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OBJECTIVES

TICKBORNE • Describe the epidemiology, origin, treatment, and prevention of borne diseases. • Solve case studies. Lynda Britton, Ph.D., MLS(ASCP)CM, SM LSU Health Shreveport

TICK LIFE CYCLE BLACKLEGGED

HOW TICKS SPREAD MOUTH PARTS

• Preparing to feed 10 min to 2 hrs • Cuts skin surface & inserts feeding tube • Secrete saliva to modulate host defenses – Pain and itch – Hemostatis – and wound healing • Transmits pathogen while feeding for days • Drops off to complete next life stage

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• Emerging Program • CDC in 2007 • Coordinate surveillance – Public health impact –Cost – Tick density and acaridice treatment – Trap and treat with fipronil – Identify novel pathogens molecularly

WWW.CDC.GOV/PUBS RESEARCHER DRAGS FOR TICKS

CASE 1

• 12 y. o. from Santa Cruz, CA • Swollen painful right knee and hip • Recurrent knee swelling & pain lasting several days every 4-5 months • Treated with herbs instead of antimicrobials • WBC = 7000, HCT 33%, ESR 73mm/h • Knee aspirate: 59,000 WBCs and protein of 5 g/dL • No growth on bacterial cultures but positive by PCR

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WHAT DO YOU SUSPECT IS THE PATHOGEN? • Most common tick-borne disease in North America 25% 25% 25% 25% • Caused by burgdorferi A. Rickettsia • >21,000 cases reported during 2014 rickettsii • 5th among all nationally notifiable conditions B. Borrelia • 90% cases occur in 12 states burgdorferi • Tick vectors: scapularis C. I. pacificus D. Ehrlichia

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I. SCAPULARIS I. PACIFICUS

STAGE 1: LOCALIZED LYME DISEASE • • Seasonal (April-September) • Occurs in ~90% • Low risk of disease if tick • Begins 7-10 days after tick attached <36 hrs bite • Signs/symptoms begin 7-10 • Expands over days to weeks days after bite (range 3-30 days) • Central clearing occurs in • May be asymptomatic minority • Rarely fatal • Constitutional: flu-like and

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DISSEMINATED STAGE DISSEMINATED: • Multiple skin lesions RHEUMATOLOGIC MANIFESTATIONS •Generalized • 60% untreated 20 yrs ago developed joint lymphadenopathy swelling –10% •Malaise, fatigue, – Synovial fluid 24,000 WBC with granulocytes • 5% develop cardiac • Migratory transient intermittent and effusions involvement • Pain in muscles, bones, – Conductional abnormalities—atrio- tendons, bursa ventricular node block • Baker’s cyst – Myocarditis – Pericarditis

DISSEMINATED EARLY NEUROLOGIC LATE NEUROLOGICAL LYME MANIFESTATIONS DISEASE--RARE • Cranial neuropathy • Encephalomyelitis – Bell’s palsy – Parenchymal inflammation of brain and/or spinal • Meningitis-lymphocytic cord – CSF= lymphocytic, mod • Cognitive difficulties ↑ protein, normal glucose • Peripheral neuropathy • Memory, mood, – Intermittent ↓ vibratory sensaon of legs and feet • Sleep disturbances • Encephalopathy – Memory and cognitive impairment – CSF normal

HOW IS LYME DISEASE BEST DIAGNOSIS DIAGNOSED? • Characteristic clinical A. Culture in Kelly 25% 25% 25% 25% picture medium • Serology: 2-step B. Histochemical – 1) Polyvalent ELISA: 60- examination of tissue 70% positive by wk 4 C. Peripheral blood – if equivocal or + smear – 2) Western blot (IgG and D. EIA followed by separate IgM): requires 5 Western blot of 10 bands .. .. . n. dium at r e smear e in st m m d • PCR lly We exa bloo y Ke b n i ical ed re m u w lt llo • Culture: low yield (27%) che o Cu o Peripheral f ist H EIA

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SOUTHERN TICK-ASSOCIATED RASH ILLNESS

• Seronegative Lyme Disease • Southern Lyme Disease • “One of the more obtuse diseases. . .”

SOUTHERN TICK-ASSOCIATED RASH ILLNESS AMERICANUM

• Red, expanding-3” • 7 days of bite • Long star tick • Geography • Cause unknown

LONE STAR TICK CLINICAL MANIFESTATIONS

• Range and abundance ↑over past 20-30 years • Large numbers in Maine and as far west as • Early Lyme Disease central and Oklahoma – Fatigue, , , and muscle pains • All life stages will feed on humans— • No arthritis, neurological disease or aggressive chronic symptoms • Feed readily on dogs and cats • Saliva can be irritating; redness and discomfort at a bite site does not necessarily indicate an infection

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DIAGNOSIS DIFFERENCE WITH LYME DISEASE

• Clinically: symptoms, geographical • STARI patients recall tick bite location and tick bite • Time from bite to symptoms shorter • No blood tests because don’t know • Patients with rash less likely to have etiological agent symptoms • Smaller and fewer lesions • More likely to have central clearing

CASE #2 WHAT SHOULD BE INCLUDED IN THE ? A. Meningococcemia B. RMSF 13% 13% 13% 13% 13% 13% 13% 13% • In June, 5 y.o. female C. HME • Taken to an ED in Missouri D. Enterovirus • 3-day history of , E. headache, mild , and a sore throat F. Drug reactions ° º • Fever of 105 F (40.6 C) G. Streptococcal

• Maculopapular rash on her legs, including a F E e n infection i ase v MS HM io R se tions ct bo c a ccem di fe e co rea in h the soles of her feet. t go Enterovirus al f asaki rug o H. All of the above in cc ll n aw D e K A M ptoco re St

FURTHER INFO NEEDED CASE CONTINUED • Rash began on the arms and legs same • How long has rash been there? day • Where it appeared before onset of fever? • Did not own a dog • ? • No history of recent travel out of the local • Immunocompromising conditions? area • Recent activities? • No history of a tick bite but ticks in the • Ill contacts? area around their house 9 •Travel? • 8.8 x 10 WBC with 5% bands, 70% neutrophils • Tick exposures? • 50 x 109 platelets

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ROCKY MOUNTAIN • Etiologic agent: • Vectors: – variabilis (dog tick) – D. andersoni (wood tick) – (lone star tick)

RMSF

• 91 cases in 2014 • Spring and summer • Incubation period: ~ 7 days (2-14) • Abrupt onset severe HA, F/C, prostration, myalgias, nonproductive cough (later) • GI manifestations very common • CNS: meningitis, • Death: 1-2 weeks after symptom onset in 4- 8% (untreated)

RASH

• Macular rash develops day 2-6 (90%): wrists, ankles, palms, & soles then centrally • Lesions become petechial, hemorrhagic • Vasculitis

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WHAT IS THE PREFERRED METHOD DIAGNOSIS TO DIAGNOSE RMSF IN THE LAB? • Clinical & epidemiologic

A. Blood culture 25% 25% 25% 25% • Nonspecific lab findings: B. Direct fluorescent – anemia, hyponatremia, low plts, ↑AST antibody • RMSF PCR from rash site C. PCR of rash biopsy is now preferred D. Immunohisto- • IFA: IgM +: 1-2 w but may chemical staining of be false + blood y sy ... • IgG +: 4-6 w iop st culture b d antibod ical t ash r m Bloo f o ‐che escen o • Immunostaining: skin r CR t P is h fluo o t n u m biopsy prior to therapy Direc Im

RICKETTSIA PARKERI CASE 3

• Healthy 2 y.o. female southeast Missouri • Mild form of RMSF • Fever 104⁰F, vomitting and diarrhea • Confirmed 2002 • Red maculopapular rash that blanched began on cheek • Amblyomma maculatum tick • 4.9 x 109 WBC, 10.9 g/dL Hgb, 102 x 109 plt • Cattle on Gulf Coast of Texas • Hyponatremia and mildly elevated enzymes • Virginia • Inclusion bodies in cytoplasm of monocytes • Antibodies cross react with RMSF • PCR confirmed diagnosis

WHAT IS THE SUSPECTED PATHOGEN IN THIS CASE? • Obligate intracellular form A. Anaplasma 25% 25% 25% 25% distinct microcolonies called morulae B. Rickettsia rickettsii • Diseases: C. Ehrlichia • Human Monocytotropic Ehrlichiosis chafeensis • Human Granulotropic D. Borrelia hermsii • E. ewingii • “Rocky Mountain Spotless Fever”

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EHRLICHIOSIS • Southeastern and south-central US • Lone star tick • OK, MO, AR 35% cases • Ehrlichia muris-like in upper midwest • 966 reported case in 2014

SIGNS AND SYMPTOMS BLOOD TRANFUSION AND ORGAN TRANSPLANTATION • Fever, headache • Chills, malaise • Survive for > 1week in refrigerated blood • Muscle pain • Leukoreduced blood • Nausea, diarrhea, • Infected within 1 mo • Confusion • No cases confirmed by organ • Conjuctival injection transplantation • Rash—more common in children

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GENERAL LAB FINDINGS LABORATORY DIAGNOSIS

• Serology (IFA) – Negative in first 7-10 days • Anemia – Minimum peak of 1:80 • Leukopenia – Fourfold change • Thrombocytopenia – Positive: week 3 • Elevated AST – Peak: week 6 – Cross-reactivity • Elevated ALT • Morulae detected in 20% • PCR

LABORATORY DIAGNOSIS IF MORULAE WERE SEEN IN SEGMENTED NEUTROPHILS, WHAT WOULD BE THE AGENT? • Antibody titer to 25% 25% 25% 25% antigen by IFA in paired serum samples A. Ehrlichia •PCR chaffeensis • Identification of morulae in leukocytes and B. Anaplasma a positive IFA titer phagocytophilia • Immunostaining of E. chaffeensis antigen C. Rickettsia ricketsii in a biopsy or autopsy sample ii lia D. Borrelia ensis hi p ffe rickets yto cha sia urgdorferi b • Culture from a clinical specimen agoc a burgdorferi chia h li p ickett rreli r a R o Eh sm B la nap A

ANAPLASMA PHAGOCYTOPHILUM • Human granulocytotropic ehrlichiosis • Fever, shaking chills • Severe headache • Malaise, myalgia • Nausea, vomiting, diarrhea, anorexia • Cough • Mild self-limiting in most • Fatal if advanced age or immunosuppressed, malignancy or chronic inflammatory • Rash 60% children; 30% adults • More likely to have morulae

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• Persons aged >70 and 60–69 years • <1% fatality • Ixodes scapularis and Ixodes pacificus (blacklegged ticks) • New England, North Central and Pacific states

LABORATORY DIAGNOSIS

• IgG antibody titer by IFA in paired serum samples • Canine granulocytotropic ehrlichiosis (first week and 2-4 weeks later) • 20 human cases • Positive PCR whole blood in 1st week and •: A. americanum confirmation • First 4 cases of human infection reported • Identification of morulae in leukocytes and a July, 1999 positive IFA titer • Immunocompromised patients from Missouri, • Immunostaining in a biopsy or autopsy sample Oklahoma, and Tennessee • Culture of A. phagocytophilum from a clinical • Antigenic similarity to E. chaffeensis and E. specimen in HL60 cells canis • Consider coinfection with Babesia or B. • Infects granulocytes burgdorferi

EHRLICHIA MURIS-LIKE OR EML CASE 4

• ? • 1-2 weeks after bite • In June, woman attempted to take dead from her dog • Minnesota, Wisconsin • Her thumb had a splinter and became • Fever, malaise, headache, lymphopenia infected • Thrombocytopenia, ↑ liver enzymes • Lesion developed • E. muris Japan and Russia • In 7 days • PCR test of choice – Fever of 104⁰F

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THE MOST LIKELY PATHOGEN IN THIS CASE IS: • Causative agent: tularensis 25% 25% 25% 25% • Small, gram‐negative coccobacillus A. • Tick bites account for > 50% cases B. C. Borrelia burdorferi D. Rickettsia rickettsii

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VECTORS

• > 12 tick species – A. americanum, D. variabilis, D. andersoni • Deer flies • Skin contact with infected animals • Drinking contaminated water • Aerosol • No person to person • June-September and December

CLINICAL MANIFESTATIONS

• Depends on route of infection • Ulceroglandular—most common – Skin at entry site – Enlarged lymph glands armpit or groin • Glandular—like ulceroglandular without the ulcer • Oculoglandular—enter eye • Oropharyngeal—eating or drinking contaminated food or water • Pneumonic—most serious from breathing aerosols

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GENERAL LABORATORY LABORATORY DIAGNOSIS FINDINGS • Alert laboratory—potential for • lab exposure • Thrombocytopenia •Culture • Elevated sedimentation rate – Skin lesions, • Elevated ALT/AST aspirates, pharyngeal washings, sputum • Sterile pyuria in 20-35% •DFA •PCR • Immunohistochemical staining

CASE 5 LABORATORY STUDIES

• I mo. old infant from Massachusettes • Hemolytic anemia, thrombocytopenia, ↑ALT • Fussy, pale, warm skin, and vomiting • Other chemistry tests normal • UA- dark red, cloudy, pH of 7.0, specific • 38.6⁰C; tachycardia gravity of 1.015, a large amount of blood, • Poor perfusion 100 mg per deciliter of protein, and trace • leukocyte esterase • Microscopic 0 to 5 red cells and white • Pulmonary cells/HPF,15 to 20 granular casts/LPF • Normal CSF

AFTER RULING OUT A BACTERIAL INFECTION, WHAT IS THE CAUSE?

A. Borrelia burdorferi 25% 25% 25% 25% B. Ehrlichia chaffensis • Intraerythrocytic parasite C. Anaplasma • Babesia microti transmitted by I. scapularis phagocytophilum • B. divergens—splenectomized Europe D. Babesia microti • B. duncani—WA, CA i er sis rf fen do microti r af cytop... a bu ch • Currently unnamed strain designated MO- ia phago a Babesi Borrelia Ehrlich sm 1--Missouri la p Ana

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CLINICAL MANIFESTATIONS

• Asymptomatic 25-50% • Fatal • Fever, chills, sweats, myalgia, arthralgia • Anorexia, nausea, vomiting • Fatigue • Splenomegaly, hepatomegaly,

AT RISK SEVERE CASES

• Marked thrombocytopenia •DIC • Asplenic • Hemodynamic instability • Malignancy • Renal failure •HIV • Compromised liver • >50 y.o. • Acute respiratory failure • Altered mental status •Coma • Death

COINFECTION LABORATORY

• Hemolytic anemia ↑ • Lyme disease retic • Anaplasmosis • Thrombocytemia • Ehrlichiosis • Proteinuria •RMSF • ↑ liver enzymes, BUN, • Infected by tickbite or congenitally Creatinine • Mother visited island off coast of MA and • Parasitemia of 10% is 100 times higher than mainland

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LABORATORY DIAGNOSIS • ID on Giemsa stained blood smears – Multiple smears – Multiple rings – Maltese cross •IgG IFA •PCR

CONGENITAL BABESIOSIS

• Rare: 5 infants • Mother may be asymptomatic but have high titer • Symptoms begin 19-41 days after birth • Parasitemia of 2-15% • All received transfusion for anemia

CASE 6 CASE 6 CONTINUED • CBC normal with 81% segs, 6% lymphs, 3.37% • 60 y. o. man Boise, ID retics • • 1 month history of intermittent and UA: protein 1+ headache • ↑ bilirubin • 105⁰F with 3 –day headache • Giemsa‐stained blood smear • 2nd fever 13 days later lasted 2 days • 3rd fever 26 days later • Camped in Bear Valley region of Idaho

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WHAT IS THE MOST LIKELY TICKBORNE RELAPSING PATHOGEN INFECTING THIS MAN? FEVER 25% 25% 25% 25% • B. hermsii most common cause A. Borrelia • Soft tick: Onithodoros hermsi burgdorferi • Transmission brief nighttime feed B. Borrelia hermsii • Overnight stay in infected dwellings >2000 C. Borrelia feet elevation recurrentis D. Rickettsia rickettsii

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1990-2011

County of Exposure County of residence

TBRF TBRF

• hermsi prefers coniferous • Most cases in summer forests at altitudes of 1500 to 8000 feet • Vacationers sleep in rodent-infested cabins • Fires to warm cabins sufficient to activate ticks in • Feeds on tree squirrels and chipmunks winter • 70% of all reported TBRF cases (CA 33%, WA • O. turicata, found at lower altitudes in 25%, and CO 11%) Southwest • Bite of soft ticks brief, < 30 min. – cattle, rodents, pigs, snakes, tortoises, and • Soft ticks do not search for prey in tall grass or possibly brush • Live within rodent burrows or cabins • Painless so unaware of being bitten

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TICK BORNE BORRELIA SYMPTOMS

• DNA rearrangement • Periodically change molecules on their outer surface--antigenic variation • Allows evasion of host immune system • Causes relapsing episodes • Fever lasting several days • Interval without fever • Episode of fever • 1-4 times • Body, muscle, joint and headache • Nausea, vomiting, anorexia

GENERAL LABORATORY LABORATORY DIAGNOSIS VALUES • Observation of spirochetes in a blood smear • Mild leukocytosis taken during a febrile episode • Elevated erythrocyte sedimentation rate • Stained with Wright-Giemsa stain or • Anemia examined with dark field microscopy • Thrombocytopenia (i.e., ≥ 50,000 platelets per mm3) • Testing for serum antibodies not valuable in • ↑ serum unconjugated bilirubin levels acute setting • ↑ aminotransferase levels • IFA might be useful for convalescent • Prolonged PT and PTT patients • Proteinuria •PCR • Microhematuria

BORRELIA MIYAMOTOI SENSU B. MIYAMOTOI SENSU LATO LATO • Borrelia sp. • Of 5 patients testing positive, 4 were co‐infected • Same ticks (I. scapularis) that transmit B. burgdorferi with Lyme disease and occurs in all Lyme disease‐ areas of • 1 also co‐infected with babesiosis U.S. • All 5 patients had fever, but no relapsing fever • Common in Southern New England pattern • Northern California‐‐prevalence of B. miyamotoi • 52 residents residing in southern New England or New sensu lato in ticks equals or exceeds the prevalence York State during 1991– 2012tested positive of B. burgdorferi • 1/3 of the cases of Lyme Disease

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CASE 7 IF THIS IS A VIRAL ILLNESS, WHAT IS IT LIKELY TO BE? • Healthy 49‐year‐old man from Manhattan with fever and malaise A. Enterovirus 25% 25% 25% 25% • 3 days after returning from horseback trip on Western slope of Rocky Mountains B. Herpes virus • Removed 4 ticks from his body C. Western equine • Reported chills, fever and severe myalgias encephalitis • Symptoms resolved but recurred 2 days later D. tick fever • 38.1⁰C, conjunctivitis and sore throat

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COLORADO TICK FEVER

• Vector: ‐‐ Rocky mountain wood tick • RNA Coltivirus intraerythrocytic orbivirus • Reservoirs: small mammals • Western U.S. 4,000‐10,500 feet • 83 cases reported 2002‐2012 but only 6 states require reporting—voluntary in others

COLORADO TICK FEVER COLORADO TICK FEVER

• 3‐4 days and up to 2 weeks after tick bite • Typical flu‐like illness – Sore throat – Vomiting – Lymphadenopathy – 5‐16% rash • Biphasic especially in adult > 30 years – Remit after 2‐4 days and reoccur 1‐3 days later • Prolonged convalescence • Rarely death or menigoencephalitis in children

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LABORATORY FINDINGS PREVENTION OF TICK BITES

• Avoid wooded and brushy areas with high grass • Leukopenia with relative (2000‐ and leaf litter. 4000) • Walk in the center of trails. – Atypical lymphs • Use repellents that contain 20 to 30% DEET (N, • Thrombocytopenia (20,000‐60,000) N-diethyl-m-toluamide) on exposed skin and • Viral culture of blood clothing • IgM IFA of peripheral blood • Permethrin on clothing--treat clothing and gear, • Neutralizing antibodies such as boots, pants, socks and tents with • RT‐PCR products containing 0.5% permethrin – It remains protective through several washings • State Health Departments – Pre-treated clothing is available and may be protective longer

FIND AND REMOVE TICKS

• Bathe or shower as soon as possible (preferably within two hours) to wash off and find ticks • Conduct a full-body tick check using a hand-held or full-length • Parents should check children for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair. • Examine gear and pets • Use fine-tipped tweezers to grasp the tick as • Tumble clothes in a dryer on high heat for an close to the skin's surface as possible hour • Pull upward with steady, even pressure • Don't twist or jerk the tick

HOW TO REMOVE A TICK

• Thoroughly clean bite area and your hands with rubbing alcohol, iodine scrub, or soap and water • Dispose of a live tick by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet • Never crush a tick with your fingers

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