TICKBORNE DISEASES IN MICHIGAN: A REFERENCE FOR HEALTH CARE PROVIDERS Lyme disease Anaplasmosis Borrelia burgdorferi Anaplasma phagocytophillum Blacklegged (deer) tick Blacklegged (deer) tick Vector Incubation Period 3 – 30 days 1 – 2 weeks Early localized disease: • Characteristic erythema migrans (EM) rash . Fever, chills • Fever & chills . Severe headache • Headache . Malaise • Myalgia & arthralgia . Myalgia • Lymphadenopathy . Gastrointestinal symptoms Signs and Disseminated disease (weeks to months after . Cough Symptoms exposure): . Rash (rare cases) • Multiple EM lesions . Stiff neck* • Nervous system abnormalities including nerve . Confusion* paralysis (facial muscles), meningitis • Arthritis in large joints, especially the knee *May present later (5 days after onset of symptoms) • Myocarditis, pericarditis, or atrioventricular node and may be prevented by early treatment block Typically observed during the first week of clinical disease: • Mild anemia • Elevated erythrocyte sedimentation rate • Thrombocytopenia • Mildly elevated hepatic transaminases General • Leukopenia (characterized by relative and absolute • Microscopic hematuria or proteinuria lymphopenia and a left shift) Laboratory • In Lyme meningitis, CSF typically shows • Mild to moderate elevations in hepatic Findings lymphocytic pleocytosis, slightly elevated transaminases may occur in some patients protein, and normal glucose • Visualization of morulae in the cytoplasm of granulocytes is highly suggestive of a diagnosis; however, blood smear examination is insensitive. Antibodies to A. phagocytophillum are detectable 7- • Demonstration of diagnostic IgM or IgG 10 days after illness onset. antibodies in serum. A two-tier testing protocol • Demonstration of a four-fold change in IgG-specific is recommended – EIA or IFA should be antibody titer by IFA test in paired serum samples; Laboratory performed first; if positive or equivocal it is or followed by a Western blot. Diagnosis • Detection of DNA by PCR of whole blood. This • Isolation of organism from a clinical specimen method is most sensitive within the first week of • In suspected Lyme meningitis, testing for illness; sensitivity may decrease after intrathecal IgM or IgG antibodies may be helpful administration of antibiotics. The below antibiotics are recommended for the Anaplasmosis, ehrlichiosis, and Rocky Mountain treatment of early Lyme disease. Consult the spotted fever are treated in the same manner with reference below for more information: doxycycline*. Clinical suspicion of any of these diseases is sufficient to begin treatment. Delay in Adults & Children treatment may result in severe illness and even death. • Doxycycline • Cefuroxime axetil * Note: Unless otherwise indicated, use doxycycline as Treatment • Amoxicillin first-line treatment for suspected anaplasmosis in patients of all ages. The use of doxycycline to treat The clinical assessment, treatment and prevention suspected anaplasmosis in children is recommended by of Lyme disease, human granulocytic anaplasmosis, both the CDC and the American Academy of Pediatrics. and babesiosis: clinical practice guidelines by the At the recommended dose and duration needed to Infectious Diseases Society of America. Clin Infect Dis treat anaplasmosis, no evidence has been shown to 2006; 43:1089-1134. cause staining of permanent teeth. Babesiosis Rocky Mountain spotted fever Babesia microti Rickettsia ricketsii Blacklegged (deer) tick American dog tick Vector Incubation Period 1 – 9+ weeks 2 – 14 days • Fever, chills, sweats . Fever, chills • Malaise, fatigue . Severe headache • Myalgia, arthralgia, headache . Malaise • Gastrointestinal symptoms, such as anorexia and . Myalgia nausea (less common: abdominal pain, vomiting) . Gastrointestinal symptoms • Dark urine . Cough Signs and • Less common: cough, sore throat, emotional . Conjunctival injection, + photophobia Symptoms lability, depression, photophobia, conjunctival . Altered mental status injection . Focal neurologic deficits, including cranial or • Mild splenomegaly, mild hepatomegaly, or peripheral motor nerve paralysis or sudden jaundice may occur in some patients transient deafness . Maculopapular rash Note: Not all infected persons are symptomatic or febrile. Petechial rash Symptoms may develop within several weeks to months. • Decreased hematocrit due to hemolytic anemia General Laboratory • Thrombocytopenia • Thrombocytopenia • Elevated serum creatinine and blood urea • Mildly elevated hepatic transaminase levels Findings nitrogen (BUN) values • Hyponatremia • Mildly elevated hepatic transaminase values • Identification of intraerythrocytic Babesia Antibodies to R. rickettsia are detectable 7-10 days parasites by light-microscopic examination of a after illness onset. peripheral blood smear; or • Demonstration of a four-fold change in IgG- • Positive Babesia (or B. microti) polymerase chain specific antibody titer by immunofluorescence Laboratory reaction (PCR) analysis assay (IFA) test in paired serum samples; or Diagnosis • Detection of DNA in a skin biopsy of rash by Supportive laboratory criteria: polymerase chain reaction (PCR) assay (generally • Demonstration of Babesia-specific antibody titer unreliable for acute blood samples). by indirect fluorescent antibody (IFA) testing for • Immunohistochemical (IHC) staining of organism total immunoglobulin (Ig) or IgG. Rocky Mountain spotted fever, anaplasmosis, and Treatment decisions and regimens should consider ehrlichiosis are treated in the same manner with the patient’s age, clinical status, doxycycline*. Clinical suspicion of any of these immunocompetence, splenic function, diseases is sufficient to begin treatment. Delay in comorbidities, pregnancy status, other medications, treatment may result in severe illness and even and allergies. Expert consultation is recommended death. for persons who have or are at risk for severe or relapsing infection or who are at either extreme of * Note: Unless otherwise indicated, use doxycycline as Treatment age. first-line treatment for suspected RMSF in patients of all ages. The use of doxycycline to treat suspected For ill patients, babesiosis is treated for at least 7-10 RMSF in children is recommended by both the CDC days with a combination of two medications – and the American Academy of Pediatrics. At the typically either atovaquone PLUS azithromycin; OR recommended dose and duration needed to treat clindamycin PLUS quinine (this combination is the RMSF, no evidence has been shown to cause staining standard of care for severely ill patients). of permanent teeth. Tickborne diseases are reportable in Michigan. For more information, please see the “Healthcare Professionals Guide to Disease Reporting in Michigan” - - www.michigan.gov/cdinfo Updated Developed by the Michigan Department of Health & Human Services - EZID Section May, 2017 Adapted from “Tickborne Diseases of the United States: A Reference Manual for Health Care Providers.” CDC, 2017..