1 Tick-Borne Diseases and Update Melissa Kemperman, MPH Minnesota Department of Health Acute Disease Investigation & Control Essentia Health Essentia Health Hot Topics in Pediatrics Conference Duluth, MN April 20, 2012 Objectives • Identify signs and symptoms of tick-borne diseases (TBDs) • Explain regional endemicity of TBDs, including emerging diseases and incidence • Describe available testing for TBDs and appropriate use of testing • Identify practical approaches for diagnosis and • Identify practical approaches for diagnosis and treatment of the patient with a possible TBD • Summarize current guidelines on prevention and treatment of TBDs
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Tick-Borne Diseases and Update
Melissa Kemperman, MPHMinnesota Department of Health
Acute Disease Investigation & Control
Essentia HealthEssentia HealthHot Topics in Pediatrics Conference
Duluth, MNApril 20, 2012
Objectives
• Identify signs and symptoms of tick-borne diseases (TBDs)
• Explain regional endemicity of TBDs, including emerging diseases and incidence
• Describe available testing for TBDs and appropriate use of testing
• Identify practical approaches for diagnosis and• Identify practical approaches for diagnosis and treatment of the patient with a possible TBD
• Summarize current guidelines on prevention and treatment of TBDs
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Audience Response System:Case Presentation
• In June, a previously-healthy 10-year-old girl i it li i ith 2 d hi t f fvisits your clinic with a 2-day history of fever,
muscle aches, fatigue, and headache
• She lives on a wooded property near Cloquet, Minnesota (MN), where her family notices a lot of “deer ticks or wood ticks”
• Her mom asks whether you can test her for Lyme disease
“Chronic Lyme Disease” (cont.)• Some patients seek long-term or repeated antibiotic
therapy for persistent symptoms attributed to chronic B burgdorferi infectionchronic B. burgdorferi infection
• Interpretation of tests often questionable
• Often lack current or previous objective evidence of Lyme disease
• In 2009, MDH Clostridum difficile surveillance ,detected a C. difficile-associated fatality in a woman receiving prolonged antibiotic therapy for Lyme disease (CID 2010;51[3]:369-70)
* Minnesota Medicine 2008;91(7):37-41
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Babesiosis
Babesia microtiin red blood cell
CDC Pubic Health Image Library
Babesiosis Signs & Symptoms
• Agent: Babesia microti, other Babesia spp.
• Many infections are asymptomatic, especially in young or healthy individuals
• Symptomatic persons can have fever, chills, headache, muscle aches, fatigue, loss of appetite, anemia, low platelets
• Severe infections leading to organ failure and g gdeath can occur (most likely if elderly, asplenic, or otherwise immune compromised)
• Persistent infections can occur in symptomatic or asymptomatic individuals
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Babesiosis Diagnosis and Treatment
• Diagnostic tests
– Ideally order PCR plus either peripheral blood smear or serology
• Treatment
– Milder cases: Atovaquone-azithromycin
– Severe cases: Clindamycin-quinine
M d d bl d ll t f i• May need red blood cell transfusion
• With certain forms of immune compromise, multiple treatment courses may be necessary* *Krause et al 2008. CID 46:370-6
Human Anaplasmosis/Ehrlichiosis
Anaplasmaphagocytophilumi l f hitin vacuole of white blood cell
Dumler et al. 2005.EID 11(12)
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Anaplasmosis versus Ehrlichiosis
• Anaplasmosis (Anaplasma phagocytophilum)
Expected in MN– Expected in MN
– Affects granulocytes (neutrophils)
• Ehrlichiosis (Ehrlichia chaffeensis)
– Affects agranulocytes (monocytes)
– NOT expected in MNNOT expected in MN
• Ehrlichiosis (Ehrlichia muris-like [EML] agent)
– Expected in MN
Anaplasmosis/EhrlichiosisSigns and Symptoms
• Many infections are asymptomatic, especially in young or healthy individualsy g y
• Symptomatic persons have acute onset within 3-21 days after tick bite
– High fever, chills, shaking, severe headache, muscle aches
L hit bl d ll l l t l t l t d– Low white blood cells, low platelets, or elevated liver enzymes
• Severe complications (e.g. organ failure) and death can occur
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Anaplasmosis/Ehrlichiosis Diagnosis and Treatment
• Diagnostic testsOrder PCR plus either peripheral blood smear or– Order PCR plus either peripheral blood smear or serology
– Serologic cross-reactivity occurs between Anaplasma, E. chaffeensis, and EML agent; to differentiate, compare strength of titers or, ideally, order PCR
• Treatment
– Begin empiric treatment with doxycycline for suspect cases while test results pending
– Cases usually improve within 3 days
*Krause et al 2008. CID 46:370-6
Powassan (POW) Disease
• Agent: Powassan virus (POWV), flavivirus closely related to West Nile virus (WNV);
Li II t i (“d ti k i ”) i d b– Lineage II strain (“deer tick virus”) carried by blacklegged ticks
• Manifestations
– Encephalitis or meningitis: of known cases, 10-15% die; half have long-term sequelae
Some infections may cause only febrile illness or be– Some infections may cause only febrile illness or be asymptomatic
• Rarely identified: ~60 cases in N. America, 1958-2010
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POW Diagnosis
• Available tests
– Serology: POWV-specific IgM and IgG
– Molecular: PCR
– Specimens: serum, CSF
• Few laboratories in the U.S. offer POWV testing
St t bli h lth l b C t f Di C t l– State public health labs or Centers for Disease Control and Prevention (CDC)
Audience Response System:Case Presentation
• A 15-year-old boy comes to the emergency i S t b ith 4 d hi t froom in September with a 4-day history of
fever, headache, fatigue, and spotty rash
• His symptoms have worsened over the past day, and he is becoming disoriented
• He had spent August working at a boy scout p g g ycamp and had multiple tick bites
– Most reported cases have recent travel histories to endemic states or unconvincing illnesses or titersendemic states or unconvincing illnesses or titers
• One PCR-confirmed fatal case reported in 2009 from Minnesota (Dakota County) in a pediatric case with no travel
• Primary vector (dog/wood tick) very common th h t MN i i lthroughout MN in spring, early summer
• Also carried by brown dog tick, which can be in dog kennels year-round
TBD Risk from Blood Transfusions, Minnesota
• Babesiosis: Increased numbers of transfusion-associated cases in recent years in MN and ynationwide
• HA: Two well-documented cases in MN, 2007-2008
• POW: plausible, although no transfusion-acquired cases identifiedacquired cases identified
• No screening of donated blood products performed routinely at this time for TBDs
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Prevention Messages for Your Patients
Avoid Tick Bites
• Be aware of high-risk times and places
• Walk in the center of trails to avoid picking up ticks from brush
• Wear long pants, light-colored clothing, and repellentrepellent
• Perform tick checks
• Control ticks at home
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Use Effective Tick Repellents
• DEET
U d t ith t 30% DEET– Use product with up to 30% DEET
– Apply to skin or clothing
– Focus below the knees
• Permethrin
Apply to clothing only– Apply to clothing only
– Lasts through multiple washings
– Good choice for people outside frequently
CDC: DVBID
Check for Ticks
• Ticks are easier to spot against light-colored clothing than dark clothingthan dark clothing
• Look for ticks while outside and again at home
• Under clothes, ticks tend to attach at points of constriction
• Parents should check young children
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Control Blacklegged Ticks at Home
• Modify landscape
– Remove leaf litter and brush from yardy
– Construct landscape barrier between lawn and woods
• Apply acaricide (pesticide) to low-lying vegetation
Clinical Pearls: Tick-Borne Diseases and Pediatric Patients in MN
• A patient with a classic erythema migrans rash and• A patient with a classic erythema migrans rash and signs/symptoms <30 days should be started on antibiotic treatment for Lyme disease without Lyme disease serology, which is likely to be negative within 2-3 weeks of illness onset
• If a patient with signs/symptoms suggestive of Lyme• If a patient with signs/symptoms suggestive of Lyme disease has been ill for >30 days but the Lyme disease Western blot IgG result is negative, consider etiologies other than Lyme disease
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Clinical Pearls: Tick-Borne Diseases and Pediatric Patients in MN (cont.)
• For patients with history of tick exposure and• For patients with history of tick exposure and spring, summer, or fall onset of central nervous system disease of apparent infectious etiology, consider Powassan virus and submit CSF and serum specimens to the MN Department of Health
Thank You!
• Clinicians
• Infection preventionists
• Clinical laboratory staff
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References• Aguero-Rosenfeld ME et al. Diagnosis of Lyme borreliosis. Clinical Microbiology
Reviews 2005; 1893:484-509.• Chapman AS et al. Diagnosis and management of tickborne rickettsial
diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis—United States. MMWR 2006; 55(RR-4):1-27.
• Dumler JS et al. Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis, and treatment. CID 2007; 45:S45-51.
• Ebel GD. Update on Powassan virus: emergence of a North American tick-borne flavivirus. Annu Rev Entomol 2010; 55:95-110.
• Holzbauer SM et al. Death due to community-associated Clostridium difficile in a woman receiving prolonged antibiotic therapy for suspected Lyme disease. CID 2010;51(3):369-70.
• Kemperman MM et al. Dispelling the chronic Lyme disease myth. Minnesota Medicine 2008; July:37-41.K l P i d l i b b i i i i i d• Krause et al. Peristent and relapsing babesiosis in immunocompromised patients. CID 2008; 46(3);370-6.
• Wormser GP et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. CID 2006; 43:1089-134.
For More Information
Minnesota Department of HealthMinnesota Department of Health