Title: Tick-Borne and Zoonotic Diseases in the United States David Spach, MD Professor, Division of Infectious Diseases University of Washington, Seattle
1- Tick-Borne and Zoonotic Diseases in the United
StatesDavid Spach, MDProfessor, Division of
Infectious DiseasesUniversity of Washington,
Seattle
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2DHS/PP
3Tick Quiz
1
2
From Spach DH et al. N Engl J Med
1993329936-47.
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4Important North American Ticks
Ixodes Female (Adult)
Ixodes Male (Adult)
Ixodes Nymph
Amblyomma Female (Adult)
Dermacentor Female (Adult)
Ornithodoros (Adult)
From Spach DH et al. N Engl J Med
1993329936-47.
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5Ixodes scapularis Ticks
Adult Female
Adult Male
Nymph
Larva
Centimeter Scale
From CDC Lyme Disease Home Page.
www.cdc.gov/ncidod/dvbid/lyme/
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6Ixodes Nymph Tick
From Spach DH et al. Washington State Lyme
Disease Monograph.
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7Ixodes Adult Females Unfed and Fed
From Spach DH et al. Washington State Lyme
Disease Monograph.
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8Case History Question
- A 17-year-old girl presented to the emergency
room with lower extremity weakness. She had
prolonged recent outdoor exposure. Her weakness
was symmetrical and had begun about 8 hours prior
to coming to the ER sensation is intact. A tick
is found embedded in her scalp. The most
appropriate course of action is1. Give IV
ceftriaxone x 14 days2. Remove tick and observe
closely3. Give IM streptomycin x 10 days4.
Arrange for emergent plasmapharesis
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9Tick ParalysisClinical Features
- Early Features- Paresthesias- Leg weakness-
Absence of fever - Later Findings- Ascending paralysis- Ataxia-
Hyporeflexia/Areflexia - Late Findings- Bulbar signs- Hypoventilation
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10- How should you remove at tick?
11Tick Removal
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12Case History
- A 48-year-old woman presents with myalgias and a
painful skin rash on her leg. She recently
returned from a one week vacation in eastern
Washington and says the rash began one day after
she was bitten by something on her leg. The most
appropriate course of action is1. No
antibiotics required2. Give PO Doxycycline for
14 days3. Give IV Ceftriaxone for 14 days4.
Give IV Ampicillin and Gentamicin x 10 days
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13Case History
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14Tegenaria agrestis (Hobo Spider)
Male
Female
From http//hobospider.org
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15Recluse Spiders (Loxosceles sp) Distribution in US
From Vetter RS.
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16Diff Dx of Skin Lesions
From Young DM, et al. Arch Surg 2004139951-3.
From CDC Prevention
From Lowy FD. N Eng J Med 1998339520-32.
From CDC Prevention
From Darwin Vest
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17Case History
- A 28-year-old man presented to clinic with a 16
cm erythematous, annular skin lesion on his right
flank and flu-like symptoms. He spent the past
30 days hiking in the mountains. The most
appropriate course of action is1. Give PO
Doxycycline for 14 days2. Reassure and dont
give antibiotics3. Draw serology (Lyme) and
treat if positive4. Give IV Ceftriaxone for 14
days
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18Erythema Migrans Rash
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19Erythema Migrans Rash
From Steere AC. N Engl J Med 2001345115-25.
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20Lyme Disease Erythema MigransTreatment
- Preferred- Doxycycline 100 mg PO bid x 14
days- Amoxicillin 500 mg PO tid x 14 days-
Cefuroxime 500 mg PO bid x 14 days - Alternative - Azithromycin 500 mg PO qd x 7-10
days - Clarithromycin 500 mg bid x 14-21 days
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21Case History
- A 43-year-old man from Westchester county, NY
presents with fever and erythema migrans 7 days
after a tick bite. He is started on
amoxicillin, but 4 days later returns with
headache, fever, and myalgias. Labs show
leukopenia, thrombocytopenia, and increased
hepatic aminotransferase levels. The most
appropriate course of action is1. Give high
dose corticosteroids2. Give PO Doxycycline3.
Give IV Ceftriaxone4. Give IV Gentamicin
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22Ehrlichiosis Anaplasmosis in United States
E. chaffeensis A.
phagocytophilium E. ewingii
Amblyomma
Ixodes
Amblyomma
Monocytes
Granulocytes
Granulocytes/Eos
HME
HGA
HGE
From CDC Ehrlichiosis Home Page.
www.cdc.gov/ncidod/dvrd/ehrlichia/Index.htm
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23Ehrlichiosis Anaplasmosis
- Human Monocytic Ehrlichiosis- Organism
Ehrlichia chaffeensis- Transmission Amblyomma
ticks- Cells Monocytes/Macophages - Human Granulocytic Anaplasmosis- Organism
Anaplasma phagocytophilium- Transmission Ixodes
ticks- Cells Granulocytes
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24Ehrlichiosis Laboratory Studies
Liver Function Tests
Platelet Count
From Fishbein DB et al. Ann Intern Med
1994120736-43.
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25Ehrlichiosis AnaplasmosisTreatment
- First Line- Doxycycline 100 mg PO bid x 10 days
- Second Line (Doxycycline allergy, Pregnancy)-
Rifampin 300 mg bid x 10d
Since rifampin does not treat Lyme disease,
patients should also receive amoxicillin or
cefuroxime
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26Case History
- A 67-year-old man from Wisconsin develops fever,
severe malaise, and dark urine while visiting in
Seattle. Two weeks prior he went on a 7-day
hunting trip in rural Wisconsin. Labs show HCT
31 platelet count 49,000. Optimal therapy
would consist of1. Ceftriaxone x 10 days2.
Penicillin x 10 days3. Quinine Clindamycin x
7 days4. Streptomycin x 7 days
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27Babesiosis Treatment
- First Line Azithromycin 500-1000 mg PO day 1,
then 250 mg PO qd x 6-9d plusAtovaquone 750
mg PO bid x 7-10d ORClindamycin 300-600 mg
IV q6h (600 mg PO q8h) x 7-10 d plusQuinine
650 mg of salt PO q8h x 7-10d
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28Case History
- A 71-year-old geologist presents with a 3-day
history of fever, chills, and myalgias. Seven
days prior he was in rural eastern Washington and
slept in an old cabin. Labs show hematocrit
42, platelet count 67,000, and an abnormal blood
smear. The most likely diagnosis is1.
Relapsing fever2. Lyme disease3.
Leptospirosis4. Colorado tick fever
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29From Spach DH et al. N Engl J Med
1993329936-47.
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30Relapsing FeverTreatment
- First Line- Doxycycline 100 mg PO bid x 7-10
days-
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31Tick-Borne Relapsing Fever in NorthwestNumber of
Relapses
From Dworkin MS et al. Clin Infect Dis
199826122-31.
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32Case History
- A 29-year-old woman is admitted with suspected
RMSF. Which laboratory study is NOT often
observed with RMSF1. WBC gt 12, 0002. Platelet
count lt 150,0003. Hyponatremia4. Increased CSF
WBC count
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33RMSF in US 1981-1992 Average Incidence by County
From Thorner AR et al. Clin Infect Dis
1998271353-9.
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34RMSF Clinical Manifestations
From Catherine Wilfert (Duke University Medical
Center)
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35RMSF Treatment
- First Line- Doxycycline 100 mg PO bid x 7-10
days - Second Line- Chloramphenicol
- Promising
- - Fluoroquinolones
From CDC RMSF Home Pagewww.cdc.gov/ncidod/dvrd/rm
sf
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36DHS/PP
37Case History Question
Silver-Haired Bat
- A 29-year-old male is bitten on the shoulder by
a bat and the bat escaped. What percent of
Rabies Immune Globulin should be given at the
wound site?1. 252. 503. 754. 100
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38Rabies Postexposure ProphylaxisRabies Immune
Globulin
- Administer 20 IU/kg body weight. If
anatomically feasible, the full dose should be
infiltrated around the wound(s) and any remaining
volume should be administered IM at an anatomical
site distant from vaccine administration. MMWR
199948 (RR-1) 275-9.
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39Rabies Post-Exposure Prophylaxis
Previously Vaccinated
Not Previously Vaccinated
- Wound cleansing
- No RIG
- Vaccine day 0 and 3
- Wound cleansing
- RIG
- Vaccine day 0,3,7,14,28
Administer vaccine as IM in deltoidAdminister
full dose of RIG around wound if possible
remaining volume give at site distant from
vaccine site
From
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40Rabies Post-Exposure Prophylaxis
Not Previously Vaccinated
- Wound cleansing
- Rabies Immune Globulin
- Rabies Vaccine day 0,3,7,14
Administer vaccine as IM in deltoidAdminister
full dose of RIG around wound if possible
remaining volume give at site distant from
vaccine site
Note Number of recommended doses of rabies
vaccine changed from 5 to 4 (ACIP June 24, 2009)
From CDC. MMWR 2008571-26.
41Case History Question
- In which of the following scenarios you
administer rabies post-exposure
prophylaxis 1. A 41-year-old woman is bitten
by her neighbors dog 7 days ago while jogging by
their house the dog is behaving normally2. A
mother awakens and finds a bat in the room of her
4-year-old child (and the bat escapes3. A
22-year-old man picks up a dead bat in his yard
(with bare hands) and throws it down into a large
ravine4. A 48-year-old man tells you during a
routine medical visit that he suffered a
unprovoked dog bit in Thailand 3 months ago
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42- Hantavirus Pulmonary Syndrome
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43Case History Question
- A 49-year-old woman is admitted to the hospital
with a suspected diagnosis of hantavirus
pulmonary syndrome. Which of the following would
be LEAST characteristic of the clinical
presentation of hantavirus pulmonary syndrome? -
- 1. CSF pleocytosis
- 2. Increased hematocrit
- 3. Increased white blood cell count with
immature forms - 4. Thrombocytopenia
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44Hantavirus Pulmonary Syndrome Reservoir
Peromyscus maniculatusDeer Mouse
Source CDC and Prevention
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45Hantavirus Pulmonary SyndromeThrough November
11, 2009
By State of Exposure
Source CDC and Prevention
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46Hantavirus Pulmonary Syndrome Chest Radiograph
Early Stage
Severe
CDC
Later Stage
Interstitial
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47 Hantavirus Pulmonary SyndromeProgression of
Disease
Recovery
Prodrome
Cardiopulmonary
Death
Picture
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48DHS/PP
49Case History Animal Bite
- A 33-year-old woman living in Washington State is
bitten on her hand by her cat while trying to
break up a fight between her cat and dog. One
day later her wound is red and painful and she
comes to the ER for evaluation. Which ONE of the
following is TRUE? 1. Her risk of getting
rabies from this cat bite is about 22. Cat
bites become infected more often than dog bites
3. Bartonella is a likely cause of the
infection4. Pseudomonas is a likely cause of the
infection
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50Microbiology of Infected Cat Bites
From Talan DA, et al. NEJM 199934085-92.
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51Microbiology of Infected Dog Bites
From Talan DA, et al. NEJM 199934085-92.
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52Dog Cat Bites Wound Infections Therapy
- Therapy (Oral) - Amoxicillin-CA (Augmentin) x
7-14 days - Therapy (Intravenous - Ampicillin-sulbactam
(Unasyn) - Ertapenem (Invanz) - Therapy (Penicillin-Allergic) - Clindamycin plus
Fluroquinolone
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53Bartonella henselae Soft Tissue Infection
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54Cat Scratch Disease Azithromycin Therapy
From Bass JW et al. Pediatr Infect Dis
199817447-52.
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55Cat Scratch Disease Neuroretinitis Macular Star
Left Fundus. Eight days later, the infiltrate of
the optic nerve is less discrete. Exudates in a
star pattern are clearly evident around the fovea.
From Bhatti MT et al. Arch Neurol 2001581008-9.
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56Case History Skin Soft Tissue
- This 36-year-old man is admitted to intensive
care unit 3 days after suffering a dog bite on
his right knee. He has a BP 85/60, he has
diffuse purpura, and lab studies that show
evidence of DIC. Tragically, he died 6 hours
after admission to the ICU. Which organism
likely caused this infection? 1. Moraxella
catarrhalis2. Pasteurella canis3.
Capnocytophaga canimorus (DF-2)4. Pseudomonas
aeruginosa
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