Tick-borne infections: clinical features Lenka Krbková Children´s Clinic for Infectious Diseases Medical Faculty, Masaryk University Brno Tick as a vector: viruses •Flaviviridae: •TBEV (CEEV, NEEV,FEV) •Tick-borne encephalitis virus •Reoviridae: (Coltivirus: Eyach virus) •Colorado tick fever virus •Bunyaviridae: (Nairovirus) •Crimean- Congo hemorrhagic fever virus • • > Tick-borne encephalitis •Tick-borne infection •Biphasic course •Severity according to the age •Neurologic disease accompanied by pareses → permanent involvement •Prevention: vaccination > Etiology •Flavivirus •TBEV: •3 antigenic variants: •Central-European subtype I (CEEV) •Near-east subtype II (NEEV) •Far-east subtype III (FEEV) • > The routes of transmission •1) Tick-borne (Ixodes ricinus) –Seasonal incidence (spring-summer) – •2) Drinking of non-pasteurized milk containing the virus (family epidemies) • •3) Breast-feeding (newborns of mothers with viremia – rare!) • • > Clinical course of TBE •IP: 3 to 14 days •I. phase: fever, myalgia, arthralgia • ↓ •Asymptomatic interval (4-10 days) • ↓ •II. phase: headache, fever, vomiting, meningeal signs, ataxia, disturbances of consiousness, focal neurologic signs • – – – > Clinical forms of TBE •Inaparent •Abortive •Meningitis •Encephalitis •Encephalomyelitis •Bulbar > Lyme borreliosis •Lyme disease, tick-borne borreliosis •Endemic in North America, Europe, Asia •The most frequent tick-borne infection in Europe and USA •Involvement of the skin, nervous and musculoskeletal system • > Epidemiology •Reservoirs: vertebrates (small mammals, rodents, birds) •All stages of ticks play role in the transmission (larvae, nymphae, adults) •Transstadial and transovarial transmission in ticks •Seasonal zoonosis (spring to autumn) • > Patogenic borreliae in Europe •Borrelia burgdorferi sensu lato: •B. afzelii •B. garinii (euroasian and asian typ) •B. burgdorferi sensu stricto •B. valaisiana •B. lusitaniae •B. spielmanni (isolat A14S) • > Clinical course in LB •80-95 % abortive •5-20 % symptomatic •Cutaneous manifestation: 70-75 % (mostly EM) •Nervous manifestations: 15-20 % •Joint manifestations: 5 % •Cardiac manifestations: 1 % •Chronic course: 1-2 % > Clinical stages of LB > Erythema migrans •IP = one to several weeks •In Europe: B.afzelii (88,7 %), B.garinii, B.burgdorferi s.s. •Expanding red or bluish-red patch with central clearing, advancing edge intensely coloured, not markedly elevated, around the tick bite •Laboratory evidence: none •Clinical findings are sufficient for the diagnosis of EM > EM10 > EM_7 > Erythema migrans multiple •Multiple lesions of EM, not only at the site of the tick bite •Secondary lesions are similar to primary EM •Non-specific symptoms: fatigue, fever, headache, arthralgia, myalgia •Laboratory evidence: antiborrelial antibodies positive • > EMM9 > Borrelial lymphocytoma •IP: several weeks to months •Causative agent: B. afzelii •Painless bluish-red nodule, usually on ear lobe, ear helix, nipple or scrotum •More frequent in children •Laboratory evidence: 1) essential: significat change in levels of specific antibodies • 2) supporting: histology, culture from skin biopsy • > ucho > Snímek 008 > BL_3 > Acrodermatitis chronica atrophicans •IP = several months to years •Long-lasting red or bluish-red lesions, usually on the extensor surfaces of extremities. Initial doughy swelling. Lesions become atrophic. Possible skin induration over bony prominences. •Laboratory evidence: high level of specific serum IgG antibodies > Lyme arthritis •Recurrent brief attacks of objective swelling in one or a few of large joints, occasionally progressing to chronic arthritis •Autoimunne Lyme arthritis (LFA-1, HLA-DRB1*0401 a 0101), resistant to ATB therapy •Laboratory evidence: 1) essential: high level of specific serum ( or/and synovial) IgG antibodies • 2) supporting: culture from synovial fluid and/or tissue > BorrArth1 > Snímek 024 > Neuroborreliosis •IP = one to twelve weeks •Causative agent: B.garinii •Neurologic involvement: primary meningitis •Minimal clinical signs can lead to dramatic inflammatory changes in subarachnoideal space !!! > Clinical syndromes in NB •Aseptic meningitis •Garin-Bujadoux-Bannwarth syndrome (=meningopolyradiculoneuritis) in adults •Disseminated encefalomyelitis (rare) •Cranial neuritis (facial palsy): isolated or with meningitis (90 % of all cases with NB) •Radiculoneuropathies • > Ehrlichiosis Anaplasmosis •Seasonal tick-borne zoonosis with the tropism of etiologic agent to white blood cells • •Ehrlichia spp. – intracellular bacteriae (Rickettsiae, Coxiellae, Chlamydiae) •1986 – first infection by Ehrlichia in Fort Chaffee, Arkansas •1991 – isolation and classification of the agent = E.chaffeensis > HME (human monocytic ehrlichiosis) •Emerging human pathogen •Transmission: tick Amblyoma americanum, only in the USA •Etiologic agent: Ehrlichia chaffeensis • (Rickettsiaceae) •Infection of ticks: in the USA 32,5 % •Reservoirs: deer • > HGA (human granulocytic anaplasmosis) •Formerly known as HGE •Transmission: I. scapularis - USA – I. ricinus - Europe •Etiological agent: Anaplasma phagocytophilum • (Rickettsiaceae), intracellular pathogen •Infection of ticks: USA 50 %, Europe: Switzerland - 26 %, CZ – 16 % • • > Clinical symptoms (similar in HME and HGA) •IP = 7 to 14 days (3 – 10 days) •Fever £ 38,5 st. C (100 %) •Myalgia (100 %) •Headache (100 %) •Chills (100 %) •Hepatomegaly •Rash (petechial, maculopapular) •Erythema • > Laboratory findings •Leukopenia - neutropenia, lymphopenia •Trombocytopenia •Anemia •Liver enzymes elevation •High sedimentation rate and CRP • > Complications •Respiratory abnormalities (ARDS) •Renal failure (anuria) •Gastrointestinal bleeding •Hepatocellular necrosis •Aseptic meningitis • • •fatal course in 2 % of cases (ehrlichiae in lungs, liver, spleen) > Differential diagnosis after a tick bite •Lyme borreliosis •Tick-borne encephalitis •Tularemia •Q Fever •Bartonellosis (cat scratch fever) •TIBOLA (tick-borne lymphadenopathy) •HGA (granulocytic anaplasmosis) •Boutonneuse fever •Babesiosis •Rocky Mountain spotted fever (USA) •Colorado tick fever (USA) >