Too Ticked Off To Be Bored - Review

Holy Tick the Inservice is TOMORROW! No time for chatting. Here is a quick review on something that always trips me up: Tick-Borne Infections.

Here’s the story: Something-year-old somebody was camping at somewhere sometime ago. They come to you with the following symptoms. What is the diagnosis and treatment?

Lymphadenopathy and ulcers

Tuleremia. ulceroglandular form (most common). There are actually a few different kinds/presentations: may present with pneumonia, lymphadenopthy and malaise without ulcers, fever/chills/headache/abdominal pain.

Tx: First line is streptomcin or gentamycin. Second line is doxycycline.

Ataxia, foot drop, loss of deep tendon reflexes on exam

Tick Paralysis. Ascending paralysis (like Guillan-Barre!). Tx: remove tick + supportive care.

Localized rash, followed by fever and neuropathy. Did someone say bilateral bell's palsy?

Lyme disease. Starts with bull’s eye rash with central clearing around the tick bite – erythema migrans. Second stage has a wide array of possible complications, including fever, lymphadenopathy, cardiac problems, neuropathies (one of the few causes of bilateral bell’s palsy, but can have unilateral as well). Third stage is vague…. chronic arthritis, encephalopathy, myocarditis, and other diffuse problems.

Tx: doxycycline

Fever, headache, nausea, vomiting, diarrhea, arthralgia. May progress to renal failure, respiratory failure, or encephalitis

Ehrlichosis. Lab tests may show leukopenia, thrombocytopenia, and transaminitis. Symptoms start abruptly after tick bite.

Tx: you guessed it… Doxy!

Fever, flu-like symptoms, followed by diffuse rash. Rash started on distal extremities and then spread inward.

Rocky Mountain Spotted Fever. Rash starts maculopapular on ankles/wrists and moves inward, after a few days the rash becomes petechial. May have GI symptoms. Labs tests may show leukopenia, thrombocytopenia, liver abnormalities, and hyponatremia, but labs are nonspecific and inconclusive. 5-10% of cases are FATAL, causing ARDS/respiratory failure and myocarditis.

Tx: Doxycycline for the win! Even with kids, doxy is preferred choice.

Fever that waxes and wanes, dark urine, myalgia... maybe renal failure

Babesiosis. Malaria-like illness with fevers, hemolytic anemia and flu-like symptoms. Hemolysis can cause dark urine and renal failure. 20% have concurrent Lyme disease!

Dx: thin and thick peripheral blood smears

Tx: atovaquone PLUS azithromycin – or – quinine PLUS clindamycin

Hiking around Denver, then fevers/chills, headache, myalgia, photophobia.

Colorado Tick Fever. This one actually is in Colorado or places of high elevation. May have biphasic fever (lasts a few days, goes away a few days, then returns) with flu-like symptoms +/- rash. Caused by a virus, tx is supportive.

Words of advice:

Lyme, Rocky Mountain Spotted Fever, and Ehrlichosis are the most common and the most tested.
Give doxycycline – it’s gonna be the answer in most of these cases

Good luck on the Inservice tomorrow! “Tick ass!”

References

Tintinalli’s 7th ed. Meredith JT. Ch 155.

Rosh Review

Hippo EM