LYME DISEASE T HE DI SE ASE I N YOUR BACK YARD Kevin I. - PowerPoint PPT Presentation

LYME DISEASE T HE DI SE ASE I N YOUR BACK YARD Kevin I. Young, MD Free copy of full slide presentation available on request at kevin@plymouthfamilypractice.com

LYME DISEASE INSTRUCTIONS TO PATIENTS Rules: 1.Don’t get it in the first place. 2.If you do get it, treat it early! 3.Know the “red flags” for the disease. 4.If you don’t treat it early, study both national guidelines about diagnosis and treatment. (They don’t agree.) 5.Never trust the lab test (completely). 6.If there is any possibility of Lyme disease, never take a steroid (or immunosuppressant).

LYME DISEASE TAKE HOME INFORMATION 1. Avo ida nc e a nd pro phyla xis 2. E rythe ma mig ra ns 3. Se c o nda ry dise a se L yme a rthritis Be lls pa lsy 4. Po st L yme syndro me / Chro nic Ne uro lo g ic L yme dise a se 5. L yme se ro lo g y E L I SA We ste rn b lo t 6. T re a tme nt pro to c o ls

HIGH RISK BEHAVIOR: BRUSHING AGAINST LEAVES • De finitio n o f e nde mic e xpo sure to L yme dise a se is a ny b e ha vio r tha t re sults in b rushing a g a inst le a fy ve g e ta tio n in a re g io n o f mo de ra te o r hig h tic k infe c tio n ra te .

PROBLEM WITH TICK BITE PROPHYLAXIS T ic k bite Only 14- 32% of pa tie nts with L yme dise a se re c a ll a tic k bite . Othe r me tho ds o f tra nsmissio n: • Ve rtic a l tra nsmissio n fro m mo the r to fe tus • L a c ta tio n • Blo o d tra nsfusio n • Se xua l tra nsmissio n 1. Nadelman RB; Wormser GP. Erythema migrans and early Lyme disease. American Journal of Medicine, 98(4A):15S-23S. 2. Gardner, T. 2001. Lyme disease, pp. 519-641. In J. S. Remington and J.O. Klein (eds.), Infectious Diseases of the Fetus and New Born Infant. W. B. Saunders Co., Philadelphia, PA. 4. Stricker, R.B., D.H. Moore, and E.E. Winger. 2004. Clinical and immunologic evidence of transmission of Lyme disease through intimate human contact. J. Invest. Med. 52, S151.

NEW HAMPSHIRE TICKS American dog tick (Dermacentor viriabilis), carries Ricketsia and tularemia. Deer tick (Ixodes scapularis), the species of black legged tick native to NH, carry Lyme, Borrelia, Bartonella (cat scratch fever), Babesia (North American “malaria”), Ehrlichia, Mycoplasma fermentans, Mycoplasma pneumoniae Lone star tick (Amblyomma americanum), is known to transmit ehrlichiosis, tularemia, and southern tick-associated rash illness.

DEER TICK BLACK LEGGED TICK IXODES SCAPULARIS Scutum = hard shield Black is bad—black scutum, black legs

TICK IDENTIFICATION SIZE VS. APPEARANCE L one Sta r tic k Dog tic k De e r tic k (All pictures are of adult ticks.)

TICK SIZE varies by stage DEER TICK BLACK LEGGED TICK

TICK SIZE IXODES SCAPULARIS (MALE AND FEMALE) Deer tick, adult— Female and male (July-November) Dog Tick Dear tick nymph— Dog tick, adult Female and male (March – June)

DEER TICK VECTOR • Nymphs tra nsmit 85% of c a se s . • Nymphs a re a c tive in la te spr oug h the summe r . ing thr • Adult de e r tic ks a re most c ommon tic k bite in the fa ll. • More then 50% of the ticks from Lee and Durham and more then 70% from the Concord sample infected with Lyme causing bacteria. Alan Eaton, UNH, 2008. • T ic k e xposure ra te s inc re a se with we t we a the r , dro p o ff sig nific a ntly with dry we a the r. • T ic ks hide in fissure s in b a rk during dry we a the r to a vo id dying o f de hydra tio n • T ic ks re ma in a c tive until the te mpe ra ture is <28 de g re e s.

TAKE HOME MESSAGES: DON’T FEED THE TICKS! • Ne w Ha mpshire ha s the 2 nd hig he st inc ide nc e o f L yme dise a se pe r c a pita in the US (2012). INCIDENCE OF LYME DISEASE (NEW HAMPSHIRE)

DEET • DE E T = N,N-die thyl-me ta -to lua mide • Mo st c o mmo n inse c t re pe lle nt sinc e 1946 • Adva nta g e : e ffe c tive • (E me rg ing re sista nc e —in mo sq uito , thro ug h g e ne tic muta tio n o f inse c t re c e pto r , I r40a re c e pto r in a nte nna e ) • Disa dva nta g e s • Sme ll • Ne e d to re a pply e ve ry 30 min (5% so ln) to 5 hrs (50% so ln) • Disso lve s synthe tic fa b ric s, type s o f pla stic , pa inte d surfa c e s • We a k a nti-c ho line ste ra se inhib ito r • E xtre me ly ra re inc ide nc e o f se izure s in c hildre n up to a g e 6

PERMETHRIN • Spra ye d o n c lo thing . No n-to xic whe n dry. • 1 a pplic a tio n la sts up to 6 wa shing s whe n se lf a pplie d, 75 wa shing s whe n c o mme rc ia lly a pplie d • Odo rle ss a fte r a pplic a tio n. • 3 o z is pro pe r a mo unt fo r shirt-pa nts-so c ks. • Pe rspira tio n a nd e xpo sure to wa te r do e s no t de c re a se e ffic a c y. • Ava ila b le a t Wa lma rt (se a so na lly), E MS, Ca b e lla s, e tc .

TAKE HOME MESSAGES: AVOIDANCE • Hig h risk b e ha vio r = any be havio r that le ads to brushing against le afy ve ge tatio n in e nde mic are a • Ne w Ha mpshire ha s the 2 nd hig he st inc ide nc e o f L yme dise a se pe r c a pita in the US (2012). • 50-70% o f de e r tic ks te ste d in Co nc o rd a re infe c te d. • Do g tic ks do no t tra nsmit infe c tio n to huma ns. • De e r tic k (b la c k le g g e d tic k)s, b la c k shie ld o n uppe r b a c k, sma ll size • Nymph = Ma rc h-July = “po ppy se e d size ”=hig he st risk o f tra nsmitting infe c tio n • Adult = mo st c o mmo n tic k o n huma ns in Oc to b e r , b ig g e r, e a sie r to se e a nd re mo ve • Pre ve nt with DE T (o n skin) o r pe rme thrin (o n c lo the s). E

TICK BITE PROPHYLAXIS • I ndic a tio ns fo r pro phyla xis: • De e r tic k b ite in e nde mic a re a • Atta c hme nt g re a te r tha n 36 ho urs (? ) • Sta rting a ntib io tic with 72 ho urs o f finding tic k. • No o ne with a do g tic k b ite ne e ds a ntib io tic pro phyla xis fo r L yme dise a se . Meta-analysis of 4 placebo-controlled clinical trials, 1082 subjects Placebo risk of Lyme disease 2.2%, compared with 0.2% in antibiotic treated group (p=0.0037) 3 of the 4 studies involved 10 day course of antibiotics (PCN, amox, amox+TCN), 4 th study used doxycycline 200 mg dose, study ended at 6 wks, outcome measure EM 1 case of Lyme prevented for every 50 people treated (depending on case definition). Efficacy of antibiotic prophylaxis for the prevention of Lyme disease: an updated systematic review and meta-analysis. Warshafsky S; Francois LK, Nowakowski J, Nadelman RB, Wormser GP, The Journal Of Antimicrobial Chemotherapy [J Antimicrob Chemother] 2010 Jun; Vol. 65 (6), pp. 1137-44. Date of Electronic Publication: 2010 Apr 09

TRANSMISSION RATE • 14-32% o f pe o ple with L yme dise a se re me mb e r a tic k b ite . • T ra nsmissio n usually o c c urs a t the e nd o f the 48 ho ur me a l. Atta c hme nt T ra nsmission 24 hr 5% 48 hr 38% 72 hr 92% Ma tusc hka F R,Spie lma n A. Risk if infe c tio n fro m a nd tre a tme nt o f tic k b ite s. L a nc e t 1993;342;8870:529-30. Na de lma n RB,Wo rmse r GP.Re c o g nitio n a nd tre a tme nt o f e rythe ma Ann I nte rn Me d. 2002 Ma r 19;136(6):477- 9.mig ra ns: a re we o ff ta rg e t?

Borre lia burg dorfe ri • Spiroc he te , de sig ne d to tra ve l • E a sily pa sse s throug h me mbra ne s • L ive s in both intra c e llula r a nd e xtra c e llula r e nvironme nts • F la g e lla is built into the spiroc he te sha pe • Proka ryotic • Ha s up to 23 pla smids • Some pla smids re quire d for virule nc e • Ha s hype r- va ria ble DNA re g ions tha t c ode s for isome r s of immunog e nic surfa c e prote ins • Ca n e limina te surfa c e prote ins (L - form or c yst form) • L ive s in biofilms • Use s ma ng a ne se ra the r tha n iron

L-FORM • L - form la c ks immunog e nic surfa c e prote ins • Adva nta g e : • Minima l a ntig e nic stimula tion • Re sista nt to ma ny c e ll wa ll a ntibiotic s. • Disa dva nta g e : • L ose s its motility • Stric tly intra c e llula r

CYST FORM • If the ba c te ria is stre sse d by c ytokine s, hig h oxyg e n le ve ls, a ntibiotic s, e tc ., it will pa c ka g e its DNA in a sma ll “c yst”. • Cysts show minima l me ta bolic a c tivity. • T he c yst form ha s ve ry fe w immunog e nic surfa c e prote ins. • Afte r a pe riod of up to 3 we e ks, e a c h c yst c a n tra nsform itse lf ba c k into a c omple te spiroc he te .

BLEB • Purpose of ble b: unknown • Spe c ulatio n : sourc e of “a uto- immunity” ? Ble b form 1.T he L yme ba c te ria ma ke s thousa nds or short strips of DNA, pa c ka g e s the m, a nd e xtrude s the m a s a “ble b” throug h e xoc ytosis. 2.T his DNA e nte rs huma n c e lls, a nd is c opie d into the huma n DNA throug h re ve rse DNA tra nsc ripta se . Spe c ula tion: • T he huma n c e ll the n ma ke s prote ins from this ba c te ria l DNA. • T he n the prote in is e xpre sse d on the surfa c e of the c e ll, the immune syste m will a tta c k the huma n c e ll. • T he immune syste m c a nnot te ll “frie nd from foe ” be c a use both c onta in fore ig n ba c te ria l surfa c e prote ins.