November 2, 2020

Emerging Tick-Borne Illnesses: Not Just Lyme Disease Part 1

Tick Borne Illness

Tick-borne disease surveillance studies have shown increasing prevalence, transmission, and disease burden over the last decade. Tick-borne illnesses remain a public health threat and the true incidence remains unknown and is thought to be underrepresented. Although Lyme Disease is the most frequently reported tick-borne disease in the United States, the incidence of four other tick-borne diseases is noted to be increasing in the United States:

  1. Anaplasmosis (Nov 3rd, 2020)
  2. Ehrlichiosis (Nov 4th, 2020)
  3. Rocky Mountain Spotted Fever (Nov 5th, 2020)
  4. Babesiosis (Nov 6th, 2020)

In this five-part post, we will review the salient features of these other emerging tick-borne illnesses to increase recognition of these disease entities.

This overview will serve to lay a foundation and summarize shared features of tick-borne illnesses prior to diving into each specific disease.

History and Physical:

A thorough history should inquire about the following in order to help make a presumptive diagnosis:

  • Recent Tick Exposure
  • Recreational or Occupational History/Exposure
  • Travel History
  • Occurrences of Similar Symptoms in Family Members, Coworkers, and Animals (dogs)
  • Absence of a recognized tick bite does not rule out the consideration of tick-borne illness in the right clinical context

Poor Prognostic Factors:

  • Increased Age
  • Immunocompromised States
  • Delays in Diagnosis and Treatment

Signs/Symptoms and Laboratory Work-Up:

Tick-borne diseases have several shared signs, symptoms, and laboratory findings.

  • A simplified way to approach tick-borne illnesses is to look for the presence of unexplained fever along with non-specific flu-like symptoms
  • These clinical symptoms along with thrombocytopenia and transaminitis should clue the clinician into further exploring tick-bore illnesses as an etiology of the patient’s symptoms

 

Management of Tick-Borne Illnesses

Anaplasmosis-Ehrlichiosis-Rocky Mountain Spotted Fever:

Doxycycline is the drug of choice in both pediatric and adult patients (Biggs 2016)

  • 100 mg orally or intravenously twice daily for 10 days
  • 2 mg/kg (not to exceed 100 mg/dose) twice daily for 10 days in children
  • Response to therapy is rapid and failure to improve within 48 hours of treatment suggests possibility of alternative diagnosis.
  • The American Academy of Pediatrics and the CDC recommend doxycycline in the pediatric population as the risks of dental staining stem from older tetracycline-class drugs that bound more readily to calcium than newer agents such as doxycycline (Biggs 2016).
  • Studies have shown a tooth discoloration rate of 0% in children less than 8 years of age treated with doxycycline (Biggs 2016, Todd 2015, Volovitz 2007).

Rifampin: Possible alternative agent for Anaplasmosis or Ehrlichiosis in those with severe doxycycline allergy or mild infection in the pregnant patient.

  • 300 mg orally twice daily for adults for 10 days
  • 10 mg/kg (not to exceed 300mg/dose) twice daily for 10 days in children

Chloramphenicol: Possible alternative agent for Rocky Mountain Spotted Fever

  • 50-75 mg/kg intravenously every 6 hours for 7-19 days

Babesiosis:

Doxycycline does not cover Babesia species

Mild to Moderate Disease: Atorvaquone plus Azithromycin

  • Atorvaquone: 750 mg orally twice daily for 7-10 days
  • Azithromycin: 500 mg orally on day 1 followed by 250 mg orally once daily for 7-10 days

Severe Disease: Clindamycin plus Quinine

  • Clindamycin: 300-600 mg intravenously every 6 hours for 7-10 days
  • Quinine: 650 mg orally every 6 hours for 7-10 days

Exchange Transfusion

  • Indications: Parasitemia > 10%, Severe Anemia, Pulmonary, Liver, or Renal Impairment

Take Home Approach:

Guest Post By:

Akash Ray, DO
PGY-2 Emergency Medicine Resident Inspira Medical Center
Vineland, NJ
Twitter: @_kashray

References:

  1. Biggs H et al. Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis – United States. MMWR Recomm Rep. 2016. PMID: 27172113
  2. Todd S et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr. 2015. PMID: 25794784
  3. Volovitz B et al. Absence of tooth staining with doxycycline treatment in young children. Clin Pediatr (Phila). 2007. PMID: 17325084

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Muhammad Durrani, "Emerging Tick-Borne Illnesses: Not Just Lyme Disease Part 1", REBEL EM blog, November 2, 2020. Available at: https://rebelem.com/emerging-tick-borne-illnesses-not-just-lyme-disease-part-1/.
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Muhammad Durrani

Assistant Clerkship Director & Assistant Research Director at Inspira Medical Center
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