Disclosures Ticked off: What every NP needs to know · –Approximately 3–30 days after initial...
Transcript of Disclosures Ticked off: What every NP needs to know · –Approximately 3–30 days after initial...
Ticked off: What every NP needs to know about tick-borne infections
Vanessa Pomarico-Denino, EdD, FNP-BC, FAANP
FacultyFitzgerald Health Education Associates,
North Andover, MANortheast Medical Group (NEMG) APRN
Adjunct faculty for Southern CT State University and Quinnipiac University
Disclosures
• No real or potential conflict of interest to disclose.
• No off-label, experimental or investigational use of drugs or devices will be presented.
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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.
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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.
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ReferencesAll references are listed in your
program, as well as at the end of this presentation.
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Tick-borne Pathogens
•Transmitted through bite of infected 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
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Ticked off: What every NP needs to know about tick-borne infections
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Tick-borne Pathogens(continued)
•Transmitted through bite ofinfected ticks (cont.)– Are considered reportable diseases
to DPH– Consider widespread testing due to
concomitant infection risk
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Types of Tick-borne Diseases
• Lyme• Babesia• Anaplasmosis (also
known as Ehrlichia)• Rocky Mountain
Spotted fever• Powassan
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Lifecycle of a Tick
• Lifecycle approximately 2 years• 4 life-stages
– Egg– Six-legged larva– Eight-legged nymph– Adult
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Lifecycle of a Tick (continued)
• When eggs hatch, ticks must feedon a blood meal at every stage inorder to survive.– Feedings are approximately 10 minutes
to 2 hours.– A cement-like substance is secreted to
insure attachment to host.
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How Transmitted
• “Questing”• Ticks wait on hind legs
on ends of blades of grass and leaves.
• They attach to suitable host aftermaking contact.
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Source: www.CDC.gov/ Public Health Image Library ID #10871 Photo by James Gathany
How Transmitted(continued)
• Front legs attach onto host to begin feed– Infection is
transmitted through tick saliva that has an anesthetic property.
• Tick will feed thenfall off host untiltime to feed againin next lifecycle.
Fitzgerald Health Education Associates 12
Source: www.CDC.gov/ Public Health Image Library ID #8680. Photo by James Gathany
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How to Remove a Tick
• There are several commercially made tick removal kits.
• Fine-tipped tweezers as close to the skin where tick is embedded work just fine.– Pull upward with steady, even pressure.– Clean area with soap, water, or
rubbing alcohol.– Pincers (mouth parts) can remain in
the skin despite removal and allowed to heal over.
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How to Remove a Tick (continued)
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Image source: https://www.cdc.gov/lyme/removal/
How NOT to Remove a Tick
• Lit cigarette or match• Nail polish• Petroleum jelly
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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
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Lyme Disease True or false?
Tick must generally be in place>24 hours in order to transmit
infection to host.
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True
Lyme Disease (Borrelia Burgdorferi) (continued)
• 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
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Ticked off: What every NP needs to know about tick-borne infections
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Tick vector
Geographic location
% 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
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Source: www.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
Fitzgerald Health Education Associates 21 Fitzgerald Health Education Associates 22
Source image: https://www.cdc.gov/lyme/datasurveillance/maps-recent.html
Incidence of RecentlyConfirmed Lyme Cases (2017)
• CT: 1381*• CA: 84• MA: 321*• NJ: 3629*• NY: 3502*
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• PA: 9250* • TN: 15• IN: 92• HI,OK: 0
– Source: https://www.cdc.gov/lyme/datasurveillance/maps-recent.html
* Denotes high incidence of infection
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.
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Fitzgerald Health Education Associates 25
Source: www.CDC.gov/ Public Health Image Library ID #14476
Source: www.CDC.gov/ Public Health Image Library ID #14481
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.
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Clinical Presentation(continued)
• Stage 2: Early disseminated infection (cont.)– Cranial nerve VII
palsy or meningitis(10–15%)• Rare complication –
AV block (~4–10%) or myopericarditis, panophthalmitis
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Source image: author-James Heilman, MD https://commons.wikimedia.org/wiki/File:Bellspalsy.JPG
Clinical Presentation(continued)
• 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 neutrophils
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Clinical Presentation(continued)
• Rare neurologic manifestations– Subacute encephalopathy, sleep
disturbance, memory loss, mood changes, intermittent paresthesias, ataxia, spastic paraparesis, bladder dysfunction
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Clinical Presentation(continued)
• If patient presents with symptoms of Bell’s palsy, heart block or myopericarditis, test for Lyme disease!
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Source: www.CDC.gov/ Public Health Image Library ID #6633
Source: ECG courtesy of Nick Tullo, MD
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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
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• 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., and McPhee, S. (2017). Current Medical Diagnosis And Treatment. (56th ed). New York, NY: McGraw-Hill
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Incidence of Lyme Disease
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
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Lab Testing (continued)
• ELISA two step testing (EIA) (cont.)– IgG must have 5/10 bands + for diagnosis– ESR may be elevated.– LFT abnormalities, shift in WBC
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Criteria for Prevention Treatment for Known Tick Bite ≤72 Hours
• Tick is identified as an adult or nymph Ixodes scapularis tick.
• Estimated to have been attached and engorged for ≥36 h
• Must be in a highly endemic area where prevalence of B. burgoderferi infections are ≥20%
– Source: NEJM Journal Watch
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Outpatient Treatment of Lyme Disease One of the following regimens…
• Doxycycline 100 mg PO BID × 10–21 d– Do not use in pregnancy, ? Lactation
OR• Amoxicillin 500 mg PO TID × 14–21 d
– Safe for pregnancy/lactating womenOR
• Cefuroxime axetil 500 mg PO BID ×14–21 d
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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 hoursFitzgerald Health Education Associates 37
Outpatient Treatment – PediOne of these regimes…
• Amoxicillin 50 mg/kg PO daily in 3 divided doses– Maximum of 500 mg
per dose– 14–21 days
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• Doxycycline– Age ≥8 years– PO 4 mg/kg per day
in 2 divided doses– 100 mg per dose– 10–21 days
Outpatient Treatment – PediOne of these regimes…(cont.)
• Pedi (cont.)– Cefuroxime axetil 30 mg/kg PO daily in
2 divided doses• Age >8 years• Maximum of 500 mg per dose • 14–21 days
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Treatment Alternatives – Adult
• To be used if PCN allergic or intolerant of other recommended medications– Lower efficacy profile
• Azithromycin– 500 mg PO daily ×
7–10 days
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• Clarithromycin– 500 mg PO BID ×
14–21 days
• Erythromycin– 500 mg PO QID ×
14–21 days
Treatment Alternatives – Pedi
• Azithromycin– 10 mg/kg/day PO daily × 7–10 days
• Erythromycin– 30–50 mg/kg/day PO in 4 divided doses
× 14 days
• Clarithromycin– 15 mg/kg/day in 2 divided doses ×
14–21 days
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PosttreatmentLyme Disease Syndrome (PTLDS)
• Formerly referred to as chronic Lyme– Controversial– No documentation or studies to
prove/disprove its existence• Persistent joint pain, fatigue, or
difficulty thinking for >6 months after treatment for Lyme
• Refer to infectious disease specialist if symptoms persist beyond treatment.
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Fitzgerald Health Education Associates 43
Source: The Hartford Courant 9/14/2017
University of Massachusetts Medical School trialing a single injection as prevention from acquiring Lyme disease before someone is even exposed.
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Source: www.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• Became nationally reportable disease in 2011
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Babesiosis (continued)
• 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 fetusFitzgerald Health Education Associates 46
Clinical Presentation of Babesia
• Flu-type symptoms gradually worsening– Fever, HSM
• Arthralgias, myalgias– May not have any rash
• Hemolytic anemia, thrombocytopenia
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Clinical Presentation of Babesia(continued)
• Symptomatic within a week but may be asymptomatic for many months– Incubation can be 1–9 weeks
• Can be fatal in elderly or peoplewithout spleen
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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
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Diagnosing Babesia(continued)
• Manual peripheral blood smear– Can need more than one sample to
detect parasites– Must request manual reading!
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Diagnosing Babesia(continued)
• 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
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BabesiaOutpatient 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
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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.
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BabesiaMedication 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
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BabesiaMedication 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
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Babesia Case Study
• Isabelle, 85-year-old female patient• Presents with one week history of
fatigue, fever (unmeasured) and “feeling washed out”
• PMH- Type 2 DM, HTN, hyperlipidemia, hypothyroid
• PSH- Noncontributory
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Babesia Case Study(continued)
• Medications– Metformin 500 mg PO daily– Amlodipine/valsartan/HCTZ (Exforge
HCT®) 160/5/25 mg– Levothyroxine (Synthroid®) 175 mcg– ASA 81 mg– MVI
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Babesia Case Study(continued)
• SH- Married to husband 61 years• Lives in own home• Still drives• Active at home
– Reports having been working in her garden two weeks prior to onset of symptoms
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Babesia Case Study(continued)
• VS– BP 100/62 mm Hg– HR 44 bpm– RR 14– Temp 102˚F (38.9˚C)
• Pt was transferred to ED for admission and sepsis workup.
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Babesia Case Study Labs
• WBC 7.4 × 1000 units/L (4–10 ×1000 units/L)– Platelets 105 × 1000 units/L (140–440)– Neutrophils 50% (37–84%)
• 0.5 proportion (0.37–0.84 proportion)
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Babesia Case Study Labs (continued)
• WBC 7.4 × 1000 units/L (4–10 ×1000 units/L) (cont.)– Lymphocytes 25% (8–49%)
• 0.25 proportion (0.08–0.49 proportion)• Atypical lymphocytes 9% (0.9 proportion)
– Monocytes 14% (4–15%)• 0.14 proportion (0.04–0.15% proportion)
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Babesia Case Study Labs(continued)
• RBC– 3.4 (3.8–5.9 M/uL)
• Hgb– 9.7 g/dL (12.0–18.0)
(97 g/L [120–180])• Hct
– 29.1 g/dL (37–52%) (0.29 proportion[0.37–0.52])
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• BUN– 30 mg/dL (10.7 mmol/L)
• Creatinine– 1.0 mg/dL (88.4
µmol/L)• ALT
– 49 unit/L (0–34 unit/L)• AST
– 53 unit/L (0–34 unit/L)
Babesia Case Study Labs(continued)
• Rapid Lyme– Negative
• TSH– 23 milli-international
units of per liter (0.4–4.0 mIU/L)
• CXR– Negative for PNA
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• UA– Negative
• EKG– Sinus bradycardia
• Day 3– Babesia peripheral
smear + for parasites
Babesia Case Study Medications
• Doxycycline 100 mg IV BID empirically• Azithromycin 1000 mg IV on day 1
then 500 mg IV days 2–9• Atovaquone 750 mg PO every 12 hours• Clindamycin 600 mg IV every 6 hours• Probiotic
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Complications during Hospitalization
• Afib– Fever induced – Temps 103˚F (39.4˚C)
• Aspirational PNA• Sick sinus syndrome
– ITP post pacemaker insertion• CHF – Acute diastolic HF• Hearing loss secondary to antibiotics• Colitis
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Babesia Case Study (continued)
• Multiple PRBC and platelet transfusions• Pt discharged to home on day 28
with VNA• Weekly CBC until normal range • Weekly Babesia smears until negative
parasite count (4 weeks)• PATIENT EDUCATION!
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Fitzgerald Health Education Associates 67
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)
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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 untreatedFitzgerald Health Education Associates 69
Ehrlichiosis or Anaplasmosis(continued)
• Other modes of transmission– Has been found in refrigerated blood– Blood transfusions– Organ transplant
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Ehrlichiosis or Anaplasmosis(continued)
• Prodrome– Malaise, rigors, fever, HA, myalgia, N/V/D– Rash is rare.– Coinfection with Lyme disease, Babesia
not uncommon
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Diagnosis and TreatmentEhrlichiosis or Anaplasmosis
• Indirect immunofluorescence assay (IFA) – Gold standard
• PCR assay– Most sensitive during first week of illness
• Enzyme immunoassay (EIA)– Serologic only gives + or (-) result
High false positive• Peripheral blood smear
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Diagnosis and TreatmentEhrlichiosis or Anaplasmosis
(continued)• CBC/diff
– Thrombocytopenia and leukopenia are common.• Platelets <150,000/mL• WBCs <4000/mL
– Lymphopenia• <1500 lymphocytes/mL
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Diagnosis and TreatmentEhrlichiosis or Anaplasmosis
(continued)
• LFTs– Transaminitis is common in ~83%
of patients.– Elevated ALT/AST and indicator of
liver damage– Generally is reversible.
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Diagnosis and TreatmentEhrlichiosis and Anaplasmosis
(continued)• Presence of morulae
– Large, mulberry-shaped aggregates or microcolonies of Ehrlichia inside the monocyte in approximately 20% of infected patients
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Diagnosis and TreatmentEhrlichiosis and Anaplasmosis
(continued)• Treatment
– Doxycycline 100 mg PO BID × 10–14 days• Pedi <45 kg (100 lbs.)• 2.2 mg/kg body weight given twice a day
× 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
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Rocky Mountain Spotted Fever (RMSF)
• 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
Fitzgerald Health Education Associates 77
Rocky Mountain Spotted Fever (RMSF) (continued)
• Has been detected in almost every state in the US– >60% of cases have been found in
• North Carolina• Oklahoma• Arkansas• Tennessee• Missouri
Fitzgerald Health Education Associates 78
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Rocky Mountain Spotted FeverClinical Presentation
• 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.Fitzgerald Health Education Associates 79
Rocky Mountain Spotted FeverClinical Presentation
(continued)
• HA– Most common presenting complaint
with Pedi
• N/V/abdominal pain• Anorexia• Conjunctival irritation
Fitzgerald Health Education Associates 80
Rocky Mountain Spotted FeverDiagnosis
• 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– Can remain elevated for several months
after resolution of infection
Fitzgerald Health Education Associates 81
Rocky Mountain Spotted FeverDiagnosis(continued)
• 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
Fitzgerald Health Education Associates 82
Rocky Mountain Spotted Fever Complications
• Vasculitis due to infection of endothelial cells
• Limb amputation due to decreased circulation
• Internal organ damage
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• Neurological deficits• Thrombocytopenia• Hyponatremia• Elevated LFTs
Rocky Mountain Spotted FeverTreatment
• Doxycycline 100 mg PO BID × 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
Fitzgerald Health Education Associates 84
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Outpatient Treatment of RSMFAdditional 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 age <8 yo who had received doxycycline and those who had not.
– Source: https://www.cdc.gov/rmsf/doxycycline/index.html
Fitzgerald Health Education Associates 85 Fitzgerald Health Education Associates 86
Source: www.CDC.gov/ Public Health Image Library ID #14489
PreventionPermethrin 0.5% Spray
• Synthetic molecule derived from chrysanthemum flowers– Meant for use on clothing and fabric
goods only– Avoid contact with face, eyes, skin or
breathing vapor mist• One application lasts through 6 washes
or up to 6 weeks.
Fitzgerald Health Education Associates 87
Prevention
• Adequate covering of all exposed skin• DEET or permethrin products• Extensive skin checks if in exposed area• Removal of tick in its entirety
Fitzgerald Health Education Associates 88
Prevention (continued)
• Use of essential oils has not been studied well but is becoming more widely used by consumers.– Are considered safe for people and pose
minimal risk per CDC– Have not been evaluated by the EPA
for effectiveness
Fitzgerald Health Education Associates 89
Prevention (continued)
• Use of essential oils has not been studied…(cont.)– Not all essential oils can be applied
directly to the skin without causing severe skin irritation.
Fitzgerald Health Education Associates 90
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Examples of Essential Oils Used to Prevent Tick Bites
• 2-undecanone– Essential oil from
leaves and stems of the wild tomato plant, Lycopersiconhirsutum
Fitzgerald Health Education Associates 91
Examples of Essential Oils Used to Prevent Tick Bites
(continued)
Fitzgerald Health Education Associates 92
• Garlic oil– Essential oil from
garlic plants
Examples of Essential Oils Used to Prevent Tick Bites
(continued)
• Mixed essential oils– Rosemary, lemongrass, cedar,
peppermint, thyme, and geraniol
Fitzgerald Health Education Associates 93
• Nootkatone– Essential oils from Alaska
yellow cedar trees, some herbs, and citrus fruits
• Fungi (Metarhizium brunneum, Metarhizium anisopliae)– Used only on lawns
and gardensFitzgerald Health Education Associates 94
Examples of Essential Oils Used to Prevent Tick Bites
(continued)
Alpha-gal Galactose-alpha-1,3-galactose
• Immune response due to tick bite from a Lone Star tick causing allergy to beef and pork
• Immunoglobulin E (IgE)– Allergen binds to IgE antibodies to promote
a histamine reaction that is mild to severe (anaphylaxis)• Epinephrine (EpiPen®)
• Diagnosed via specific allergy testing labsFitzgerald Health Education Associates 95
Testing the Tick
• Many labs only test tick specimen for Lyme.
• Tickencounter.org tests for Lyme disease, Babesia and Anaplasma.– UMass Laboratory of Medical Zoology
• Tickcheck.com tests for 9 different diseases.
Fitzgerald Health Education Associates 96
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Tick-borne Disease Follow-up
• Serial CBC/diff, CMP and Babesia peripheral 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.
Fitzgerald Health Education Associates 97
Questions?
Fitzgerald Health Education Associates 98
End of PresentationThank you for your attention
Vanessa Pomarico-Denino,EdD, APRN, FNP-BC, FAANP
www.fhea.com [email protected]
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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. and 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.
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References(continued)
• Mcneil C., Shreve M., Jarrett A., and 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.
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References(continued)
• NEJM Journal Watch. https://www.jwatch.org/fw115560/2019/06/27/new-draft-lyme-disease-guidelines-issued
• Papadakis M., and McPhee S. (2017). Current Medical Diagnosis And Treatment. (56th ed). New York, NY: McGraw-Hill
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References (continued)
• Theophilus P., Victoria M., Socarras K., Filush K., Gupta K., Luecke D. and Sapi E. (2015). Effectiveness of Stevia RebaudianaWhole Leaf Extract Against the Various Morphological Forms of Borrelia Burgdorferiin Vitro. European Journal of Microbiology & Immunology. 5(4): 268–280.
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References(continued)
• van Nunen, S. (2015). Tick-induced allergies, mammalian meat allergy, tick prophylaxis and their significance. Asia Pacific Allergy. 5(1): 3–16.
• Wooten, A. (2015). Zika Virus: An emerging threat to travelers. The Journal for Nurse Practitioners. 12(5): e237–238.
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References (continued)
• Wormser G., Dattwyler R., Shapiro E., HalperinJ., Steere A., Klempner M., Krause P., Bakken J., Strle F., Stanek G., Bockenstedt L., Fish D., Dumler JS., and 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.
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Photo Credits
• Graham Hickling, PhD, University of Tennessee.
• CDC public health image library. https://phil.cdc.gov
• Pixnio. www.pixnio.com
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• 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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Statement of Liability
• 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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