medical history, underlying health conditions, pregnancy In: Pickering LK, Baker CJ, Long SS, McMillan JA, status or allergies. Consult an infectious disease specialist for the most current eds. Red Book: 2009 Report of the Committee on † treatment guidelines or for individual patient treatment decisions. Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009: 430-435.

Early Localized Stage Bunikis J., Barbour A. Laboratory Testing for Suspected Lyme Disease. Medical Clinics of North age category drug dosage maximum duration America. 2002; 86(2): 311-340. (days/ note: For patients intolerant of Centers for Disease Control and Prevention. Case range) amoxicillin, doxycycline, and cefuroxime Definitions for Infectious Conditions Under Public Adults Doxycycline 100 mg N/A 14 (14-21) axetil, the macrolides azithromycin, Health Surveillance. http://www.cdc.gov/ncphi/ twice per day , or erythromycin may orally or IV disss/nndss/casedef/case_definitions.htm. Accessed be used, although they have a lower 12/10/2009. 500 mg N/A 14 (14-21) efficacy. Patients treated with macrolides Nadelman RB. The Clinical Spectrum of Early twice per day should be closely observed to ensure Lyme Borreliosis in Patients with Culture-Confirmed Amoxicillin 500 mg N/A 14 (14-21) resolution of clinical manifestations. Erythema Migrans. The American Journal of 3 times per day Medicine. 1996; 100: 502-508. Treatment guidelines for patients with Children Amoxicillin 50 mg/kg 500 mg 14 (14-21) disseminated or late stage Lyme disease Steere AC, et al. The Early Clinical Manifestations per day in per dose 3 divided doses are outlined in the references.† of Lyme disease. Annals of Internal Medicine. 1983; 99: 76-82. Doxycycline 4 mg/kg 100 mg 14 (14-21) per day in per dose Steere AC. Borrelia burgdoferi (Lyme Disease, 2 divided doses Lyme Borreliosis). In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s Cefuroxime axetil 30 mg/kg 500 mg 14 (14-21) Principles and Practice of Infectious Diseases. 7th per day in per dose ed. Philadelphia, PA: Churchill Livingstone; 2010. 2 divided doses p. 3071-3081.

†Wormser GP, Dattwyler RJ, Shapiro ED, 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. Clinical Infectious Diseases. 2006; 43: 1089-1134. ROCKY MOUNTAIN

AGENT Signs/Symptoms Labs Bacteria: rickettsii [incubation period 2-14 days] Common Findings on Routine notes

Tick: • Fever, chills Laboratory Tests • Tests for IgM antibodies are generally not • • Severe headache Anemia useful for serodiagnosis of acute disease, • due to cross-reactivity and persistence of • Malaise Thrombocytopenia the antibody. • • Myalgia Mildly elevated hepatic transaminase levels • Confirmation of the diagnosis is based on • Gastrointestinal symptoms (nausea, vomiting, anorexia, abdominal pain, • Hyponatremia laboratory testing, but antibiotic therapy should not be delayed in a patient with a diarrhea, abdominal tenderness) • Azotemia suggestive clinical presentation. • Rash, 2-5 days after fever starts, begins as small, blanching, pink macules on Diagnostic Laboratory Criteria the ankles, wrists, or forearms that • Detection of DNA in a clinical specimen evolve to muculopapules. May expand by PCR assay (generally unreliable to the entire body including the palms for acute blood samples) (preferred and soles. The classic spotted, or method); or generalized petechial, rash is not • Demonstration of a four-fold change usually apparent until the 5th or 6th in IgG-specific antibody titer by IFA day of illness. in paired sera; or • Cough • IHC staining of organism in a • Conjunctival injection, +/-photophobia or autopsy specimen; or • Altered mental status • Isolation of organism in cell culture. • Focal neurologic deficits, including cranial or peripheral motor nerve paralysis or sudden transient deafness

NOTE: Rash may be completely absent or atypical in up to 20% of RMSF cases. Rocky Mountain “spotless” fever is more likely to occur in older patients. ROCKY MOUNTAIN SPOTTED FEVER

treatment REFERENCES The regimens listed below are guidelines only and may need to be adjusted depend- American Academy of Pediatrics. Rocky Mountain Spotted Fever. In: Pickering LK, Baker CJ, Long ing on a patient’s age, medical history, underlying health conditions, pregnancy SS, McMillan JA, eds. Red Book: 2009 Report of status or allergies. Consult an infectious disease specialist for the most current the Committee on Infectious Diseases. 28th ed. Elk † treatment guidelines or for individual patient treatment decisions. Grove Village, IL: American Academy of Pediatrics; 2009: 573-575.

age category drug dosage maximum duration (days) †Centers for Disease Control and Prevention. NOTE: Because RMSF can be life- Diagnosis and Management of Tick-borne Rickettsial Diseases: Rocky Mountain Spotted Adults Doxycycline 100 mg N/A At least 3 days after the threatening and limited courses of Fever, Ehrlichiosis, and Anaplasmosis—United twice daily, fever subsides and until therapy do not pose a substantial risk for States: A Practical Guide for Physicians and Other orally or IV evidence of clinical im- tooth staining, the American Academy provement is noted which Health-care and Public Health professionals. is typically for a minimum of Pediatrics has identified doxycycline MMWR 2006; 55 (No. RR-4). total course of 5-7 days. as the drug of choice for treating RMSF Centers for Disease Control and Prevention. Case in children of any age. Children weighing Doxycycline 100 mg Consult a At least 3 days after the definitions for infectious conditions under public =>100 lbs (45.4 kg) twice daily, pediatric fever subsides and until health surveillance. http://www.cdc.gov/ncphi/disss/ infectious evidence of clinical im- orally or IV nndss/casedef/case_definitions.htm. Accessed disease provement is noted which 12/10/2009. specialist is typically for a minimum total course of 5-7 days. Walker DH, Raoult D. Rickettsia ricketsii and Other Spotted Fever Group Rickettsiae (Rocky Mountain Children weighing Doxcycline 2.2 mg/kg Consult a At least 3 days after Spotted Fever and Other Spotted ). In: < 100 lbs (45.4 kg) body pediatric the fever subsides and Mandell GL, Bennett JE, Dolin R, editors. Manell, weight infectious until evidence of clinical per dose disease improvement is noted Douglas, and Bennett’s Principles and Practice of twice daily, specialist which is typically for a Infectious Diseases. 7th ed. Philadelphia, PA: orally or IV minimum total course Churchill Livingstone; 2010. p. 2499-2507. of 5-7 days. TULAREMIA

AGENT Signs/Symptoms Labs Bacteria: tularensis [Average incubation period 3-5 days, Typhoidal Common Findings on Routine Tick: Dermacenter variabilis range 1-21 days] • Characterized by any combination Laboratory Tests of the general symptoms • Leukocyte count and sedimentation rate may be normal or elevated NOTE: The clinical presentation Oculoglandular • Thrombocytopenia of tularemia will depend on a number • • Hyponatremia of factors, including the portal of entry. Photophobia • Excessive lacrimation • Elevated hepatic transaminases • Conjunctivitis • Elevated creatine phosphokinase General (may be present in all forms • Preauricular, submandibular and • Myoglobinuria of tularemia) • Sterile pyuria • Fever, chills Diagnostic Laboratory Criteria • Headache Phyaryngeal • Demonstration of a four-fold change • Malaise, fatigue • Severe throat pain in antibody titer in paired sera; or • Anorexia • Cervical, preparotid, and retropharyn- geal lymphadenopathy • Isolation of organism. • Myalgia • Chest discomfort, cough Pneumonic • Sore throat NOTE: Detection of organism by fluorescent • Non-productive cough • Vomiting, diarrhea assay or a single elevated serum antibody • Substernal tightness titer is supportive of the diagnosis; however, • Abdominal pain • Pleuritic these results should be confirmed by either one of the methods above. Ulceroglandular • Localized lymphadenopathy NOTE: Pneumonic tularemia should be considered in any patient presenting with • Cutaneous ulcer at infection site community-acquired pneumonia who resides on, or has recently visited, Martha’s Glandular Vineyard, Massachusetts. • Regional lymphadenopathy with no cutaneous lesion TULAREMIA

treatment REFERENCES The regimens listed below are guidelines only and may need to be adjusted depend- American Academy of Pediatrics. Tularemia. In: Pickering LK, Baker CJ, Long SS, McMillan JA, ing on a patient’s age, medical history, underlying health conditions, pregnancy eds. Red Book: 2009 Report of the Committee on status or allergies. Consult an infectious disease specialist for the most current Infectious Diseases. 28th ed. Elk Grove Village, IL: † treatment guidelines or for individual patient treatment decisions. American Academy of Pediatrics; 2009: 708-710.

Centers for Disease Control and Prevention. age category drug dosage maximum duration Case Definitions for Infectious Conditions Under (days) NOTES Public Health Surveillance. www.cdc.gov/epo/ dphsi/casedef/case_definitions.htm. Downloaded Adults 5 mg/kg IM or IV daily N/A 10 • Doses of both and gentamicin 12/10/2009. (with desired peak need to be adjusted for renal insufficiency. serum levels of at least †Dennis D, Inglesby TV, Henderson DA, et al. 5 mcg/mL) • Chloramphenicol may be added to strepto- Tularemia as a Biological Weapon: Medical OR mycin to treat meningitis. and Public Health management. Journal of the American Medical Association. 2001. 285(21): Streptomycin 1 g IM twice daily N/A 10 • Alternative therapies to the preferred 2763-2773. regimens of streptomycin and gentamicin Feldman KA, Enscore RE, Lathrop SL, et al. Children Gentamicin 2.5 mg/kg IM or IV Consult a 10 are outlined in references.† An Outbreak of Primary Pneumonic Tularemia 3 times daily pediatric infectious on Martha’s Vineyard. New England Journal of disease Medicine. 2001; 345: 1601-1606. specialist Penn RL. (Tularemia). In: OR Mandell GL, Bennett JE, Dolin R, editors. Manell, Douglas, and Bennett’s Principles and Practice Streptomycin 15 mg/kg IM twice daily 2 g/day 10 of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone; 2010. p. 2927-2937. Additional resources

For more information on tick-borne diseases or to report a case of tick-borne disease Maine Center for Disease Control and Prevention Infectious Disease Epidemiology 800-821-5821 www.mainepublichealth.gov

Other resources: Centers for Disease Control and Prevention www.cdc.gov

American College of Physicians/American Society of Internal Medicine http://www.acponline.org/lyme/ acknowledgements: Maine CDC would like to acknowledge the following for their contribution to this physicians reference guide: • Federal CDC • Maine Medical Center Research Institute Vector-borne Disease Lab • Massachusetts Department of Public Health

June 2012 Maine Center for Disease Control and Prevention Infectious Disease Epidemiology 800-821-5821 www.mainepublichealth.gov