Tick-Borne Diseases and Associated Diseases

1. Tick-Borne Diseases and Associated Diseases

2. Jack Dunham, DVM Kathy White, BA Ed.; MSW Representing the Lyme Association of Greater Kansas City, Inc. A non-profit, all-volunteer organization P.O. Box 25853, Overland Park, KS 66225 Phone: (913) 438-5963 (GET-LYME) Email: Lymefight @aol.com Website: www. lymefight.info

3. Our Mission • To provide services to people who have Lyme disease. • To cooperate with the medical community. • To promote public awareness and prevention education.

4. Presentation Purpose To increase awareness of... • tick-borne diseases in Kansas • associated diseases To present information about... • symptoms • tests and treatments being used by Lyme disease doctors who are members of ILADS (International Lyme and Associated Diseases Society) This presentation is for information only and should not be used as diagnostic or treatment advice.

5. Jack Dunham's Story • Tick bite in 2006 • InBonner Springs in Wyandotte County, KS • Developed Lyme rash and symptoms • Began treatment but didn't get well • Later was diagnosed with WA-1 babesia • Still have symptoms • Still on treatment

6. 2007 Kansas Research Study A researcher from Kansas State U. collected ticks and mice from four counties in NE Kansas in 2007. Results from a farm: • 10 Acres in Western Wyandotte County • Lyme and WA-1 Babesia were found in • All of the mice • Most of the ticks (all Lone Star ticks) It is not widely known that Lone Star ticks are carrying these diseases.

7. 2007 - Research on aJefferson County, KS Farm Lyme found in: • Some of the ticks collected. • All four family members who live there have been infected with Lyme disease and have been treated. This research has not been published. We do not have information concerning the testing done in the other two counties.

8. Kathy White's Story • Tick bite in April, 1998 • In Wyandotte County, KS • Bull's-eye rash and illness • Developed Lyme, babesia, and what was probably a spotted fever group rickettsial disease • Treatment began 4 ½ weeks after tick bite. • Three weeks of 200 mg. of doxycycline per day was not enough. The disease became much worse when treatment stopped.

9. Handouts Green folder containing: • Handbook • ILADS "Basic Information" • Brochure

10. References (Primary sources of information for this presentation): • Dr. Joseph Burrascano's "Diagnostic Hints and Treatment Guidelines" (www. ilads.org) • The CDC (www. cdc.gov) • ILADS "Basic Information" (www. ilads.org) ILADS (International Lyme and Associated Diseases Society) is an organization of doctors who are interested in treating tick-borne diseases. They offer a physician training program and have an annual scientific conference.

11. Ticks • Are arachnids, related to spiders, mites, and chiggers. • Have 8 legs, except the larvae have 6. • Feed on the blood of animals and humans. • Adult female drops off and lays several thousand eggs. • Larvae hatch in late spring or summer. • Nymphs emerge in spring. • Adults are active year-round, even in winter. • Some adults are active even when it's below freezing.

12. Tick-Borne Diseases General Information • Ticks carry many diseases, some fatal. • Ticks commonly transmit 3 or more diseases at once. • It can take years to diagnose them all. • There are no reliable tests for many tick-borne diseases. • There are no tests for some strains of some of these diseases. • About half of patients are unaware of having had a tick bite. • The tick can be too tiny to be noticed. • Diagnosis may need to be clinical, based on symptoms and history of tick exposure during the past month. • Symptoms resemble many other diseases. • If a patient is still ill after being treated for a tick-borne disease, consider co-infections.

13. Types of Ticks Argasidae (soft ticks) • Live in animal nests • Feed many times during their lives • Feed for a few minutes during the night and then drop off • Example: relapsing fever tick Ixodidae (hard ticks): • Feed 3 times during their lives • Once as larvae, once as nymphs, once as adults • Remain attached for several days and then drop off • Genera: Ixodes, Amblyomma, Dermacentor, Rhipicephalus

14. Western Black- Legged Tick Deer Tick Types of Ticks 1. Ixodes (black-legged ticks) ex.: Ixodes scapularis (deer tick) 2. Amblyommaex.: Amblyomma americanum (lone star tick) Amblyomma maculatum (Gulf Coast tick)

15. 4. Rhipicephalus – ex.: Rhipicephalus sanguineus (brown dog tick) Female Male Types of Ticks 3. Dermacentorex: Dermacentor variabilis (American dog tick) Dermacentor andersoni (wood tick)

16. Ticks Change Size And Color As They Feed Female, Deer Tick Female, Lone Star Tick Female, Lone Star Tick

17. Tick Anatomy Female American dog tick (ventral view)

18. Tick Drawings from CDCLeft to Right:Adult Female, Adult Male, Nymph, Larva Black-Legged Tick, Deer Tick (Ixodes Scapularis) American Dog Tick, Wood Tick (Dermacentor) Lone Star Tick (Amblyomma americanum)

19. Lone Star Tick

20. American Dog Tick

21. Gulf Coast Tick

22. Rocky Mountain Wood Tick

23. Brown Dog Tick

24. Black-Legged Ticks

25. Reported Cases in Dogs in Kansaswww. dogsandticks.com Lyme Disease Anaplasma Erlichia

27. Kansas Counties Endemic for Lyme • The CDC definition of a Lyme disease endemic county: Two or more confirmed cases contracted in the county and reported since 1986. • The following counties are endemic: • Johnson Sedgwick Wyandotte Jefferson • Butler Shawnee Leavenworth • Riley Atchison Douglas • Many other counties may be endemic. • The EM (erythema migrans) rash is reportable in endemic counties as a confirmed case if the patient is known to have been in a wooded, brushy, or grassy area in the county during the past 30 days. A positive test is not required to report these cases. • The EM rash must be at least 5 centimeters (about 3") in diameter to be reportable. It can just be a red spot. Central clearing or rings are not required for reporting purposes.

28. Herxheimer Reaction Dr. Adolph Jarisch and Dr. Karl Herxheimer first discovered this reaction in syphilis patients. A Jarisch-Herxheimer reaction is... • Common when Lyme patients begin antibiotics. • Often called a "Herx." • A temporary worsening of symptoms. • Caused by toxins released by dying bacteria. • Can last several days or longer.

29. Increased pain Heart problems Exacerbation of previous symptoms New symptoms Herxheimer ReactionSymptoms can include: • Severe headache • Profound fatigue • Insomnia • Depression • Suicidal thoughts

30. Herxheimer Reaction Severity and duration depend on how long a person has had untreated Lyme and the quantity of bacteria. Detoxifying the body helps to reduce the severity and duration of this reaction. If symptoms are severe or life-threatening, doctors often temporarily stop treatment and resume it later, often starting with a lower dose and gradually increasing it. Supplements and vitamins can boost the immune system and also cause a Herx.

31. Other Rickettsial diseases (Spotted fever group Rickettsia, SFGR) Mycoplasma Bartonella Tularemia Q Fever Tick Paralysis Tick-Borne Diseases in Kansas • Lyme Disease • STARI • Babesia • Ehrlichiosis • Anaplasma • Rocky Mountain Spotted Fever

32. BabesiaBabesia is caused by a protozoan, closely related to the protozoan that causes malaria. Symptoms At onset of Lyme (8 days or more after tick bite): High fever and chills in some patients Later: • Severe fatigue • Global headaches, like a hat is too tight • Body aches, muscle pain • Fevers of up to 104 degrees • Chills, sweats, especially night sweats • Eye pain • Breathing problems, "air hunger" • Occasional dry cough • Poor balance • Encephalopathy • Hemolytic anemia • Hypercoagulation

33. Babesia Facts • Babesia & malaria are both caused by protozoans that reproduce inside red blood cells and destroy them. • A very common co-infection with Lyme. Many members of our Lyme Association have babesia. • Nationally reportable as of January, 2011. • Reporting criteria can be found at www.cdc.gov. • Found in Cattle in Miami County forty years ago. • Not known to affect humans in this area of the country until recently.

34. Babesia Blood Smear A blood smear can show protozoans in red blood cells. However, a person may be ill with only a few red blood cells infected, and there may be none visible in the sample being viewed. A negative test does not rule out babesia.

35. Babesia and Lyme • A combination of babesia and Lyme makes both diseases much worse. • Both diseases suppress the immune system and make it more difficult to recover. • Babesia enables the Lyme bacteria to survive Lyme treatment. • Lyme disease spirochetes cycle and cause a Herx every 4 to 6 weeks. • Babesia cycles every 4 to 6 days.

36. Babesia Blood Transfusion Risk • Many people infected are healthy and don't know they carry babesia. • Babesia is unknowingly being transmitted through blood transfusions. • At least 9 people in the U.S. have died after receiving babesia-infected blood. • There are no tests to screen donated blood for babesia. • CDC recommends babesia patients not donate blood. • Wise for people who get a lot of tick bites to refrain from donating blood. • Lyme disease can also survive in stored blood, as can agents of some other tick-borne diseases.

37. Babesia Testing Quest Diagnostics, LabCorp, and Igenex (www. igenex.com, 1-800-832-3200) have tests for Babesia microti and Babesia duncani (WA-1). There are no specific tests for Babesia MO-1 (Missouri strain) or the other strains. There are at least 13 strains of babesia carried by ticks. Quest Diagnostics has an ECP (Eosinophil Cationic Protein) test. It can indicate a protozoan infection without identifying the species – useful for species for which we don't have tests.

38. Babesia Treatment(According to Dr. J. Burrascano's Guidelines, pp. 23-24) Mepron (atovaquone) or Malarone (atovaquone + proguanil) + Azithromycin (Zithromax) or Clarithromycin (Biaxin) or Telithromycin (Ketek) + Artemisia (a non-prescription herb) (It increases the effectiveness of the medications.)

39. Babesia Treatment(According to Dr. J. Burrascano's Guidelines, pp. 23-24) • Research is showing atovaquone does not get absorbed well unless taken with food containing fat. • Treatment for acute illness should be 3 weeks, and at least 4 months for chronic cases. Relapses occur. Re-treatment may be needed. • Dr. Burrascano no longer recommends the clindamycin and quinine protocol. Almost half of patients had to abandon treatment because of side effects, and there was a failure rate of almost 50%. Some doctors find it helpful. • Can cause a terrible Herx when beginning treatment, which can cause profound fatigue, headache, profuse sweating, and other symptoms that last a few days or longer.

40. Tick-Borne Bartonella • A very common co-infection with Lyme disease. • Ticks carry Bartonella henselae (cat scratch disease). • Ticks also carry other bartonella strains. • There are no tests for most strains of bartonella. • Consider bartonella if a person remains ill after Lyme disease treatment.

41. Symptoms of Bartonella • Swollen lymph nodes, can be the size of golf balls • Fever • Headache • Fatigue • Poor appetite • Abdominal pain • Endocarditis • Uveitis, retinitis, other eye problems • Red papular rashes • Parallel lines resembling stretch marks • Insomnia • Seizures, in some patients

42. Bartonella Symptom Pictures Swollen Lymp Node

43. Bartonella Symptom Pictures

44. Bartonella Treatment(Burrascano, pp. 24-25) For Bartonella henselae: • erythromycin or doxcycline For other strains: • levofloxacin for adults over age 18 • various other drugs For children: • azithromycin

45. Mycoplasma • Common co-infection with Lyme disease • Bacterial infection • Treated with certain antibiotics that are effective for cell-wall deficient bacteria • Several species found in ticks, most commonly mycoplasma fermentans. • Difficult to diagnose. • Mycoplasma fermentans can disrupt the immune system.

46. Mycoplasma Multitude of symptoms that can resemble other diseases. Found in patients with: Lyme disease Gulf War syndrome Chronic fatigue syndrome Fibromyalgia Rheumatoid arthritis MS ALS Chronic asthma Crohn's disease Autism Other inflammatory bowel diseases Very common co-infection with Lyme disease, but many doctors are not looking for it. MDL Laboratories has a PCR test for mycoplasma (1-877-269-0090, www. mdlab.com).

47. Some Diseases Caused by Rickettsia Bacteria(Source: www. cdc.gov) Ehrlichiosis (HME, human monocytic ehrlichiosis) Anaplasmosis (HGA, human granulocytic anaplasmosis, formerly called HGE) Rocky Mountain spotted fever (RMSF) Spotted fever group rickettsias (SFGR) (R. parkeri, R. amblyommii, etc.)

48. Confusion Abdominal pain Nausea Vomiting (sometimes) Diarrhea (sometimes) These diseases share similar symptoms • Fever • Chills • Severe headache • Muscle aches or pain • Malaise

49. Additional Symptoms Maculopapular and/or petechial rash (rare in anaplasmosis and ehrlichiosis) Black, crusty eschar at site of tick bite is typical of RSFG but rare in Rocky Mountain spotted fever Rash: Doesn't appear until a person has been ill with one of these diseases for several days. Many patients don't get a rash. The RMSF rash typically begins at the wrists and ankles and moves up the limbs. May also occur on the palms of the hands and soles of the feet. A petechial rash can occur later, and the toes may turn black. There is some evidence that spotted fever group rickettsias may usually cause a milder illness than RMSF.

50. Rocky Mountain Spotted Fever Picture