General Diagnosis & Treatment of Tick-borne Diseases

Here is a link to a video with expert commentary on testing for Lyme disease provided by Barbara J.B. Johnson, PhD, a supervisory research microbiologist with the US Centers for Disease Control and Prevention, Division of Vector-Borne Diseases, in Fort Collins, Colorado. She conducts research to improve the laboratory diagnosis of Lyme disease and other tick-borne illnesses, prevent Lyme disease by vaccination, and understand the pathogenesis of Borrelia burgdorferi infection. Dr. Johnson holds a doctoral degree in biochemistry from the University of Wisconsin, Madison.

http://www.medscape.com/viewarticle/758995

For Information Regarding Diagnosis and Treatment of Lyme Disease see here: 

1. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. 

Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. (2006). Clin Infect Dis; 43(9):1089-134. 

See full article here: http://cid.oxfordjournals.org/content/43/9/1089.full.pdf

2. The presenting manifestations of Lyme disease and the outcomes of treatment.

A.C. Steere, V.K. Sikand. (2003). N Engl J Med, 348: 2472–2474

See full article here: http://www.nejm.org/doi/pdf/10.1056/NEJM200306123482423

3. An update on the diagnosis and treatment of early Lyme disease: “focusing on the bull’s eye, you may miss the mark”.

Stonehouse A, Studdiford JS, Henry CA. (2010). J Emerg Med; 39(5):e147-51. 
 
Abstract: To confidently diagnose and treat Lyme disease, the clinician must first understand the natural history of this disease, especially its protean early manifestations. Emergency physicians, primary care physicians, and other providers need to be vigilant in terms of the timely recognition of erythema migrans (EM), the unique marker of early localized stage 1 disease. The classic EM, originally described as a slowly expanding bull’s eye lesion, is now recognized to be present in only the minority of cases (9%); the dominant morphologic lesion of EM is now recognized to be the diffusely homogenous red plaque or patch, which occurs in over 50% of cases. This update will define the current morphologic features of early Lyme disease, the indication for serologic studies, and the most recent treatment guidelines, including therapeutic pitfalls.

See full article here: http://www.sciencedirect.com/science/article/pii/S0736467907004052

4. Chronic Lyme Disease: A Review
Marques, A. (2008). Infect Dis Clin North Am; 22:341-60.
 
 

For Information Regarding Ehrlichioses, Anaplasmosis and Rocky Mountain Spotted Fever see here:

1. Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever, Ehrlichioses, and Anaplasmosis — United States

 A Practical Guide for Physicians and Other Health-Care and Public Health Professionals

Prepared by: Alice S. Chapman, DVM in collaboration with the Tickborne Rickettsial Diseases Working Group

SummaryTickborne rickettsial diseases (TBRD) continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low cost, effective antimicrobial therapy. The greatest challenge to clinicians is the difficult diagnostic dilemma posed by these infections early in their clinical course, when antibiotic therapy is most effective. Early signs and symptoms of these illnesses are notoriously nonspecific or mimic benign viral illnesses, making diagnosis difficult. In October 2004, CDC’s Viral and Rickettsial Zoonoses Branch, in consultation with 11 clinical and academic specialists of Rocky Mountain spotted fever, human granulocytotropic anaplasmosis, and human monocytotropic ehrlichiosis, developed guidelines to address the need for a consolidated source for the diagnosis and management of TBRD. The preparers focused on the practical aspects of epidemiology, clinical assessment, treatment, and laboratory diagnosis of TBRD. This report will assist clinicians and other health-care and public health professionals to 1) recognize epidemiologic features and clinical manifestations of TBRD, 2) develop a differential diagnosis that includes and ranks TBRD, 3) understand that the recommendations for doxycycline are the treatment of choice for both adults and children, 4) understand that early empiric antibiotic therapy can prevent severe morbidity and death, and 5) report suspect or confirmed cases of TBRD to local public health authorities to assist them with control measures and public health education efforts.

For the full article see here: http://www.cdc.gov/mmwr/PDF/rr/rr5504.pdf

2. Tick-borne Illnesses: A CME Update

Graham J, Stockley K, Goldman RD. (2011). Pediatr Emer Care; 27: 141-150

Abstract: North American tick-borne illnesses are a group of important emerging diseases whose incidence has been increasing for the past decade. Emergency physicians may be the first contact for patients with symptoms of tick-borne illness, thus it is important that these diseases remain on a physicians’ differential diagnosis when presented with an appropriate clinical presentation. This CME activity provides an overview of the most common tick-borne illnesses in North America and will help physicians evaluate their clinical presentation, order appropri- ate diagnostic tests, develop pediatric treatment recommendations, and prepare to include tick-borne illnesses in the differential diagnosis of pediatric patients presenting with multisystem disease.

For the full article see here: http://graphics.tx.ovid.com.ezproxy.library.wisc.edu/ovftpdfs/FPDDNCGCMBGAPP00/fs046/ovft/live/gv025/00006565/00006565-201102000-00018.pdf

3. Clinical findings and diagnosis in human granulocytic anaplasmosis: a case series from Massachusetts.

Weil AA, Baron EL, Brown CM, Drapkin MS. (2012). Mayo Clin Proc; Mar;87(3):233-9.

Objective: To describe clinical findings and the use of a tick-associated pathogen panel in a series of patients with human granulocytic anaplasmosis (HGA) at a suburban Boston hospital.

Patients and Methods: Medical records were reviewed for inpatients and outpatients at Newton-Wellesley Hospital with a positive polymerase chain reaction (PCR) result for Anaplasma phagocytophilum during the study period March 1 through November 30, 2009. A PCR panel was used to test for tick-borne pathogens. Postal zip code data from the patients’ areas of residence were used to estimate the area of disease transmission.

Results: Thirty-three cases were confirmed during the 2009 transmission season, and 14 of these patients (42%) required hospitalization. Thrombocytopenia and/or leukopenia were observed at the time of presentation in 25 of 30 patients (86%) in whom both white blood cell and platelet counts were determined, and 28 of 33 patients (85%) reported fever. Rash occurred in only 2 of the 33 patients (6%), and 25 (76%) reported one or more respiratory or gastrointestinal symptom. Cases were geographically distributed diffusely throughout the hospital catchment area, with one possible focus of infection identified in Weston, MA. Due to a lack of clinical data reporting to the Massachusetts Department of Public Health, only 20 of 32 HGA cases (63%) fulfilled the case confirmation criteria.

Conclusion: Diagnosis of HGA requires a high suspicion for infection even in endemic areas. Use of a tick-associated pathogen panel that includes PCR assays for several organisms could improve detection of underrecognized tick-borne diseases in endemic areas. Lack of epidemiological follow-up to confirm corroborating clinical findings prevents accurate case reporting and assessment of the true HGA burden.

For the full article see here: http://www.sciencedirect.com/science/article/pii/S0025619612001255

 

For Information regarding treatment and diagnosis of human babesiosis see here: 

1. Emergence of resistance to azithromycin-atovaquone in immunocompromised patients with Babesia microti infection.

Wormser GP, Prasad A, Neuhaus E, Joshi S, Nowakowski J, Nelson J, Mittleman A, Aguero-Rosenfeld M, Topal J, Krause PJ. (2010). Clinical Infectious Diseases;50 (1 February):381–6

Background: Babesiosis is an emerging tickborne malaria-like infection principally caused by Babesia microti. This infection typically resolves either spontaneously or after administration of a 7–10-day course of azithromycin plus atovaquone or clindamycin plus quinine. Although certain highly immunocompromised patients may respond suboptimally to these drug regimens, unlike the situation with malaria there has been no reported evidence that the cause of treatment failure is infection with drug-resistant strains of B. microti.

Methods: Emergence of drug resistance in B. microti was defined as the development of a microbiologic relapse (recurrent parasitemia or a marked increase in parasitemia) in association with both clinical and laboratory abnormalities indicative of active babesiosis in a patient after 28 days of uninterrupted antibabesia drug therapy and while still receiving treatment.

Results: The clinical case histories of 3 highly immunocompromised patients who received a subcurative course of azithromycin-atovaquone associated with the eventual development of resistance to this drug regimen are described. One of the 3 patients died of complications related to babesiosis.

Conclusions: B. microti may become resistant to azithromycin-atovaquone during the treatment of babesiosis with this combined drug regimen in highly immunocompromised patients. Although research is needed to determine the optimal therapy for highly immunocompromised patients with babesiosis, reducing the level of immunosuppression when possible would appear to be a desirable strategy.

For the full article see here: http://cid.oxfordjournals.org/content/50/3/381.full.pdf

For information regarding diagnosis and treatment of Rocky Mountain spotted fever see here:

Chen LF and Sexton DJ. (2008). What’s new in Rocky Mountain spotted fever? Infect Dis Clin North Am; 22(3): 415-32, vi-viii. 

Abstract

Rocky Mountain spotted fever (RMSF) remains an important illness despite an effective therapy because it is difficult to diagnose and is capable of producing a fatal outcome. The pathogenesis of RMSF remains, in large part, an enigma. However, recent research has helped shed light on this mystery. Importantly, the diagnosis of RMSF must be considered in all febrile patients who have known or possible exposure to ticks, especially if they live in or have traveled to endemic regions during warmer months. Decisions about giving empiric therapy to such patients are difficult and require skill and careful judgement.