1. Tick-Borne and Animal-Associated Diseases David Spach, MD Professor of Medicine Division of Infectious Diseases University of Washington, Seattle

2. North American Ticks

3. 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.

4. Tick Quiz From: Spach DH, et al. N Engl J Med. 1993;329:936-47. 12

5. Case Studies: Tick-Borne Disease

6. 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

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

8. How should you remove at tick?

9. Tick Removal

10. 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?

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

12. Erythema Migrans Rash From: Steere AC. N Engl J Med. 2001;345:115-25.

13.  Early Disease (Absence of serious Neurologic/Cardiac) - Doxycycline - Amoxicillin  Late Disease or Serious Neurologic/Cardiac Disease - Ceftriaxone Lyme Disease: General Approach to Treatment

14. Case History  A 67-year-old man from Wisconsin develops fever, severe malaise, and dark urine. Two weeks ago he went on a 7-day hunting trip in rural Wisconsin. Labs show hematocrit = 31 and platelet count = 49,000.  The most likely diagnosis and treatment?

15. Babesiosis: Transmission  Ticks - Ixodes scapularis - Ixodes pacificus  Transfusion-Associated - RBCs - Platelets

16.  First Line - Clindamycin plus Quinine  Second Line - Azithromycin plus Atovaquone Babesiosis: Treatment

17. 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

18. From: Spach DH, et al. N Engl J Med. 1993;329:936-47. Ornithodoros Tick

19.  First Line - Doxycycline  Second Line - Erythromycin Tick-Borne Relapsing Fever: Treatment

20.  A 29-year-old woman is admitted with suspected RMSF.  Which finding is NOT often observed with RMSF: 1. WBC > 12,000 2. Platelet count < 150,000 3. Rash that begins on extremities 4. Exposure to a Dermacentor tick Case History

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

22. RMSF: Clinical Manifestations From: Catherine Wilfert (Duke University Medical Center)

23.  First Line - Doxycycline  Second Line - Chloramphenicol Rocky Mountain Spotted Fever: Treatment

24.  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 transaminases. 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

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

26.  First Line - Doxycycline: 100 mg PO bid x 7-10 days  Second Line - Chloramphenicol - Rifampin Ehrlichiosis: Treatment

27. Rabies

28. In the United States, how do most people get rabies?

29. 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

30.  “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. CDC and Prevention. MMWR. 1999;48 (RR-1): 275-9. Rabies Postexposure Prophylaxis Rabies Immune Globulin

31. Rabies: Post-Exposure Prophylaxis  Wound cleansing  * Rabies Immune Globulin  + Rabies Vaccine: day 0,3,7,14 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 *Note: Number of recommended doses of rabies vaccine changed from 5 to 4 (ACIP June 24, 2009) From: CDC. MMWR 2008;57:1-26.

32. Hantavirus Pulmonary Syndrome

33. Case History: Question  What is the main reservoir for Hantavirus in the United States? 1. Deer mice 2. Deer 3. Mosquitoes 4. Horned nose black fly

34. 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

35. Hantavirus Pulmonary Syndrome: Reservoir Source: CDC and Prevention Peromyscus maniculatus Deer Mouse

36. * Hantavirus Pulmonary Syndrome Through November 11, 2009 *By State of ExposureSource: CDC and Prevention

37. Hantavirus Pulmonary Syndrome: Chest Radiograph CDC Early Stage Later Stage Severe Interstitial

38. Hantavirus Pulmonary Syndrome Progression of Disease Picture ProdromeCardiopulmonary Death Recovery

39. Hantavirus Pulmonary Syndrome Therapy  Careful volume replacement (PAP=12-15 mm)  Vasopressors -Dopamine -Dobutamine  Extracorporeal membrane oxygenation (ECMO)  Intravenous Ribavirin? - NIH Trial (1-888-866-7257)

40.  52-year-old previously healthy woman presents to urgent care following a macaque monkey bite? The patient works as a researcher at a primate laboratory at the UW.  What is the name of the organism you are concerned about that she may have acquired from this macaque bite?  What therapy would you recommend? 1. Amoxicillin-clavulanic acid + Zidovudine 2. Amoxicilin-clavulanic acid + Valacyclovir 3. Moxifloxacin + Interferon-alpha 4. Moxifloxacin + Entecavir + Ribavirin Case History: Question

41. Case History

42. B Virus (Cercopithecine herpesvirus 1)  Endemic among macaque monkeys  Shedding from oral, conjunctival, or genital mucosa  Incubation: 2-35 days (most 5-21 days after exposure)  Clinical infection: vesicular rash, peripheral NS, CNS  Mortality rate if untreated: 80% From: Cohen JI. Clin Infect Dis 2002;35:1191-203.

43. B Virus (Ceropithecine herpesvirus 1)  Prophylaxis (1) Valacyclovir: 1g PO q8h x 14 days (2) Acyclovir: 800 mg PO 5x/day x 14 days  Treatment (NO CNS Symptoms) (1) Acyclovir: 12.5-15.0 mg/kg IV q8h (2) Ganciclovir: 5 mg/kg IV q12h  Treatment (CNS Symptoms Present) (1) Ganciclovir: 5 mg/kg IV q12h From: Cohen JI. Clin Infect Dis 2002;35:1191-203.

44. Dog & Cat Exposure

45. Case History  A 28-year-old healthy woman is scratched on her neck by cat and 1 week later develops a scab at the site. Three weeks later she develops preauricular and postauricular adenopathy.  The most likely organism and appropriate treatment are:

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

47.  A 26-year-old woman is bitten on her leg by her dog while trying to break up a dog fight. 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 dog bite is about 15% 2. Pasturella is rarely involved in dog bites 3. Cat bites become infected more often than dog bites 4. Anaerobic organisms are more common in dog bite than cat bite infections Case History: Skin & Soft Tissue

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

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

50. 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

51. Questions/Wrap-Up