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Tick-Borne Diseases 79 Tom E P1: Trim: 8.375in × 10.875in Top: 0.373in Gutter: 0.664in LWBK915-79 LWW-KodaKimble-educational June 21, 2011 21:25 Tick-Borne Diseases 79 Tom E. Christian CORE PRINCIPLES CHAPTER CASES LYME DISEASE 1 Lyme disease is a multisystem spirochetal disease transmitted by tick bite. Geography, Case 79-1 (Question 1) tick species, and duration of attachment guide the decision to use antibiotic prophylaxis. 2 Presence of erythema migrans skin rash is the only manifestation sufficiently specific to Case 79-2 (Questions 1, 2) allow a clinical diagnosis without confirmatory tests. 3 The existence of post-Lyme disease syndromes, although controversial, has resulted in Case 79-4 (Question 1) criteria for fulfilling a provisional diagnosis. 4 Prevention of tick-borne diseases is always preferable to acquisition. Personal Case 79-5 (Question 1) protective measures and other methodologies aid in prevention. ENDEMIC RELAPSING FEVER 1 Tick-borne relapsing fever epidemiology varies with geography, tick, and spirochete Case 79-6 (Questions 1, 2) species involved. SOUTHERN TICK-ASSOCIATED RASH ILLNESS 1 Southern tick-associated rash illness (STARI) is a recently described tick-borne disease Case 79-7 (Question 1) whose etiology and pathogenesis are still being defined. HUMAN GRANULOCYTIC ANAPLASMOSIS 1 Because the clinical manifestations of human monocytic ehrlichiosis (HME) and human Case 79-8 (Question 1) granulocytic anaplasmosis (HGA) are so similar, the presence of a skin rash and other findings may lead to diagnosis. BABESIOSIS 1 Babesiosis is an erythrocytophilic parasitic illness with symptoms that range from Case 79-9 (Questions 1, 2) asymptomatic disease to potential fatality, especially in immunocompromised patients. COLORADO TICK FEVER 1 Colorado tick fever (CTF) is a virally mediated tick-borne disease that can be more Case 79-10 (Question 1) severe in children than adults. TICK PARALYSIS 1 Tick paralysis occurs worldwide, affecting humans and livestock. It can be reversed by Case 79-11 (Question 1) tick removal. 1 P1: Trim: 8.375in × 10.875in Top: 0.373in Gutter: 0.664in LWBK915-79 LWW-KodaKimble-educational June 21, 2011 21:25 2 TABLE 79-1 Tick-Borne Diseases Disease Causative Agent Tick Vector Host Region Lyme Borrelia burgdorferi Ixodes Wild rodents Worldwide Relapsing fever (endemic) Borrelia species Ornithodoros Wild rodents Worldwide Southern tick-associated Borrelia lonestari? Amblyomma ? South-central to Northeast rash illness United States Tularemia Francisella tularensis Dermacentor Rabbits, ticks North America Amblyomma Rocky Mountain spotted Rickettsia rickettsii Dermacentor Wild rodents, ticks Western Hemisphere fever Rhipicephalus Arizona Spotted fever group Rickettsia parkeri, Amblyomma Horses? United States others Various rickettsia Various species ? Worldwide Boutonneuse fever Rickettsia conorii Ixodes Wild rodents, dogs Africa, India, Mediterranean North Asian tick typhus Rickettsia sibirica Ixodes Wild rodents Mongolia, Siberia Queensland tick typhus Rickettsia australis Ixodes Wild rodents, marsupials Australia Qfever Coxiella burnetii Dermacentor Sheep, goats, cattle, ticks, Worldwide cats Amblyomma Section 14 Babesiosis Babesia species Ixodes Mice, voles Europe, North America Human monocytic Ehrlichia chaffeensis Amblyomma Deer, dogs United States, Mexico, ehrlichiosis Europe, Africa, Middle East Dermacentor Deer Human granulocytic Anaplasma Ixodes pacificus Deer, elk, wild rodents United States, Europe anaplasmosis phagocytophilum Ixodes Infectious Disease Human ehrlichial ewingii Ehrlichia ewingii Amblyomma Dogs? United States Colorado tick fever Coltivirus species Dermacentor Wild rodents, mammals North America Tick-borne encephalitis Flavivirus Ixodes Rodents Eurasia, Far East Tick paralysis Neurotoxin Dermacentor, others N/A Worldwide N/A, not applicable. OVERVIEW LYME DISEASE Ticks belong to the class Arachnida, which includes scorpions, Lyme disease, or more accurately Lyme borreliosis, is a multi- spiders, and mites. As a vector of human illness worldwide, ticks system spirochetal disease transmitted by a tick bite.3 Although are second in importance only to mosquitoes.1 Ticks transmit the responsible spirochete, Borrelia burgdorferi, was not identified more infectious agents than any other arthropod. Disease can until 1982,4 late manifestations of a dermatitis produced by a be spread by ticks, either by transmission of microorganisms Borrelia species were described in Europe more than a century or by injection of tick toxin into a host. Bacterial, rickettsial, ago. protozoal, and viral disease pathogens can be transmitted from ticks to humans (Table 79-1). Spirochete Identification Tick Genus and Pathology Only two of the three families of ticks are of medical significance Three genomic subgroups of B. burgdorferi worldwide prob- to humans: the soft-bodied ticks, Argasidae, and the hard-bodied ably account for the clinical variations observed in the dis- ticks,Ixodidae.2 Fourofthe13generaofIxodidaetransmitdisease ease. The North American strains identified to date belong in the United States: Dermacentor, Ixodes, Amblyomma, and Rhipi- to the B. burgdorferi sensu stricto group. Although all three cephalus. Among the five genera of Argasidae, only Ornithodoros groups have been found in Europe, most isolates are Borre- are known to transmit pathogens to humans in the United States. lia garinii or Borrelia afzelii. An example of a disease variation Most hard ticks have a 2- to 3-year life cycle, comprising the is the condition of acrodermatitis chronica atrophicans (Table larval, nymphal, and adult stages.2 They require one blood meal 79-2), a skin lesion associated predominantly with B. afzelii during each stage before they can mature into the next stage, infection.3,4 and they usually remain attached to a host for hours or days. In Lyme disease is a multisystem condition, affecting the skin, contrast, soft ticks may have multiple nymphal stages, and both joints, and cardiovascular and central and peripheral nervous nymphal and adult forms can feast on blood multiple times, usu- systems. The ailment is named for the villages of Lyme and ally for only 30 minutes. However, Argasidae can survive many Old Lyme, Connecticut, where arthritic complications of this years without blood sustenance and are long-lived.2 Humans are disease were first recognized.5 In Europe and North Amer- the inadvertent hosts for the life cycle of almost all ticks and ica, Lyme disease is the most commonly reported tick-borne tick-borne diseases. disease.3 P1: Trim: 8.375in × 10.875in Top: 0.373in Gutter: 0.664in LWBK915-79 LWW-KodaKimble-educational June 21, 2011 21:25 3 TABLE 79-2 which parasitize domestic animals and humans, demonstrates a Lyme Disease Clinical Manifestations greater diversity of endemic vectors and cycles in Asia. There- fore, the geographic distribution of Lyme disease matches the Early Localized Infection geographic range of the specific Ixodes species that harbor Lyme Erythema migrans skin rash Borrelia. Early Disseminated Disease Heart (<4% of untreated patients in United States) HOST IDENTIFICATION Myocarditis or pericarditis Conduction defects, varying degrees of atrioventricular or The host’s ability to harbor and transmit the spirochete to bundle-branch block, but permanent pacing not indicated the tick (i.e., reservoir competency) is an important considera- Nervous System (Neuroborreliosis) tion in understanding the epidemiology and prevalence of Lyme Cranial nerve (Bell’s) palsy disease. The reservoir-competent white-footed mouse and the Meningitis, lymphocytic reservoir-incompetent (i.e., incapable of harboring and transmit- Radiculoneuritis, myelitis ting the spirochete) white-tailed deer are the preferred hosts for Sensory or motor peripheral neuropathy the immature and adult forms of I. scapularis in the northeast- 2 Skin ern United States, respectively. Subadult I. pacificus organisms Multiple secondary erythema migrans lesions; lymphocytoma preferentially feed on the western fence lizard, which is reser- , , (lymphadenosis benigna cutis) rare in the United States, but 1% in voir incompetent, and its blood is borrelicidal.3 6 7 Deer are not Europe important hosts for mature I. pacificus. Similarly, in the south- Late Disease ern United States, immature I. scapularis ticks feed primarily on lizards. The cotton mouse and cotton rat are the predominant Musculoskeletal (less common in Europe) Persistent (<10% of untreated in United States) or intermittent reservoir hosts for the spirochete in the southern United States. arthritis of >1 large joint, especially the knee In Europe, various reservoir-competent mice and vole species are reported hosts for I. ricinus as are more than 200 various species Skin (10% in Europe; rare in the United States) 2 Acrodermatitis chronica atrophicans (unique to Lyme disease) of birds, mammals, and lizards. How is Lyme borreliosis transmitted to humans in the Late Neurologic western United States if the preferred hosts are not reservoir Chapter 79 Peripheral neuropathy, subacute encephalopathy (memory impairment, sleep disturbance, dementia), and in Europe, competent? It is suggested that the dusky-footed wood rat and progressive encephalomyelitis kangaroo rat, which can support B. burgdorferi, are the hosts of the spirochete for the few immature I. pacificus, which inciden- tally feed on the rats. Thus, an estimated 0% to 14% of I. pacificus organisms are infected with spirochetes, contrasting with infec- Tick Vector tion rates for I. scapularis in the northeastern United States of
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