Thread by @WuidQ

𝗜𝗗 𝗖𝗼𝗿𝗲 𝗧𝗼𝗽𝗶𝗰𝘀 𝟭 #idcoretopics
1/20

TICKBORNE INFECTIONS (TBI)

It’s summer (= tick bites 🐞) and we have new faculty, fellows, residents, interns, & students coming from different places.
@grepmeded

This tweetorial is an overview of TBI mainly in the US.

2/20

▪️Climate change is expanding the seasonal/geographic distribution of TBI.
▪️Lack of tick bite in H/P should not dissuade you from considering TBI. In fact, only ¼ with Lyme remember a tick bite.
▪️No perfect test.
▪️Early Abx is important.

#idcoretopics

3/20

Geography matters!

An effective way of learning about TBI is learning it according to its geography.

@MohitHarshMD @TxID_Edu @rabihmgeha @DxRxEdu @Anirban63395569 @k_vaishnani @VarunPhadke2 @NNolanMD @Jncherabie @LeMiguelChavez @LParraRod @CGhaznavi

#idcoretopics

4/20

💡Mainly in the Midwest, these are the main culprits 👇.
“REST in the Heart and Bourbon of the Midwest” 😊

▪️RMSF
▪️Ehrlichia
▪️STARI
▪️Tularemia
▪️Heartland virus
▪️Bourbon virus

#idcoretopics

5/20

1️⃣ Ehrlichia
▪️Fever + ⬇️ plt/low WBC + ⬆️ AST, ALT 👉 very common ▪️Prompt initiation of doxy when suspected (don’t wait for test result)
▪️Dx: blood PCR (only 87% Sn, a negative test does not rule out)

WuidQ tweetorial here: bit.ly/3egPcrz

#idcoretopics

6/20

2️⃣ RMSF
▪️Most lethal TBI
▪️Petechial/purpuric rash (may involve palms/soles) seen in 90% of cases⚡️ however, only 50% will have it at presentation
▪️Severe sepsis and meningitis (much like meningococcemia)
▪️No classic lab findings unlike Ehrlichia

7/20

RMSF is a clinical diagnosis, labs are notoriously unreliable in acute infection.PROMPT initiation of doxy when suspected (do not wait to see a rash).

Pic: RMSF purpuric rash (CDC) 👇

8/20

3️⃣ STARI (Southern tick-associated rash illness)
▪️Causes erythema migrans-like rash, much like Lyme 👇

#idcoretopics

9/20

4️⃣ Tularemia
▪️6 clinical categories👇
▪️Not just from ticks; also from animal contact (rabbits), airborne transmission (dust particles, lawn mowing)
▪️Dx: serology, culture (alert lab of specimen)
▪️Tx: doxy or cipro (mild), streptomycin or gentamicin (mod-serious)

10/20

5️⃣ & 6️⃣ Heartland and Bourbon virus👇
▪️Newly emerged TBI
▪️Consider in patients that present like Ehrlichia but does not respond to doxy

WuidQ tweetorial: bit.ly/3fn5kcd

#idcoretopics

11/20

💡Mainly in the Northeast, upper Midwest
“LABBP” 👇

▪️Lyme
▪️Anaplasma
▪️Babesiosis
▪️Borrelia miyamotoi
▪️Powassan virus

⚡️All are transmmitted by Ixodes scapularis

#idcoretopics

12/20

7️⃣ Lyme
▪️Clinical phases and treatment outlined 👇
▪️Most common TBI in this region

Related topic (European Lyme):
WuidQ tweetorial: bit.ly/2Wa95KA

#idcoretopics

13/20

8️⃣ Anaplasma
▪️Indistinguishable clinically from Ehrlichia

⚡️For your boards, know about inclusion bodies found in Ehrlichia and Anaplasma 👇

#idcoretopics

14/20

9️⃣ Babesiosis
▪️Hemolytic anemia is a hallmark feature

WuidQ tweetorial here: bit.ly/3gMjSCw

#idcoretopics

15/20

Babesiosis for the boards:

⚡️Ring forms on blood smear w/ no travel history 👉 Babesia
⚡️Patient w/ EM but looks really sick 👉 Lyme & Babesia co-infxn
⚡️Patient w/ Anaplasma not responding to doxy 👉 Anaplasma & Babesia co-infection

#idcoretopics

16/20

🔟 Borrelia miyamotoi
▪️Can manifest similarly as Anaplasma; relapsing fever in 10% of patients
▪️Dx: serology,Tx: doxy

11. Powassan virus
▪️Tickborne encephalitis
▪️Mimics other causes of arthropod-borne encephalitis (e.g. WNV, EEE)
▪️Dx: serology,Tx: supportive

17/20

OTHER IMORTANT Tickborne illness:

12. Tick paralysis
▪️Ascending paralysis, afebrile, no sensory involvement, intact mental status

WuidQ tweetorial on how to differential this from other “paralytic” infections: bit.ly/2ZkvIOv

18/20

13. Colorado tick fever
▪️Mainly in the West coast 👇
▪️In about 1/2 of patients, a biphasic illness

More on biphasic illness, WuidQ tweetorial (⚡️leptospirosis)
bit.ly/3gNXQiT

19/20

In summary, TBI:

Best way to learn TBI is learning according to geography

Maintain high index of suspicion; no perfect test; prompt initiation of doxy important (esp for RMSF, Erhlichia, Anaplasma)

Not responding to doxy – Heartland, Bourbon, Babesia, Powassan

20/20

Are there any other tickborne infections/illnesses you want to highlight (esp. in your area, not limited to the US)?

@UAB_ID @IUIDfellowship @BIDMC_IDFellows @mgh_id @MayoClinicINFD @UNMC_ID @TempleID1

20/20 extra: Forgot to include Tick borne relapsing fever here. Check out tweetorial here:

https://twitter.com/wuidq/status/1117890592141275137?s=21

https://twitter.com/wuidq/status/1117890592141275137