Tick Talk

In 24 hours, I have discussed at some level an issue most of us in the urban prehospital, and critical care transport environment rarely encounter. So, I thought it prudent to do some research, discuss the topic, and make an article out of it. Tick-borne disease is something we rarely discuss, and to my knowledge, I have never had a patient with a tick-borne illness. However, considering the warm, humid weather and the ideal conditions for ticks, it is prime time to have this conversation(Suss, Klaus, Gerstengarbe, & Werner, 2008; Rahlenbeck, 2016). In this blog, I would like to breakdown the most prevalent tick-borne disease and the most fatal in the United States (U.S.), the symptoms associated, acute and long-term effects, and interventions related to tick-borne diseases

Prevalence of Tick-Borne Diseases

About a year ago, the New England Journal of Medicine (NEJM) published an article about the growing threat that are tick-borne diseases (Paules, Marston, Bloom, & Fauci, 2018). The authors noted that tick-borne conditions have increased from approximately 22,000 in 2004 to 48,000 in 2016 (Rosenberg et al., 2018). According to Paules et al., (2018) the most common tick-borne disease is Lyme disease, which accounts for nearly 82 percent of all cases reported to the Centers for Disease Control and Prevention (CDC). However, as many of you know, Lyme disease is not the only tick-borne illness. Rocky Mountain Spotted fever (RMSF) is another common disease associated with ticks, and it will be the second disease we talk about in this article. First, a brief list of most of the U.S. tick-borne diseases.

In no particular order is a table of the tick-borne diseases that are commonly found within the U.S. and the vector (tick) that is associated with the transmission of the disease:

Disease Vector (Tick)
Lyme disease Deer tick
Rocky Mountain Spotted Fever Wood tick, American Dog tick, and the Brown Dog Tick
Tularemia (Rabbit Fever) Wood tick, American Dog tick, Lone Star Tick

 

Anaplasmosis Lone Star tick and Black-Legged Tick
Ehrlichiosis Lone Star Tick
Babesiosis B. microti and B. duncani
Colorado tick fever Rocky Mountain Wood Tick

 

Tick-borne Relapsing fever Infected soft ticks
Powassan Black-Legged tick (Centers for Disease Control and Prevention, 2019)

 

The above table is daunting, and before my research, unexpected, that said, and according to the CDC (2019), this list is not all-inclusive. However, for the sake of brevity, I would prefer focusing on the most prevalent disease rather than getting into the weeds and covering every tick-borne illness known in the U.S. However, I do think it is worth mentioning that some conditions listed are bacteria, some are viral and parasitic this information could prove beneficial for your anticipated clinical treatment expectations.

Please take into consideration that the diseases we will be discussing are all secondary, a tick bite typically causes a primary lesion first and an immediate reaction (Haddad, Haddad, Santos, & Cardoso, 2018). Which in essence means that the tick bite is what the patient will most likely notice first, and the symptoms associated with those should be managed appropriately, for instance, proper tick removal. The secondary phase (Lyme, etc.) should be achieved after you have ensured the patient is stable or requires further care to manage the secondary phase.

Lyme Disease

Without assuming too much, I am going to guess that most of you have heard of Lyme disease. If not, here are some fast facts the CDC put out in its Morbidity and Mortality Weekly Report (MMWR) in 2017 on the societal impact Lyme disease has, the CDC typically updates annually, so current numbers are difficult to come by. However, total cases reached nearly 275,000 over seven years from 2008-2015. Most incidents occurred in areas of the Northeast, mid-Atlantic, and upper Midwest regions of the United States (Schwartz, Hinckley, Mead, Hook, & Kugeler, 2017).

Symptoms (short-term)

  • Fever
  • Myalgia
  • Headache
  • Facial palsy
  • Heart blocks
  • Lymphadenopathy
  • Erythema migrans (E.M.) (a bulls-eye rash that expands or migrates out)
  • Meningitis(Murray & Shapiro, 2010)

Symptoms (long-term)

  • Mono or oligoarticular arthritis (which means arthritis that can affect one or more joints, respectively)
  • Encephalopathy
  • Peripheral neuropathy(Schwartz et al., 2017; Murray & Shapiro, 2010)

Ticks that transmit Lyme disease rarely transmit the infection before the 48-72-hour mark (Murray & Shapiro, 2010). If your patient states that he or she noticed the tick immediately and removed it, is asymptomatic, it is unlikely that he or she has contracted Lyme disease. However, if it were me, I would suggest being cautious and transport the patient regardless.

Interventions and management.

Treatment of Lyme disease is dependent on whether the process is acute or chronic (Lacout, El Hajjam, Marcy, & Perronne, 2018). Keeping this in mind is essential; a patient with an acute onset should be managed differently than someone experiencing chronic symptoms associated with Lyme disease. For this blog, we will discuss treatments in the acute setting. Below is a list of recommended treatment modalities, some of which we may be able to administer, others are suggested to be treated by physicians:

  • Priority should always be airway, breathing, and circulation (ABCs)
  • Removing a tick is an integral part of the process; the use of nail polish or burning is not suggested.
    • Ticks should be removed using fine-tipped tweezers, grip the tick as close to the skin as possible. The objective is to remove the entire tick, head, and mouth. Pull directly up, do not twist or pull too quickly. Finally, clean the site and your hands with soap and water or whatever cleaning agent you have available.
    • Look for ticks in hair, inside of and around ears, underarms, belly button, the waist, between the legs and groin, and the back of knees.
  • Prophylactic treatment for asymptomatic patients are antibiotics, doxycycline, and amoxicillin (ensure these are not contraindicated)
  • Early onset treatment for Lyme Disease is doxycycline or cefuroxime
  • Utilizing medications such as hydroxychloroquine and tetracyclines may positively affect doxycycline since is a bacteriostatic medication and does not necessarily kill the bacteria
    • The potential for adverse effects exist with doxycycline, such as Jarisch-Herxheimer (JHR) reaction which can cause significant hemodynamic instability, similar to what a patient with sepsis might present as(but not as frequent and less mild than other disease processes), so be vigilant and trend your patient’s vitals
    • JHR, fortunately, is “short-lived” when compared with sepsis, that said treat per your protocol and manage these patients symptom appropriately.
  • Although antibiotics are most successful, some cases may require antimicrobial treatment
  • Serologic testing in most patients is not always recommended. However, it might be beneficial to rule out the disease. Serologic testing can include; IgM or IgG, this will be based on age; typically, patients less than one month will not receive Igm.(Gasmi et al., 2017; Lacout, Marcy, El Hajjam, Thariat, & Perronne, 2017; CDC 2019; National Institutes of Health, 2018; Butler, 2017; Bratton & Corey, 2005)

In summary, Lyme disease is the most prevalent tick-borne disease in the United States (Paddock, Lane, & Stapels, 2018).  It presents in various stages, typically the primary stage and secondary stage, primary includes the tick bite itself and the results from the saliva, the secondary stage is Lyme disease(Haddad et al., 2018). Manage your patients ABC’s first and then if possible, remove the tick as suggested by the CDC. These patients may be experiencing a variety of symptoms so ensure you document well and if they recall when the tick attached itself that too will be beneficial to the receiving facility. Additionally, if they are already being treating be on the lookout for signs of side effects and treat accordingly, for instance, if having a reaction to antibiotics that is hypotensive in nature treat per protocol.

Rocky Mountain Spotted Fever (RMSF)

This is another commonly referred to form of tick-borne disease, it is also bacterial, and the symptoms are closely related to that of Lyme disease. This is a fatal form of tick-borne disease in the United States. However, it is less common than Lyme disease (Gottlieb, Long, & Koyfman, 2018; Columbia Irving Medical Center (CIMC), 2019; Drexler et al., 2017). According to Gottlieb et al., (2018) RMSF is transmitted through the American Dog tick, the Rocky Mountain Dog tick, and the Brown Dog tick by the pathogen Rickettsia rickettsii (Simonsen, 2019).

According to Simonsen (2019), transmission occurs rapidly, and symptoms can begin. RMSF can be deadly. However, if treated early, it can be managed and resolve with proper treatment. The key is always ensuring you assess, ask questions, and manage appropriately. Just a precautionary note; sometimes differentiating between different tick-borne diseases is difficult due to lack of symptoms. Below is a list of symptoms associated with RMSF:

Symptoms

  • Fever
  • Myalgia
  • Headache
  • Flu-like symptoms
  • Central nervous system
    • Confusion
    • Lethargy
    • Ataxia
  • Photophobia
  • Cardiovascular issues
  • Rashes may progress to petechia
  • Thrombocytopenia
  • Nausea
  • Abdominal pain
  • Vomiting
  • Diarrhea
  • Hepatitis
  • Nuchal rigidity
  • Ascites
  • RMSF does not result in long term infections. However, there is a potential for amputations, hearing loss, paralysis, mental disability, and death if not managed appropriately and effectively
  • African American males are at an increased risk due to the chance of G6PD deficiency. So ask questions, this a perfect question to ask during an assessment or to listen for.
  • Arthralgia (Drexler, et al., 2017; Simonsen, 2019; Gottlieb et al., 2018; CDC, 2019 ; CIMC, 2019)

The onset of symptoms for RMSF can occur within 5-10 days, and some individuals who become infected will not know they are infected. It is important that you recognize symptoms early, manage your ABC’s, remove the tick, and treat appropriately (CIMC, 2019; Simonsen, 2019). I should point out that RMSF affects the young and old disproportionately. The demographic with the highest incident rates are children 5-9, and children under 15 are more likely to acquire the disease than any other population (CIMC, 2019). Keeping this in mind may help guide you in providing more focused care.

Interventions and management.

RMSF is a bacterial infection, so antibiotics are choice, but always manage appropriately and within your scope, listed below are evidence-based management techniques:

  • Priority should always be the management of ABC’s
  • Removing a tick is an integral part of the process; the use of nail polish or burning is not suggested.
    • Ticks should be removed using fine-tipped tweezers, grip the tick as close to the skin as possible. The objective is to remove the entire tick, head, and mouth. Pull directly up, do not twist or pull too quickly. Finally, clean the site and your hands with soap and water or whatever cleaning agent you have available.
    • Look for ticks in hair, inside of and around ears, underarms, belly button, the waist, between the legs and groin, and the back of knees.
  • Tetracyclines are commonly utilized within the first five days of the illness
  • Doxycycline (other broadband antibiotics are not effective)
    • Remember antibiotics like doxycycline can cause JHR which can have sepsis-like response associated with their administration
  • Serologic testing might be beneficial. However, there is some evidence that discusses false positives when utilizing IgM for the diagnosis of RMSF, the use if IFA has shown to be more accurate (Gottlieb et al., 2018; Drexler et al., 2017; 2019; McQuiston et al., 2014; Bratton & Corey, 2005).

In summary, RMSF presents similar to Lyme disease. However, it appears to have a faster time of onset with the potential to cause death if not treated effectively. That said, it is critical that you understand that definitive treatment is needed and should transport these patients to a facility that is capable of managing their symptoms and underlying disease of RMSF. It is crucial that you always manage the patient’s ABC’s and work toward definitive treatment. Most providers do not have access to doxycycline or tetracycline, so supportive care is critical. That said, removing the tick if possible is a good idea and performing a thorough assessment to look for differential diagnoses.

Conclusion

This blog discusses two major tick-borne diseases that impact the U.S., Lyme disease and RMSF. Lyme disease is the most prevalent tick-borne disease, while RMSF is the most fatal (Paules et al.,; CIMC, 2019). These diseases present very similarly and without intervention, such as antibiotics can lead to neurological issues as well as death. Our goal as prehospital and critical care transport providers is to be astute clinicians who assess and document thoroughly, we treat what we can, and follow through by providing accurate reports to the receiving facility. Lyme disease is highly prevalent, and the numbers affected are growing annually. RMSF, not as prevalent, but more fatal, is a disease that is treated with necessary antibiotics.  Always think differential diagnosis and do not put yourself in a corner when you encounter a tick-borne illness.

 

ticks

 

Symptoms Compared

Lyme Disease Symptoms RMSF Symptoms
Fever Fever
Myalgia Myalgia
Headache Headache
Facial palsy Flu-like symptoms
Heart blocks Central nervous symptoms
Lymphadenopathy Photophobia
Erythema migrans Cardiovascular issues
Meningitis Rashes and petechiae
Mono/oligoarticular arthritis Thrombocytopenia
Encephalopathy Abdominal pain/ nausea/ vomiting
Neuropathy Hepatitis
Ascites

 

Interventions Compared

Lyme Disease Interventions RMSF Interventions
Airway, breathing, circulation Airway, breathing, circulation
Effective and appropriate tick removal Effective and appropriate tick removal
Assessment for additional ticks Assessment for additional ticks
Antibiotics Antibiotics (not broad spectrum)
Possible antimicrobials
Serologic testing Serologic testing
Treat and manage side effects Treat and manage side effects
 

 


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