Tickborne Diseases

Transmission
Ticks release anesthetics, antihistamines, “cement”, and anticoagulants
Bacteria inhabit the midgut and remain dormant until feeding
During feeding, bacteria replicate and leave the midgut traveling to salivary glands
~48 hour process for bacteria to move from gut to dermis
Ehrlichiosis
Epidemiology: southeastern/southcentral US
Tick: Lonestar tick (A. americanum)
Microorganism E. chaffeensis, E. ewingii, E. muris
Incubation period 5-14 days
Clinical manifestation: Human Monocytotropic Ehrlichiosis
Fever, chills, headache, myalgia, N/V/D, anorexia, confusion
<50% have a rash; more common in children
Severe illness: cough, diarrhea, confusion, lymphadenopathy
Lab features: thrombocytopenia, leukopenia, elevated LFTs
Target hematopoietic and lymphoreticular systems
Complications 9-17%
ARDS, DIC-like syndrome, GI hemorrhage, AKI, meningoencephalitis, hemophagocytic
lymphohistiocytosis
Diagnosis
PCR assay -most sensitive in the first week and decreases following antibiotic administration
Blood smear -morulae in cytoplasm of WBCs
IgG antibody titers detectable 7-10d after onset: demonstrate four-fold change in paired serum samples
Treatment:
Adults: doxycycline 100mg PO/IV BID 5-10 days (at least 3 days after defervescence)
Children (<45.4kg): doxycycline 2.2mg/kg PO/IV BID
Life-threatening doxycycline allergy/pregnancy: rifampin 300mg PO BID 7-10 days2

Rocky Mountain Spotted Fever (RSMF)

Epidemiology: throughout most of the contiguous US
Tick: American dog tick, Rocky Mountain wood tick, brown dog tick
Microorganism: Rickettsia rickettsii
Incubation period: 3-12 days
Clinical manifestation
-Early (1-4 days)
High fever, flu-like symptoms, edema around eyes and back of hands, N/V
Rash appears 2-5 days after onset of symptoms; ~10% of patients never develop a rash
Maculopapular: small, flat, non-itchy on extremities with centripetal spreading to trunk
-Late (>5 days)
AMS, coma, cerebral edema, pulmonary edema, ARDS, necrosis
Late petechial rash: red to purple spots, sign of progression to severe disease
Laboratory findings in late stage:
Thrombocytopenia, elevated LFTs, hyponatremia
Diagnosis:
IgG antibody titers detectable 7-10d after onset: demonstrate four-fold change in paired serum samples
Detection of DNA in skin biopsy of rash lesion by PCR assay or whole blood specimen
Treatment:
Adults: doxycycline 100mg PO/IV BID 5-10 days (at least 3 days after defervescence)
Children (<45.4kg): doxycycline 2.2mg/kg PO/IV BID
 Pregnancy: chloramphenicol is a potential alternative treatment for RMSF during pregnancy; caution in
third trimester: gray baby syndrome2
Doxycycline anaphylaxis: rapid doxycycline desensitization accomplished within several hours in an
inpatient intensive care setting in patients has been described2

Lyme Disease
Epidemiology: Northeast, Midwest, West
Tick: Ixodid tick (deer tick)
Microorganism: Borrelia burgdorferi
Incubation period: 3-30 days
Clinical manifestation
-Early infection: Stage 1 (localized)
80% of patients have erythema migrans (EM)- target-like lesion
Regional lymphadenopathy, flu-like symptoms
-Early infection: Stage 2 (disseminated)
Days to weeks from onset of EM patients can develop secondary skin lesions (smaller, migrate less)
Regional lymphadenopathy, flu-like symptoms
Rheumatologic manifestations: transient, migratory musculoskeletal pain
Signs are intermittent and changing
15% neurologic manifestations: Bell’s palsy, meningitis, encephalitis
Meningeal irritation: episodic attack with excruciating HA and neck pain, mild encephalopathy
5% cardiac manifestations: AV node block, myocarditis, pericarditis, cardiomegaly
-Late infection: Stage 3 (persistent)
Months after infection
60% of patients experience intermittent attacks of joint swelling and pain (large joints) which can occur
for years
Diagnosis
Early lyme infection can be diagnosed with an EM rash; serologic tests are not sensitive at this stage
Culture from skin lesions and isolation of organism
LUAT (lyme urine antigen test) -unreliable
IgG serologic test: two test approach by ELSIA then western blot
If first step is negative, no further testing
Laboratory findings: elevated ESR, elevated LFTs, CSF with lymphocytic pleocytosis, slightly elevated
protein and normal glucose
Treatment
Early infection:
-Adults
Doxycycline 100mg PO BID x10-21 days
Amoxicillin 500mg PO TID x14-21 days
Cefuroxime axetil 500mg PO BID x14-21 days
-Children
Doxycycline 4mg/kg PO divided into 2 doses x10-21 days
Amoxicillin 50mg/kg PO divided into 3 doses x14-21 days
Cefuoxime axetil 30mg/kg PO divided into 2 doses x14-21 days
Neurologic Lyme disease:
-Adults
Ceftriaxone 2g IV daily x10-28 days
Alternative: PCN G 18-24 million U IV divided into 6 doses x10-28days
Beta-lactam allergy: doxycycline 100mg PO BID x10-28days
-Children
Ceftriaxone 50-75mg/kg IV daily
Alternative: PCN G 200,000-400,000 units/kg divided into 6 doses
 Beta-lactam allergy: doxycycline 4-8mg/kg divided into 2 doses
Lyme Carditis:
Parenteral antibiotics, such as ceftriaxone, should be used for initial hospitalization then oral
antibiotics can be used for completion of therapy
Late lyme arthritis:
Oral antibiotics for 28 days
Antibiotic-refractory lyme arthritis: NSAIDs, intra-articular corticosteroid injections, DMARDs3
Late lyme neuroborreliosis:
Parenteral antibiotics for 2-4 weeks

Alpha-Gal Allergy4,5
Epidemiology: southeastern and midwestern United States
Tick: lone-star tick
Alpha-gal is an emerging IgE-mediated allergy to the alpha-gal sugar molecule. Anaphylactic reactions
typically occur 3-6 hours after people eat meat from mammals that have alpha-gal or are exposed to products
made from mammals (medications, cosmetics, vaccines, gelatin)

References:
1. Centers for Disease Control and Prevention. Tickborne diseases of the united states: a reference manual for
healthcare providers. Fifth Edition, 2018
2. Biggs HM, Behravesh CB, Bradley KK, 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;65(No. RR-2):1–44
3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment, and Prevention
of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the
Infectious Diseases Society of America. Clin Infect Dis. 2006 Nov 1;43(9):1089-134. Epub 2006 Oct 2.
4. Centers for Disease Control and Prevention. Alpha-gal allergy. Epub 2019 Mar 28.
5. American Academy of Allergy Asthma and Immunology. Alpha-Gal. Epub 2019 April 25.