1. Tick-Borne and Zoonotic Diseases in the United States David Spach, MD Professor, Division of Infectious Diseases University of Washington, Seattle DHS/PP

2. North American Ticks DHS/PP

3. Tick Quiz From: Spach DH et al. N Engl J Med 1993;329:936-47. 12 DHS/PP

4. Important 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 1993;329:936-47. DHS/PP

5. Ixodes scapularis Ticks From: CDC Lyme Disease Home Page. www.cdc.gov/ncidod/dvbid/lyme/ Adult FemaleAdult MaleNymphLarva Centimeter Scale DHS/PP

6. Ixodes Nymph Tick From: Spach DH et al. Washington State Lyme Disease Monograph. DHS/PP

7. Case 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 is: 1. Give IV ceftriaxone x 14 days 2. Remove tick and observe closely 3. Give IM streptomycin x 10 days 4. Arrange for emergent plasmapharesis DHS/PP

8.  Early Features - Paresthesias - Leg weakness - Absence of fever  Later Findings - Ascending paralysis - Ataxia - Hyporeflexia/Areflexia  Late Findings - Bulbar signs - Hypoventilation Tick Paralysis Clinical Features DHS/PP

9. Tick Removal DHS/PP

10.  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 is: 1. No antibiotics required 2. Give PO Doxycycline for 14 days 3. Give IV Ceftriaxone for 14 days 4. Give IV Ampicillin and Gentamicin x 10 days Case History DHS/PP

11. Case History DHS/PP

12. Tegenaria agrestis (Hobo Spider) MaleFemale From: http://hobospider.org DHS/PP

13. Recluse Spiders (Loxosceles sp) Distribution in US From: Vetter RS. DHS/PP

14. Diff Dx of Skin Lesions From: Lowy FD. N Eng J Med 1998;339:520-32. From: Young DM, et al. Arch Surg 2004;139:951-3. From: CDC & Prevention From: Darwin Vest

15. DHS/PP Case 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 is: 1. Give PO Doxycycline for 14 days 2. Reassure and don’t give antibiotics 3. Draw serology (Lyme) and treat if positive 4. Give IV Ceftriaxone for 14 days

16. Erythema Migrans Rash DHS/PP

17. Erythema Migrans Rash From: Steere AC. N Engl J Med 2001;345:115-25. DHS/PP

18. Case History  A 33-year-old woman is treated for Lyme disease (erythema migrans) with doxycycline and 12 months later returns and complains of fatigue and muscle aches. She has a friend who takes chronic antibiotics for “Lyme’s disease” and she wants the same.  What would you recommend? DHS/PP

19. Antibiotic Treatment for Persistent Symptoms and a History of Lyme Disease Patients - Age > 18 yrs & H/O acute Lyme - Received appropriate Rx - Persistent symptoms (> 6 months)* - Western blot IgG+ (n = 78) - Western blot IgG- (n = 51) Regimens (90-day course) - Ceftriaxone 2 g IV qd x 30d, followed by Doxy 200 mg PO qd x 60d - Placebo (matching IV & PO) Study DesignResponse at 180 Days From: Klempner MS et al. NEJM 2001; 345:85-92. *Widespread musculoskeletal pain; cognitive impairment, radicular pain, paresthesias, dysesthesias P = NS DHS/PP

20.  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 Lyme Disease: Erythema Migrans Treatment DHS/PP

21. National Lyme Disease Risk From: CDC Lyme Disease Home Page. www.cdc.gov/ncidod/dvbid/lyme/ DHS/PP

22. Case History  A 42-year-old woman is walking in the woods and fields in a coastal New England region and is bitten by a tick.  What further questions would you ask?  What would you recommend? DHS/PP

23. Doxycycline Prophylaxis After Ixodes Tick Bite Methods - Age > 12 yrs (N = 482) - Westchester County, NY - Removed attached Ixodes tick within previous 72 hours Regimens - Doxycycline: 200 mg x 1 - Placebo x 1 Study DesignErythema Migrans From: Nadelman RB et al. NEJM 2001; 345:79-84. DHS/PP

24. Doxycycline Prophylaxis After Ixodes Tick Bite Duration of Tick Feeding: Nymphal TicksTick Engorgement: Nymphal Ticks From: Nadelman RB et al. NEJM 2001; 345:79-84. DHS/PP

25. Ixodes Adult Females: Unfed and Fed From: Spach DH et al. Washington State Lyme Disease Monograph. DHS/PP

26.  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 is: 1. Give high dose corticosteroids 2. Give PO Doxycycline 3. Give IV Ceftriaxone 4. Give IV Gentamicin Case History DHS/PP

27. Ehrlichiosis & Anaplasmosis in United States From: CDC Ehrlichiosis Home Page. www.cdc.gov/ncidod/dvrd/ehrlichia/Index.htm DHS/PP E. chaffeensis A. phagocytophilium E. ewingii Ixodes Amblyomma MonocytesGranulocytesGranulocytes/Eos Amblyomma HMEHGAHGE

28.  Human Monocytic Ehrlichiosis - Organism: Ehrlichia chaffeensis - Transmission: Amblyomma ticks - Cells: Monocytes/Macophages  Human Granulocytic Anaplasmosis - Organism: Anaplasma phagocytophilium - Transmission: Ixodes ticks - Cells: Granulocytes Ehrlichiosis & Anaplasmosis DHS/PP

29. Ehrlichiosis: Laboratory Studies Liver Function TestsPlatelet Count From: Fishbein DB et al. Ann Intern Med 1994;120:736-43. DHS/PP

30.  First Line - Doxycycline: 100 mg PO bid x 10 days  Second Line (Doxycycline allergy, Pregnancy) - *Rifampin: 300 mg bid x 10d Ehrlichiosis & Anaplasmosis Treatment DHS/PP *Since rifampin does not treat Lyme disease, patients should also receive amoxicillin or cefuroxime

31. Case 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 of: 1. Ceftriaxone x 10 days 2. Penicillin x 10 days 3. Quinine + Clindamycin x 7 days 4. Streptomycin x 7 days DHS/PP

32.  First Line Azithromycin: 500-1000 mg PO day 1, then 250 mg PO qd x 6-9d plus Atovaquone: 750 mg PO bid x 7-10d OR Clindamycin: 300-600 mg IV q6h (600 mg PO q8h) x 7-10 d plus Quinine: 650 mg of salt PO q8h x 7-10d Babesiosis: Treatment DHS/PP

33. Case 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 is: 1. Relapsing fever 2. Lyme disease 3. Leptospirosis 4. Colorado tick fever DHS/PP

34. From: Spach DH et al. N Engl J Med 1993;329:936-47. DHS/PP

35.  First Line - Doxycycline: 100 mg PO bid x 7-10 days- Relapsing Fever Treatment DHS/PP

36. Tick-Borne Relapsing Fever in Northwest Number of Relapses From: Dworkin MS et al. Clin Infect Dis 1998;26:122-31. DHS/PP

37.  A 29-year-old woman is admitted with suspected RMSF. Which laboratory study is NOT often observed with RMSF: 1. WBC > 12, 000 2. Platelet count < 150,000 3. Hyponatremia 4. Increased CSF WBC count Case History DHS/PP

38. RMSF in US 1981-1992: Average Incidence by County From: Thorner AR et al. Clin Infect Dis 1998;27:1353-9. DHS/PP

39. RMSF: Clinical Manifestations From: Catherine Wilfert (Duke University Medical Center) DHS/PP

40.  First Line - Doxycycline: 100 mg PO bid x 7-10 days  Second Line - Chloramphenicol  Promising  - Fluoroquinolones RMSF: Treatment From: CDC RMSF Home Pagewww.cdc.gov/ncidod/dvrd/rmsf DHS/PP

41. Rabies DHS/PP

42. 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. 25% 2. 50% 3. 75% 4. 100% Case History: Question Silver-Haired Bat DHS/PP

43.  “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 1999;48 (RR-1): 275-9. Rabies Postexposure Prophylaxis Rabies Immune Globulin DHS/PP

44. From Rabies: Post-Exposure Prophylaxis Wound cleansing No RIG + Vaccine: day 0 and 3 Previously Vaccinated  Wound cleansing  * RIG  + Vaccine: day 0,3,7,14,28 Not Previously Vaccinated *Administer vaccine as IM in deltoid + Administer full dose of RIG around wound if possible; remaining volume give at site distant from vaccine site DHS/PP

45. A 22-year-old woman is bitten on the shoulder by a raccoon when she was taking out the garbage at night. The raccoon ran off and has not been seen since this encounter. What would you recommend for this woman? Case History: Question DHS/PP

46.  “We agree that currently the risk of rabies from the bite of a raccoon that does not exhibit abnormal behavior appears to be low. However, the lack of an active surveillance system for rabies in Washington State makes it incorrect to assume that there are no raccoons or other wild terrestrial carnivores with rabies in our state.” King County Health Advisory—December 1, 2006 Rabies Postexposure Prophylaxis Raccoon and Other Wild Terrestrial Carnivore Bites

47. DHS/PP  “Therefore, after consultation with the Centers for Disease Control and Prevention (CDC), Public Health – Seattle & King County continues to recommend rabies PEP for raccoon and other wild terrestrial carnivore bites when the animal is not available for rabies testing.” King County Health Advisory—December 1, 2006 Rabies Postexposure Prophylaxis Raccoon and Other Wild Terrestrial Carnivore Bites

48. Case History: Question In which of the following scenarios would it NOT be appropriate to administer rabies post-exposure prophylaxis: 1. A 41-year-old woman is bitten by her neighbor’s dog 7 days ago while jogging by their house; the dog is behaving normally 2. A mother awakens and finds a bat in the room of her 4-year-old child (and the bat escapes 3. A 22-year-old man picks up a dead bat in his yard (with bare hands) and throws it down into a large ravine 4. A 48-year-old man tells you during a routine medical visit that he suffered a unprovoked dog bit in Thailand 3 months ago DHS/PP

49. Hantavirus Pulmonary Syndrome DHS/PP

50. Case 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 DHS/PP

51. Hantavirus Pulmonary Syndrome: Reservoir Source: CDC and Prevention Peromyscus maniculatus Deer Mouse DHS/PP

52. * Hantavirus Pulmonary Syndrome Through March 26, 2007 DHS/PP *By State of ResidenceSource: CDC and Prevention

53. Hantavirus Pulmonary Syndrome: Chest Radiograph CDC Early Stage Later Stage Severe Interstitial DHS/PP

54. Hantavirus Pulmonary Syndrome Progression of Disease Picture ProdromeCardiopulmonary Death Recovery DHS/PP

55. Dog & Cat Exposure DHS/PP

56.  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 of the following is TRUE? 1. Her risk of getting rabies from this cat bite is about 2% 2. Cat bites become infected more often than dog bites 3. Bartonella is the 2nd most likely cause of the infection 4. Pseudomonas is 2nd the most likely cause of the infection Case History: Animal Bite DHS/PP

57. Microbiology of Infected Cat Bites From: Talan DA, et al. NEJM 1999;340:85-92. DHS/PP

58. Microbiology of Infected Dog Bites From: Talan DA, et al. NEJM 1999;340:85-92. DHS/PP

59. Dog & 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 DHS/PP

60. Bartonella henselae: Soft Tissue Infection DHS/PP

61. From: Bass JW et al. Pediatr Infect Dis 1998;17:447-52. Cat Scratch Disease: Azithromycin Therapy DHS/PP

62. Cat Scratch Disease Neuroretinitis: Macular Star From: Bhatti MT et al. Arch Neurol 2001;58:1008-9. 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. DHS/PP

63.  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 catarrhalis 2. Pasteurella canis 3. Capnocytophaga canimorus (DF-2) 4. Pseudomonas aeruginosa Case History: Skin & Soft Tissue DHS/PP

64. Questions? DHS/PP