Fitzgerald Health Education Associates 3 Fitzgerald Health ...

Ticked-off... Myths, Truths, and Realities of Tick-borne Infections

including Lyme, Babesia, and EhrlichiaVanessa Pomarico-Denino, MS, APRN, FNP-BC, FAANP

Interim Director/Lead Faculty SCSU FNP trackSenior Consultant

Fitzgerald Health Education Associates, LLC (FHEA) www.fhea.com

Disclosures

• No real or potential conflict of interest to disclose.

• No off-label, experimental or investigational use of drugs or devices will be presented.

2Fitzgerald Health Education Associates

Objectives

• At the end of the presentation, the participant will be able to:– Differentiate between types of

tick-borne diseases. – Recognize clinical presentation of

specific infections.

Fitzgerald Health Education Associates 3

Objectives(continued)

• At the end of the presentation, the participant will be able to: (cont.)– Understand current therapies to

treat specific tick-borne and vectorborne diseases.

– Interpret findings of laboratory testing.


References

All references are listed in your program as well as at the end of

this presentation


Tick-borne Pathogens

•Transmitted through bite ofinfected ticks–Bacteria, virus, protozoal– High risk

• Those who work outdoors, high grass, forestry, construction, landscaping, RR, wildlife or park management

– Peak season• April to October; highest in June to August


Tick-borne Pathogens(continued)

•Transmitted through bite ofinfected ticks (cont.)– Are considered reportable diseases

to DPH– Consider widespread testing due to

concomitant infection risk


Types

• Tick borne– Lyme– Babesia– Anaplasmosis

(also knownas Ehrlichia)

– Rocky Mountain spotted fever

– Powassan


• Vector borne– West Nile Virus– Chikungunya– Zika Personal photo

The lifecycle of a tick.

• Lifecycle approximately 2 years• 4 life-stages

– Egg– Six-legged larva– Eight-legged nymph– Adult

• When eggs hatch, ticks must feedon a blood meal at every stage inorder to survive


How Transmitted

• “Questing”• Ticks wait on ends of

blades of grass, leaves on hind legs

• Attach to suitable host aftermaking contact


Source: CDC.gov. Public Health Image Library ID #10871

How Transmitted(continued)

• Front legs attach onto host to begin feed– Infection is transmitted

through tick saliva.

• Tick will feed thenfall off host untiltime to feed againin next lifecycle.


Source: CDC.gov. Public Health Image Library ID # 8680. Photo by James Gathany

Lyme Disease (Borrelia Burgdorferi)

• Spirochete– Transmitted by infected

ticks, usually deer ticks

• Originated in Lyme, CT– Most common

tick-borne diseasein the country.

– Also found in Australia, Asia, Europe


Lyme Disease (Borrelia Burgdorferi) (continued)

• Tick must generally be in place>24 hours in order to transmit infection to host.

• Different ticks – not all carry Lyme• Tick bite frequently unnoticed

– Tick may be in area that is not noticeable.– Can engorge itself and fall off without

ever being detected


Tick vector Geographic location

Percentage of infection (dependent upon region)

Carrier

Ixodes scapularis

Northeastern, north central and mid-Atlantic regions of U.S.

15–65% Mammals, birds, reptiles, amphibians (snakes, frogs)

Ixodes pacificus

West coast 2% adult ticks2–15% nymph ticks

Lizards, birds, mammals

Ixodes ricinus

Europe 4–16% Wood mice, cattle, deer, small rodents

Ixodes persulcatus

Asia 27% Sheep, cattle, horse, dog

Transmission

• Spread through the bite of an infected tick

• Most common areas– Groin– Axillae– Scalp

• Most common timeof year– Spring and summer


Source: CDC.gov Public Health Image Library ID #2417

Transmission(continued)

• Ticks not known to transmit Lyme disease include– Lone star ticks (Amblyomma americanum)– American dog tick (Dermacentor variabilis)– Rocky Mountain wood tick (Dermacentor

andersoni)– Brown dog tick



Source: https://www.cdc.gov/lyme/resources/reportedcasesoflymedisease_2015.pdf

Incidence of RecentlyConfirmed Lyme Cases

• CT: 1873 • CA: 83• MA: 2922• NJ: 3932• NY: 3252


• PA: 7351 • TN: 6• AK, CO, HI, WY: 0

– Source: https://www.cdc.gov/lyme/stats/tables.html

Clinical Presentation

• Flu-like symptoms (“summer flu”) and possibly a rash

• Stage 1: Early localized infection– Approximately 3–30 days after initial tick bite– Erythema migrans

• Localized erythema at site of insertion

– Target lesion with central area of clearing• 10–20% of patients do not develop rash or lesion

Fitzgerald Health Education Associates 19 Fitzgerald Health Education Associates 20

Source: CDC.gov. Public Health Image Library ID # 14476


Clinical Presentation(continued)

• Stage 2: Early disseminated infection– Weeks to months after initial infection– 50–60% of patients with EM

become bacteremia– Malaise, fatigue*, fever, HA (sometimes

severe), neck pain, generalized myalgia/arthralgia

– *Fatigue can persist for months



• Stage 2: Early disseminated infection (cont.)– Cranial nerve VII

palsy or meningitis(10–15%)• Rare complication:

AV block (~4–10%) or myopericarditis, panophthalmitis



• Stage 3: Late, persistent infection– Can occur months to years after

initial infection– Moderate to severe generalized

arthralgias (60%)– Monarticular or oligoarticular arthritis

involving the knee or hip usually self-limiting• Joint aspiration yields a mean WBC 25,000/mcL

with predominance of neutrophilsFitzgerald Health Education Associates 23


• Rare neurologic manifestations– Subacute encephalopathy, sleep

disturbance, memory loss, mood changes, intermittent paresthesias, ataxia, spastic paraparesis, bladder dysfunction



• If patient presents with symptoms of Bell’s palsy, heart block or myopericarditis, test for Lyme!



ECG courtesy of Nick Tullo, MD

Differential Diagnosis

• Bell’s palsy• Contact dermatitis• Tinea corporis• Herpes zoster• Fibromyalgia• Arthritis


Diagnosis and Treatment

• National surveillance case definition– 30-day window of exposure prior to onset

of symptoms– Erythema migrans as diagnosed by HCP– At least one late manifestation of disease– Confirmatory lab testing


• True incidence unknown due toseveral factors.– Serologic testing is not standardized.– Clinical manifestations are not specific and

can mimic other illness or infection.– Serology is not sensitive enough in early

stage of disease leading to false negative readings.

– Source: Papadakis, M., & McPhee, S. (2017). Current medical diagnosis & treatment. (56th ed). New York, NY: McGraw-Hill


Incidence of Lyme

Lab Testing

• ELISA two step testing (EIA)• If ELISA is +, Western blot assay to detect

both IgM and IgG antibodies• IgM + within 2–4 weeks (~70%); can

seroconvert to IgG after 6 weeks• IgM Western blot (IFA) must have two of the

following three bands present: 23, 39, and 41kDa for diagnosis

• IgG must have 5/10 bands + for diagnosis– ESR may be elevated.– LFT abnormalities, shift in WBC


Treatment: Prevention

• Caveats– Known tick bite <72 h– Tick is identified as an adult or nymph

scapularis tick estimated to have been attached for ≥36 h.

– Prophylaxis can be started within 72 h of the time that the tick was removed.

– Source: Wormser, et al. (2006)


Treatment: Prevention(continued)

• Caveats (cont.)– Local rate of infection of these ticks with

B. burgdorferi is ≥20%.– Doxycycline treatment is not

contraindicated.• Doxycycline 200 mg PO single dose

– Source: Wormser, et al. (2006)


Outpatient Treatment of Lyme Disease: One of the following regimens

• Doxycycline 100 mg PO BID × 21 d– Do not use in pregnancy, ? lactation OR

• Amoxicillin 500 mg PO TID × 21 d– Safe for pregnancy/lactating women OR

• Cefuroxime axetil 500 mg PO BID × 21 d OR

• Erythromycin 500 mg PO QID × 14–21 d– Use of probiotic to prevent C-diff. colitis


Inpatient treatment of Lyme disease with cardiac complications

• Ceftriaxone: drug of choice: 10-28 days of therapy– Pedi: 50-100 mg/kg/day IV once daily– Adults: 2 g IV once daily

• PCN G potassium: 10-28 days of therapy– Pedi: 200,000-400,000 million units/kg/day in

divided doses every 4 hours– Adult: 18-24 million units/kg/day IV every 4

hours


Outpatient Treatment: PediOne of these regimes

• Pedi– Amoxicillin 50 mg/kg PO QD in 3

divided doses• Maximum of 500 mg per dose

– Cefuroxime axetil 30 mg/kg PO QD in2 divided doses• Maximum of 500 mg per dose • Age >8 years: Age ≥8 years, doxycycline PO

(4 mg/kg per day in 2 divided doses [maximum of 100 mg per dose])


Treatment Alternatives

• To be used if PCN allergic or intolerant of other recommended medications

• Azithromycin– 500 mg PO daily × 7–10 days

• Clarithromycin– 500 mg PO BID × 14–21 days


Post-TreatmentLyme Disease Syndrome

• Formerly referred to as chronic Lyme– Controversial– No documentation or studies to

prove/disprove its existence

• Refer to infectious disease specialist if symptoms persist beyond treatment



Source: CDC.gov. Public Health Image Library

Babesiosis

• Protozoan parasitic infection transmitted by ticks, usually on cattle, wild animals

• Generally found in the coastal northeastern U.S.– 95% of the cases were reported by 7

states: CT (205), MA (537), NJ (159), NY(471), RI (172)• Total for U.S. in 2014= 1744


Babesiosis

• Causes B. microti or B. divergens• Infected by same ticks carrying

B. burgdoferi– Nymph ticks the size of a poppy seed– People rarely know they were bitten by

a tick.– + vertical transmission from mother

to fetus


Clinical Presentation of Babesia

• Flu-type symptoms gradually worsening– Fever, HSM

• Arthralgias, myalgias– May not have any rash

• Hemolytic anemia and thrombocytopenia


Clinical Presentation of Babesia(continued)

• Symptomatic within a week but may be asymptomatic for many months

• Can be fatal in elderly or peoplewithout spleen


Diagnosing Babesia

• Detailed history of high risk exposure and high index of suspicion

• Labs– CBC with anemia due to RBC destruction

and low platelets– Proteinuria– Hemoglobinuria– Elevated LFTs, BUN/creatinine


Diagnosis(continued)

• Manual peripheral blood smear– Can need more than one sample to

detect parasites– Must request manual reading!



• Indirect immunofluorescent antibody– Anti-babesia IgG titers >1:64– Antibodies detected 2–4 weeks

after infection– Titers generally rise to ≥1:1024 during

the first weeks of illness and decline gradually over 6 months

– Can remain detectable at low levels fora year or more


Outpatient Treatment

•First-line–Atovaquone 750 mg PO BID plus

azithromycin 500–1000 mg PO on day 1 then 250–1000 mg PO for 7–10 days

•Alternative–Clindamycin 600 mg PO TID + quinine 650

mg PO TID for 7–10 days• Higher adverse effect profile


Blood Donation

• Patients diagnosed with Babesia are indefinitely deferred from donating blood

• Currently, no routine screening for Babesia with blood donation exists

• Patients should be advised to refrain from blood donations unless their specimen is screened for Babesia


Medication Risks

• Antimalarials• Pregnancy category C• Use with caution if breast feeding• Pedi patients must weigh >11 lbs (5 kg)

– Azithromycin• Safe for pregnancy, lactation and pedi patients


Medication Risks(continued)

• Antimalarials (cont.)– Clindamycin

• Pregnancy category B• Is excreted in breast milk but is compatible

with breast feeding• Contains benzyl alcohol, which has been

associated with a fatal "gasping syndrome" in premature infants



Source: Used with permission from Graham Hickling, PhD, University of Tennessee.

Ehrlichiosis or Anaplasmosis

• Human monocytic ehrlichiosis (HGE) caused by Ehrlichia chaffeensis from the Lone Star tick from white-tailed deer

• Became reportable in 1999– <1000 cases reported in 2008

• Now known as human granulocytic anaplasmosis (HGA)


Ehrlichiosis or Anaplasmosis(continued)

• More prevalent Northeastern and Midwestern U.S.

• Peaks June-December– May-August: Highest transmission time

• Short incubation: 9 days–2 weeks• Can be fatal in <1% of those who are

untreated


Ehrlichiosis or Anaplasmosis

• Prodrome– Malaise, rigors, fever, HA, myalgia, N/V/D– Rash is rare.– Coinfection with Lyme, Babesia

not uncommon


Diagnosis and Treatment

• Indirect immunofluorescence assay (IFA)-gold standard

• PCR assay• Enzyme immunoassay (EIA)

– Serologic only gives + or (-) result high false positive

• Peripheral blood smear


Diagnosis and Treatment(continued)

• CBC/diff, LFTs– Can have thrombocytopenia,

leukopenia, transaminitis– Infect monocytes and granulocytes– Presence of morulae

– Source: American Academy of Pediatrics Committee onInfectious Diseases


Diagnosis and Treatment(continued)

• Treatment– Doxycycline 100 mg PO BID × 10–14 days– Rifampin PO if pregnant/lactating or

pediatric patient– Use of antibiotics other than doxycycline

increases the risk of patient death– Source: American Academy of Pediatrics Committee on

Infectious Diseases


Rocky Mountain Spotted Fever

• Causative organism– Rickettsia rickettsii

• Can be potentially fatal if not treated within the first few days

• Spread by dog tick or wood tick, fleas, lice and mice

• 5–14 day incubation period



• Fever• Rash: Appears 2–5 days after infection

in 90% of pts– Nonpruritic, erythematous macular rash

on wrists, forearms, ankles, trunk– Petechial rash generally not seen until

after day 6 of illness– Pedi pts will develop rash more quickly

than adults.



• HA• N/V/abdominal pain• Anorexia• Conjunctival irritation


Pediatric Clinical Presentation

• More likely to present with headache• Earlier onset of rash than adults• Abdominal pain• Conjunctival injection• Altered mental status


Diagnosis

• Important to diagnose and treat early if high index of suspicion

• Skin biopsy of rash quickest way to diagnosis due to rapid turnaround

• + antibodies after 7–10 days



• Gold standard: Indirect immunofluorescence assay (IFA) with R. rickettsii antigen– First sample within first week– Second sample 2–4 weeks after– Repeat 2–4 weeks


Complications

• Vasculitis due to infection of endothelial cells

• Limb amputation due to decreased circulation

• Internal organ damage


• Neurological deficits• Thrombocytopenia• Hyponatremia• Elevated LFTs

Treatment

• Doxycycline 100 mg PO BID x 7–14 days is treatment of choice– Fever generally subsides within 24–72

hours after initiation of treatment– Children <45 kg (<100 lbs): 2.2 mg/kg

body weight given twice a day

• Chloramphenicol if pregnant or allergic to doxycycline


Outpatient Treatment of RSMF:Additional information for Pedi

• Doxycycline binds less readily to calcium and has not been shown to cause the same tooth staining as TCN

• Blinded study in 2013 revealed that no differences in tooth color, staining, or weakness were found between children < 8 yo who had received doxycycline and those who had not

• Source: https://www.cdc.gov/rmsf/doxycycline/index.html



Source: CDC.gov. Public Health Image Library ID #14489

Powassan

• Found in Northwestern and Great Lakes region of the U.S.– Peak transmission: Late spring, early

summer, mid-fall

• Incubation: 1 week to 1 month– # of reported cases in 2013= 12



• HA• Fever• Vomiting• Weakness• Confusion• Loss of coordination• Seizures

– Indicative of meningitis or encephalitis


Diagnosing• CSF

– <500 WBC/mm3; granulocytosis earlyin disease

• EEG– With slower brain wave activity

• Brain MRI– Consistent with microvascular ischemia or

demyelinating disease

• Viral testing during autopsyFitzgerald Health Education Associates 68

Treatment

•~50% will have permanent neuro deficits•Supportive measures

– Ventilator– Respiratory support– IVF– Medications to decrease brain swelling


Prevention

• Adequate covering of all exposed skin

• DEET orpermethrinproducts

• Extensive skin checks if inexposed area

• Removal of tick inits entirety


Source: CDC.gov Public Health image library

Case Study

• Gary, 56-year-old male patient• PMH: Obesity, HLD, HTN, gout• PSH: Splenectomy age 10• CC

– Fatigue– Arthralgias– Myalgias– “No energy”


Case Study (continued)

• Medications– Valsartan-amlodipine-HCTZ 160 mg/5

mg/25 mg PO daily – ASA 81 mg PO daily– Glucosamine 500 mg PO TID



• SH –Non-smoker, social ETOH use–Avid golfer daily during the warmer

months–Walks the golf course with his dogs

daily–Married, real estate agent



• CC– “Summer flu”

• ROS– Worsening fatigue– Arthralgias and myalgias– Constant headache– Feels feverish but did not take his temp– Denies N/V/D


Case Study – Labs(continued)

• WBC 3.2×1000/uL (4–10 ×1000 u/L)– Neutrophils 70% (37–84%)

• 0.7 proportion (0.37-0.84 proportion)

– Lymphs 16% (8–49%)• 0.16 proportion (0.08-0.49 proportion)

– Monos 14% (4–15%)• 0.14 proportion (0.04-0.15 proportion)

• RBC 3.9 M/uL (3.8–5.9 M/uL)• Hgb 11.6 g/dL (12.0–18.0 g/L)

– 1160 g/L (1200-1800g/L)• Hct 36.5% (37–52%)

– 0.365 proportion (0.37-0.52 proportion)

• Platelets (140–440 ×1000/uL) 157×1000/uL

• BNP 479 pg/mL (100–400 pg/mL)

• Lyme IgM: Positive 2/3 bands

• ANA/RA: Negative• ALT: 58 U/L (0–34 U/L)• AST: 63 U/L (0–34 U/L)• Urine: Moderate

protein



• Babesia PCR + for Babesia DNA:– Detectable parasites with distinct

morphology different from malaria– Rings with basophilic stippling

• Ehrlichia: Negative



• Treatment: Need both– Azithromycin 500 mg PO daily × 7‒10

days– Atovaquone 750 mg PO BID × 7‒10 days

• Alternative– Quinine 650 mg TID x 7‒10 days PO plus

clindamycin 600 mg PO TID x 7‒10 days• Higher adverse effect profile• Usually reserved for severe disease


Follow-up

• Serial CBC/diff, CMP and Babesiaperipheral smear to determine eradication of parasites– If outpatient, weekly labs until negative

then one month after therapy has been completed

– Repeat labs if patient becomes symptomatic again


Questions?


End of Presentation.Thank you for your attention

Vanessa Pomarico-Denino,MS, APRN, FNP-BC, FAANP

www.fhea.com [email protected]


References

• Buttaro, T., Trybulski, J., Polgar Bailey, J. (2016). Primary Care: A collaborative practice. (5th ed). St. Louis, Missouri: Elsevier

• Center for Disease Control (CDC): www.cdc.gov

• Evans, D. & Meires, J. (2016). Chikungunya Virus: A rising health risk in the United States and how nurse practitioners can help address and reduce the risk. Journal for Nurse Practitioners. 12(5): 289-298.


References(continued)

• Mcneil, C., Shreve, M., Jarrett, A., & Perry, C. (2016). Zika: What providers need to know. The Journal for Nurse Practitioners. 12(6): 359-366.

• Moore, K. (2015). Lyme Disease: Diagnosis, treatment, guidelines, and controversy. The Journal for Nurse Practitioners. 11(1): 64-69.


References (continued)

• Papadakis, M., & McPhee, S. (2017). Current medical diagnosis & treatment. (56th ed). New York, NY: McGraw-Hill

• Wooten, A. (2015). Zika Virus: An emerging threat to travelers. The Journal for Nurse Practitioners. 12(5): e237-238.


References (continued)

• Wormser, G., Dattwyler, R., Shapiro, E., Halperin, J., Steere, A., Klempner, M., Krause, P., Bakken, J., Strle, F., Stanek, G., Bockenstedt, L., Fish, D., Dumler, J.S., & Nadelman, R. (2006). The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. 43 (9): 1089-1134.


Photo Credits

• Graham Hickling, PhD, University of Tennessee.

• CDC public health image library. https://phil.cdc.gov

• Pixnio. www.pixnio.com


• Images/Illustrations: Unless otherwise noted, all images/ illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.

• All websites listed active at the time of publication.


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• The information in this program has been thoroughly researched and checked for accuracy. However, clinical practice and techniques are a dynamic process and new information becomes available daily. Prudent practice dictates that the clinician consult further sources prior to applying information obtained from this program, whether in printed, visual or verbal form.

• Fitzgerald Health Education Associates disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation.


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