Parasitic, spirochete, tick Flashcards
What characterizes an early, primary syphilis infection?
primary lesions of painless chancres and lymphadenopathy
“punched out” lesion
What characterizes an early, secondary syphilis infection?
- few weeks - 6 months after chancre:
- systemic symptoms - fever, lymphadenopathy, lesions distant from site of inoculation (skin and mucosal lesions - NOT vesicular) and common on palms and soles and maybe on face
- condylomata lata, dark annular lesions, mucous patches of mucous membranes
What characterizes an early, latent syphilis infection?
symptom-free period that lasts up to a year after initial infection, lesions may reoccur
** can convert to 2ndary syphilis if not treated**
highly infectious
What characterizes a late, latent syphilis infection?
after 1st year – non-infectious except transplacental
can only diagnosis this w/o evidence of tertiary disease/neurosyphilis
What characterizes late, tertiary, neurosyphilis?
1) gummas infiltrate tumor (localized and rapid onset)
2) neuro: HA, meningitis, dementia, vision/hearing loss, incontinence, psychosis, Argyll-Robertson pupils
3) Heart: aortis, aneurysms, aortic regurg
In who should you be aware of syphilis risk?
MSM
What is the cause and transmission of syphilis?
sex!
Treponema pallidum - spirochete!
How can you prevent syphilis?
avoid infectious contact, condoms, MSM screening every 3-6 months, check in pregnancy at 1st visit and in 3rd trimester AND at birth if high risk
What makes risk of congenital spread of syphilis?
rash, condylomas, mucous membrane patches, nasal discharge
What happens if syphillis remains untreated congenitally?
Hutchinson teeth, saddle nose, TORCH syndrome
How can you diagnose syphilis?
Screening –> diagnosis
* INITIAL: nontreponemal tests (VDRL and RPR 4-6 weeks post infection or 1-3 weeks after lesion, correlated w/ other labs)
* CONFIRM: treponemal tests to confirm diagnosis; TBBA or FTA-ABS absorption test to measure antibodies
* EIA-enzyme immunoassay or CIA chemiluminescene = positive
* CNS signs = CSF study
How do you treat syphilis?
IM penicillin G
abstain from sex for 7-10 days after treatment
test for HIV!!
report to health department
What reaction is common in syphilis treatment?
Jarisch-Herxheimer reaction w/ spirochetes being treated with abx
pink maculopapular rash
What is syphilis associated with prenatally?
IGR, hepatosplenomegaly, hydrops fetalis, fetal demise, late abortion
What is syphillis associated with neonatally?
prematurity, low birth weight, jaundice, necrotizing funisitis
What is syphilis associated with in early onset babies <2 years old?
2-8 weeks old: persistent clear, purulent, or bloody rhinitis, maculopapular rash
+ hepatosplenomegaly, lymphadenopathy, skeletal abnormalities, joint pain, pseudoparalysis
What is syphilis associated with in late onset kids >2 years old?
similar to early onset but also could have visual changes, tabes dorsalis, nystagmus, headache, hearing loss, Hutchinson’s teeth, Clutton’s joints, saddle nose deformity
risk of intellectual disability and failure to thrive :(
What indicates early and localized lyme disease?
erythema migrans, bulls eye rash w/ viral like illness (myalgias, arthralgias, fatigue, HA, may/may not have fever)
How many stages does lyme disease have?
3
What characterizes early disseminated lyme disease?
days/weeks later, hematogenous spread, viral-like illness, fatigue
may have myopericarditis, arrhythmias, heart block
What’s the most common neuro issue in lyme disease?
aseptic meningitis
What’s the most common peripheral nerve issue in lyme disease?
CN7 palsy
What characterizes late persistent lyme disease?
MSK, neurologic, skin
may have joint pain/swelling, rarely w/ AMS, mood changes, sleep disturbance
What characterizes post-lyme disease?
fatigue, myalgia, cognitive difficulty
retreatment is NOT effective! consider co-infection or misdiagnosis
Where is lyme disease common?
Midwest and Northeast
What causes lyme disease?
Borrelia burgdorferi
How long does a Borrelia tick have to be attached in order to transmit lyme disease?
24-36 hours
What should you always order with a tick bite w/ symptoms?
Tick panel should be ordered
How do you diagnose lyme disease based on Hx and PE?
exposure in endemic area WITH:
1) physician documented erythema migrans w/n 30 days
2) OR 1 late manifestation of disease
3) AND lab confirmation
What labs do you do to diagnose lyme disease?
-elevated ESR and liver enzymes
2 test diagnostic approach: ELISA antibody AND confirm w/ western blot
note: may have negative antibody in first few weeks
false positives are common, patients w/ non specific symptoms w/o objective signs should NOT have this done
When is lyme prophylaxis recommended?
1) tick identified and attached 36+ hours
2) prophylaxis can be started w/n 72 hours of time tick was removed
3) more than 20% of ticks are known to be infected w/ B
4) no contraindications
DOXYCYCLINE!
How can you treat lyme disease?
doxycycline
OR amoxicillin and cefuroxime
How can you treat lyme-based cardiac disease?
outpatient: doxycycline, amoxicillin, cefuroxime
inpatient: IV ceftriaxone
How can you treat lyme-based neurologic lyme disease?
CNS: IV cephalosporin or PO doxycycline
Peripheral: ceftriaxone, cefotaxime, PEN G (IV), PO doxy
Isolated 7th nerve palsy: PO doxy or cefuroxime
What indicates relapsing fever?
abrupt onset of fever, chills, tachycardia, N/V, arhtralgia, severe HA, hepatomegaly, splenomegaly
various rashes
high fever and delirum
3-10 day termination –> relapse 1-2 weeks later, with risk of 3-10 relapses before recovery
Where is relapsing fever common?
mountainous west
What causes relapsing fever?
tick borne or louse-borne
mostly rodent-based
What signifies relapsing fever in labs?
CBC - mild anemia and thrombocytopenia
Blood smear - large spirochetes w/ Wright-Giemsa stain, dark field microscopy
Consider PCR
hematuria
anti-borrelia antibodies
CSF abnormalities w/ meningitis involvement
How do you treat relapsing fever?
post exposure prophylaxis = doxycycline
tick borne withOUT nervous system involvement:
- IV PCN G or IV ceftriaxone
- followed by tetracycline or erythromycin for 10 days
WITH CNS involvement:
- IV PCN or ceftriaxone for 10-14 days
also Jarish-Herxheimer reaction in about 50% of patients
What indicates RMSF?
2-14 days after tick bite: abrupt onset of fever, HA, rash, chills, malaise, restlessness, insomnia, irritability, anorexia, N/V, facial flushing, conjunctival injection, hard palatal lesions, cough pneumonitis
KEY: triad of fever, HA, rash w/ history, involvement of palms/soles
Where is RMSF common?
NC, TN, OK, AR, MO
What causes RMSF?
ricketta rickettsi
How long does a Ricketta tick have to remain attached to transmit illness?
6-10 hours
How can you diagnose RMSF?
hyponatremia, elevated liver eynzymes, elevated bilirubin, thrombocytopenia
skin biopsy or PCR, cutaneous swab
OR
ELISA , complement function, latex agglutination
check CSF for CNS involvement
2nd week - utilize Ab serologic studies
How do you treat RMSF?
doxycycline or chloramphenicol
are prophylatic abx recommended for RMSF?
NO
What’s the incubation period of ehrlichiosis?
1-2 weeks
What are the key symptoms of ehrlichiosis?
malaise, rigors, nausea –> high fever & HA
may have pleomorphic rash that affects up to 30% of patients
Where is ehrlichiosis common?
Missouri, Arkansas, Oklahoma from lone star ticks like from white tail deer
What has rare, serious complications like acute respiratory failure, ARDs, neuro symptoms, acute kidney disease, hemophagocytic syndrome, and multi-organ failure?
erlichiosis
How do you diagnose ehrlichiosis?
Hx & characteristics
Labs: leukopenia, lymphopenia, thrombocytopenia, transaminitis
Peripheral smear w/ stain: intraleukocytic vacuoles
Confirm w/ PCR, indirect fluorescnet antibody assay
How do you treat ehrlichiosis?
doxycycline, or rifampin for pregnant women
What does lack of improvement in treatment for ehrlichiosis mean?
not ehrlichiosis…different diagnosis. Note: may have weakness or malaise for several weeks despite treatment
What is the first test you will do to test for syphilis?
nontreponemal: VDRL And RPR
What’s the confirmatory test you will do for syphilis?
treponemal: TBBA or FTA-ABS
