Lyme Disease Update
Tick-borne Ilnesses
Luciano Kapelusznik, MD Infectious Disease Physician Common Tick Vectors
http://facstaff.cbu.edu/~seisen/IxodesSpp.htm 2
Western Black-legged Tick Distribution
Lyme diseases Cycle Confirmed Lyme disease cases by age and sex--United States, 2001-2010 Confirmed Lyme cases by month of onset--United States, 2001 -2010 Clinical Manifestations of Confirmed Lyme Cases--US, 2001-2010 Lyme in PA by County Natural History of Untreated Lyme Disease
Morrison C et al. J Am Board Fam Med 2009;22:219-222 21 Clinical Stages of Lyme Disease
EARLY LOCALIZED Days to Month post tick bite
EARLY DISSEMINATED Weeks to Months post tick bite
LATE LYME DISEASE Months to Years post tick bite Early Localized Lyme Disease Days – One Month
ERYTHEMA MIGRANS (EM) May occur in 80% “Cellulitis” in an atypical location May see a necrotic center ASSOCIATED SYMPTOMS Fever Flu symptoms Adenopathy Headache “Classic” Lyme disease rash Expanding rash with central crust Multiple rashes, disseminated infection Red, oval plaque on trunk Expanding rash with central clearing Bluish rash, no central clearing Red-blue lesion with central clearing Early Disseminated Lyme Weeks - Months . CARDITIS . 5% untreated patients . AV blocks/Cardiomyopathy/Myopericarditis . NEUROLOGIC . 15% untreated patients . Lymphocytic meningitis, encephalitis, cranial neuropathy (III, VI, VII), radiculopathy . SKIN . Days to weeks after EM with multiple irregular sized lesions Late Lyme Disease
MUSCULOSKELETAL Seen in about 60% of untreated patients Mono-oligoarticular arthritis - mostly knee(s) Expect 20-30K PMN-predominant joint fluid May include chronic synovitis or a Baker’s cyst CUTANEOUS Acrodermatitis chronica atrophicans Morphea-like lesions (Europe) NEUROLOGIC ? incidence because few cases Encephalomyelitis (cognitive), peripheral neuropathy Diagnosis Lyme Serology: Two-Tier Testing
First: EIA/IFA Screen (Total AB) Second: Western blots (immunoblots) IgM: Need 2/3 bands: 23,39,41 kDa Caution: Use only for illness < 1 month Positive IgM WB alone = frequent false (+) Lyme diagnosis Cross reactive with other bacterial and non-bacterial antigens
MMWR 1995;44:590 34 Lyme Serology
Western blot IgG: Need 5 of 10 potential bands 18,23,28,30,39,41,45,58,66 or 93 kDa More reliable test Usually positive by wk 4-6 of infection
MMWR 1995;44:590 35 LYME C 6 Testing in a 2 Tier IgG-only Approach
Using only C6 test as a second tier test after a positive ELISA screen 100% C6 peptide ELISA IgG proved 90% positive earlier in the progression of 80% stages of LD (Stage 2) in 2 70% independent labs. 60% This approach eliminates the need for, 50% Std. 2 tier and confusion with, IgM testing. 40% C6 2-tier As a “stand alone” test, C6 had a lower 30% IgM WB sensitivity (96%) and specificity (96%) 20% in late LD than 2-tier testing 10% 0% Stage Stage Stage 1 2 3 Caveats of Lyme Serology
Early/appropriate antibiotic therapy may often abort a seroconversion. Background rates of seropositivity maybe higher than 5%. Both ELISA and WB (IgM/IgG) positivity may persist for 10- 20 years. Subsequent infection Dx can only be made clinically. 79% had + 2-tier testing when asymptomatic as controls in prospective study. Misuse of Lyme Serology
No serologic “test of cure”, repeated testing after treatment useless. There is no marginal change in WB band conversions – ie: declining number of bands to monitor response to treatment. Early Lyme Disease Treatment Recommendations Doxycycline or Amoxicillin for 10 to 14 days Erythema Migrans Disseminated skin lesions Early neurologic - cranial neuropathy
Parenteral Ceftriaxone for 28 days . Early neurologic – meningitis/radiculitis Late Lyme Disease Treatment Recommendations Doxycycline or Amoxicillin po for 28 days . Arthritis . Recurrent arthritis (see below)
Ceftriaxone 2 gm IV qd . Central or peripheral nervous system disease . Recurrent arthritis . Cardiac disease Single Dose Therapy for Tick Exposure
Considered effective therapy to prevent Lyme disease in the following settings: If tick is attached for at least 36 hours – engorged in and endemic area: Doxycycline 200 mg PO x 1 dose Babesiosis - Epidemiology Parasitic tick-borne infection Agent: Babesia spp. (B. microti, B. duncani, B. divergens) Vector: Blacklegged tick (Ixodes scapularis)
Endemic foci in U.S. suspected to be similar to Lyme disease
Incubation period: varies based on mode of transmission Tick-borne: 1-3 weeks Blood-borne: weeks to months
42 Babesia microti
43 Babesia spp. Life Cycle
44 Babesiosis Incidence
Not previously reportable, so data are limited CT, RI, NY and MA have highest known incidence based on CMS claims data In 2008, 43/50 states had CMS claims for babesiosis
Limited data on seasonality and age distribution Majority of treatment dates on CMS claims: July- August
45 Transfusion-transmitted Babesiosis (TTB)
Babesia spp. can also be transmitted via blood products
Over 100 cases of TTB documented since 1980 11 total deaths documented since 1998 (10 from 2006–2008)
There is no licensed screening test available for detecting Babesia spp. in blood donors Current strategy is donor deferral-based approach using a screening question
46 Clinical Signs and Symptoms
Ranges from asymptomatic to severe infection Seroprevalence surveys indicate asymptomatic infection common
Fever, myalgias, sweats, fatigue, jaundice Hemolytic anemia, thrombocytopenia, elevated liver enzymes Several life-threatening complications
Several host factors increase disease severity
47 Diagnosis
Microscopy (gold standard) Giemsa/Wright stain
Molecular Polymerase chain reaction (PCR) Nucleic acid amplification (NAA)
Serology Indirect Fluorescent Antibody (IFA) Babesia spp. IgG (or total Ig)
48 Treatment
IDSA Guidelines (Published 2006) http://cid.oxfordjournals.org/content/43/9/1089.full
7–10 days of antibiotic treatment for active cases Atovaquone + azithromycin OR Clindamycin + quinine Oral or IV depending on severity
Severe cases may require blood transfusion
49 Kapelusznik et al. 18th International Congress on Infectious Diseases, March 2018. Patients (n = 88) with positive blood smears for Babesia by year and hospital
Year Lank BMH Paoli Riddle Total Cases 2008 1 1
2009 1 1 2
2010 1 1
2011 2 4 6
2012 3 2 2 7
2013 3 1 4 2 10 2014 1 2 1 4
2015 2 7 11 6 26 2016 1 7 4 12
2017 5 11 3 19
Totals 8 22 36 22 88 Babesia cases by patient Zip Code of residence
Kapelusznik et al. 18th International Congress on Infectious Diseases, March 2018. Ehrlichiosis and Anaplasmosis
What are they? Rickettsiaceae family Human Monocytic Ehrlichiosis (HME) Lone star tick Human Granulocytic Anaplasmosis (HGA) Ixodes ticks Where is it? Everywhere Human Monocytic Ehrlichiosis
E. chaffeensis First described in 1987 Primarily infects mononuclear cells Reservoir: deer, dogs, goats Vector: Lone star tick (Amblyomma americanum) Human Granulocytic Anaplasmosis
First described in 1994 Organism recently named Anaplasma phagocytophilum. Reservoir: deer, rodents, elk Vector: Ixodes ticks Ehrlichiosis and Anaplasmosis
SIGNS AND SYMPTOMS Incubation period: 5 - 10 days Early symptoms are non-specific (“flu-like”) Fever, headache, myalgias GI symptoms can occur Rash variable Laboratory Leucopenia, thrombocytopenia, abnormal liver enzymes Ehrlichiosis and Anaplasmosis
COMPLICATIONS Can be very severe Renal failure ARDS DIC Encephalitis 3% mortality Worse in patients with impaired host defenses Watch out for dual or triple infections with Borrelia burgdorferi and Babesia Ehrlichiosis and Anaplasmosis
DIAGNOSIS Peripheral smear looking for morulae Serology PCR (state laboratories) Culture Treat based on epidemiologic and clinical clues. Do not delay while waiting for confirmation. Ehrlichiosis and Anaplasmosis
Morulae Ehrlichiosis and Anaplasmosis
TREATMENT Treatment should not be delayed until laboratory confirmation is obtained Doxycycline: 100 mg PO/IV Until 3 days after fever abates Expect response in 24 - 72 hours Pregnancy and children ??? Rifampin 600 mg IV/PO has been used
How can you protect yourself from ticks? Wear long pants tucked into your socks to keep ticks off you.
Wear long-sleeved shirts and, light colored clothes to make it easier to Use bug spray spot ticks. What if you find a tick on you?
Carefully remove ticks with a pair of fine point tweezers. Wash the bite with soap and water. Do not use gasoline or a match. Do not use Vaseline. Protect yourself from ticks.
When you have been outside…
Check for ticks on your body every day. Prevent Lyme Disease
Make your yard Before safer—create a dry path between woods and your yard.
After Pets can get Lyme Disease, too.
Check your pet for ticks after it has been outside. There are collars, sprays, powders, and other treatments to stop ticks from biting your pet. Ask your veterinarian for advice on protecting your pet from tick bites.