spirochete and tick borne disease Flashcards
a flexible spirally twisted bacteria
- trepan pallidum syphilis
- borrelia relapsing fever and Lyme disease
spirochete
- complex disease cause by the bacterial spirochete treponema pallidum
- almost always transmitted by sex
- can affect any organ or tissue in the body (varied presentation)
syphilis
primary
secondary
early (infectious) syphilis
- symptoms free period that lasts up to a year after initial infection
-infectious lesions can recur
early latent syphilis
- after the first year of latent syphilis
- noninfectious except transplacental
late latent
tertiary or neurosyphilis
late syphilis
how to prevent syphilis
- avoid infectious contact
- use condoms
- MSM screened every 3-6 months or more
- screening in pregnant patients:
–> first prenatal visit, third trimester, and at delivery if high risk*
- includes primary lesions of chancre
- lymphadenopathy
- can occur 10-90 days after inoculation
- painless superficial ulcer
- enlargement of regional lymph nodes (painless)
syphilis: early infectious primary
hallmark of syphilis: early infectious primary
painless chancre
how to diagnose syphilis: early infectious primary
- nontreponemal tests (detects Ab to lipoidal antigens) –> VDRL and RPR
–> but this is not specific so you have to do: - treponemal tests (to confirm) –> TPPA and FTA-ABS
how to diagnose syphilis: early infectious primary
(reverse algorithm)
- treponemal test
- EIA enzyme immunoassay
syphilis: early infectious primary treatment
IM penicillin G 2.4 million units in one dose
<1 year usually highly infectious
can convert to secondary syphilis if not adequately treated
early latent syphilis
early latent syphilis treatment
IM penicillin G 2.4 million units in one dose
- usually a few weeks or up to 6 months after chancre
- systemic signs: fever, lymphadenopathy
- infectious lesions distant from the site of inoculation
- most common manifestations are skin and mucosal lesions
–> non pruritic, macular, papular, pustular, or follicular- NOT vesicular*
early infectious syphilis
–> secondary syphilis
hallmark of secondary syphilis
- rash on palms and soles
- dark skin annular lesions that look like ringworm
- mucous patches of mucous membranes
- condylomata lata
how to diagnose syphilis: early infectious secondary
serologic tests are almost always positive at this stage
early infectious secondary syphilis treatment
IM penicillin G 50,000/kg
what is common with syphilis: early infectious secondary treatment
The Jarisch–Herxheimer reaction is the abrupt onset of fever, chills, myalgia, headache, tachycardia, hyperventilation, flushing, and mild hypotension 1–2 hours after treatment of a spirochetal infection with penicillin or other antimicrobial agents.
- > 1 year after 1st year noninfectious to sex partner
- still transmissible to fetus
- can only diagnose this without evidence of tertiary disease or neurosyphilis
- can last a lifetime
late latent syphilis
late latent syphilis treatment
IM penicilli G: 3 doses of 2.4 million units each at 1 week intervals
- may occur any time after secondary
- 1 to > 20 years after initial infection
1. Gummas (infiltrative tumors of skin, bones, liver)
2. neurosyphilis (HA, meningitis, dementia, hearing/vision loss, incontinence, psychosis) (argyle-robertson pupil small irregular pupil that constricts to accommodation, but not light)
3. CV syphilis: aortitis, aneurysms, aortic regurg
syphilis: late tertiary stage
hallmarks of syphilis: late tertiary stage
- gummas
- argyll robertson pupil (no pupil response to light but pupil will constrict when object moves towards nose)
syphilis: late tertiary stage treatment
IM penicillin G 2.4 million units/week IM for 3 weeks
- can occur at any stage of syphilis infection
- can be disabling and life threatening
- CNS signs
neurosyphilis
how to diagnose neurosyphilis
- same serologic tests
- if CNS signs present –> CSF study
neurosyphilis treatment
High dose IV PCN
18-24 million units/day for 10-14 days
- variable findings at birth
- many have no signs for several weeks
- rash, condylomas, mucous membrane patches, nasal discharge
- intellectual disability and/or failure to thrive
congenital syphilis
conditions from untreated congenital syphilis
Hutchinson’s teeth
saddle nose
TORCH syndrome
- MSK, neurologic, and skin disease
- most common tick borne disease in US
- caused bye borrelia burgdorgeri
- tick must be attached for 24-36 hours for transmission
-I scapularies ticks in the midwest and northeast are infected with spirochete
Lyme disease
- early localized
- erythema migraines bullseye rash
- viral like illness
–> myalgias, arthralgias, fatigue, HA
stage 1 of Lyme disease
hallmark of stage 1 of Lyme disease
- erythema migrans bullseye rash
- early disseminated infection
- days/weeks later
- hematogenous spread*
- viral like illness common
- fatigue can last for months
- most common neuro finding: aseptic meningitis
- CN7 palsy (facial nerve palsy)
- cardiac issues: myopericarditis, arrhythmias, heart block
stage 2 Lyme disease
- months/years later
- MSK, neurologic, skin manifestations
- mono or oligoarticular joint pain/swelling-knee or other large joints
stage 3 Lyme disease
how to make a diagnosis for Lyme disease
- exposure in an endemic area + erythema migrans within 30 days
or - one late manifestation of disease + laboratory confirmation
labs for Lyme disease
two test diagnostic approach is recommended:
- ELISA antibody test
- confirmed with western blot
Lyme disease treatment
doxycycline for 10 days
Lyme disease treatment if pregnant
amoxicillin for 14 days
what to do for any known tick bite in pt presenting with symptoms regardless if mild or severe
tick panel should be ordered
when to admit pt for Lyme disease
CNS or cardiac manifestations
- illness that comes/goes in discrete episodes over several weeks
- caused by spirochete of genus borrelia
- ticks in mountainous west
- abrupt onset of fever, chills, tachycardia, N/V, arthralgia, severe HA
- hepatomegaly and splenomegaly
- high fever and delirium
relapsing fever
relapsing fever labs
- CBC: usually normal
- blood smear: large spirochetes are seen with wright gems stain
- hematuria is common
- anti borrelia antibodies develop
relapsing fever treatment
post exposure prophylaxis with doxycycline
relapsing fever treatment for tick borne disease without nervous system involvement =
- IV PCN G or IV ceftriaxone
- then tetracycline or erythromycin for 10 days
relapsing fever treatment for CNS involvement
IV PCN or ceftriaxone
-illness caused by bacteria rickettsia rickettsii
- ticks must be attached for 6-10 hours
- causes vascular permeability (petechiae)
- classic: sudden high fever
- small, blanching pink macule that spread into petechiae
- facial flushing, conjunctival injection, hard palatal lesions
Rocky Mountain spotted fever
classic triad for Rocky Mountain spotted fever
fever
HA
rash
with history of tick bite
hallmark of Rocky Mountain spotted fever
- rash starts at wrists/ankles and spreads centrally over the next 2-3 days
- involvement of palms/soles
how to diagnose Rocky Mountain spotted fever
- hyponatremia, elevated liver enzymes, elevated bilirubin, and thrombocytopenia
- acute phase: skin biopsy with immunohistologic or PCR demonstration or R rickettsii
- second week: Ab serologic studies can confirm
Rocky Mountain spotted fever treatment
doxycycline 100 mg BID x 5-7 days
Rocky Mountain spotted fever treatment if pregnant
chloramphenicol
–> but not as effective
usual cause of death of Rocky Mountain spotted fever
pneumonitis with respiratory or cardiac failure
- tick borne illness that infects monocytes or granulocytes
- found most in Missouri, Arkansas, Oklahoma
- reservoir: white tail deer, mice*
- caused by lone star tick*
ehrlichiosis
clinical syndromes of monocyte infection of ehrlichiosis
prodrome: malaise, rigors, nausea
then high fever and HA
pleomorphic rash (different stages –> ulcer, blister, papule)
complications of ehrlichiosis
- acute respiratory failure and ARDS
- neurologic complications
- acute kidney disease
- hemophagocytic syndrome
- multi organ failure
how to diagnose ehrlichiosis
- history of tick exposure and characteristic illness
- Labs: leukopenia, lymphopenia, thrombocytopenia
- peripheral smear with stain: intraleukocytic vacuoles
- confirmation: PCR
ehrlichiosis treatment
doxycycline
–> with high clinical suspicion do not delay treatment for confirmation
ehrlichiosis treatment if pregnant
rifampin
- delayed form of anaphylaxis caused by red meat consumption
- IgE mediated allergic reaction against oligosaccharide galactose-alpha-1,3-galactose
- carbohydrate allergy
alpha gal syndrome
alpha gal syndrome other offenders
- vaccines (measles, mumps, rubella, zoster)
- cetuximab
- porcine heart valve prostheses
- antivenoms
- gelatin and dairy products
how to confirm alpha gal
- serologic testing for alpha gal specific IgE
- skin prick tests
- intradermal tests
alpha gal treatment
- treat anaphylaxis
- avoid mammalian meats and medications/devices that contain alpha-gal
