Tick-Borne Illnesses in Emergency and Wilderness Medicine.

This review highlights the causative organisms, clinical features, diagnosis, and treatment of the most common tick-borne illnesses in the United States, including Lyme disease, Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, tularemia, Powassan virus, and alpha-gal syndrome. Tick bite prevention strategies and some basic tick removal recommendations are also provided.

Prevalence of Anaplasma phagocytophilum in humans in Belgium for the period 2013-2016.

Ticks are vectors for a broad range of pathogens of medical and veterinary importance, such as Borrelia spp., Babesia spp., Anaplasma spp., Rickettsia spp., Bartonella spp. and the tick-borne encephalitis virus. The Gram-negative bacterium Anaplasma phagocytophilum is present worldwide, including Belgium where numerous patients were shown to harbour antibodies against this pathogen as recorded by the Belgian National Reference Center (NRC) for Anaplasma. The clinical presentation of human granulocytic anaplasmosis is an acute, febrile, nonspecific, flu-like illness. Leukopenia, thrombocytopenia and increased hepatic transaminase activities are commonly present early in the disease. Diagnosis early in the course of infection relies on the detection of antibodies or of the bacterium in the blood, as is performed at the NRC for Anaplasma, part of the Clinical Laboratory of the Queen Astrid Military Hospital in Brussels, Belgium. In this article, we discuss diagnostic test results as well as recent clinical and demographic characteristics of patients whose samples were analyzed by the NRC for Anaplasma in a four-year period (2013-2016).

Controle de anaplasmose bovina através de imunização com Anaplasma centrale / Bovine anaplasmosis control through immunization with Anaplasma centrale

A anaplasmose bovina é uma das principais causas de perdas produtivas e mortes no Rio Grande do Sul em rebanhos bovinos. O Anaplasma marginale é o principal agente causador da enfermidade e provoca hipertermia, anemia, prostração, abortos e perdas produtivas nos bovinos acometidos. Tendo em vista o controle deste hemoparasita em uma propriedade leiteira localizada no município de Eldorado do Sul no Rio Grande do Sul, na qual a incidência da doença era alta, 471 animais foram imunizados com Anaplasma centrale na busca de desenvolvimento cruzado para Anaplasma marginale. No experimento foi verificado que a incidência que normalmente era acima de 30% na propriedade passou para níveis inferiores a 5%. No entanto, foram verificados abortos decorrentes da imunização, principalmente nos animais que possuíam menos de 90 dias de prenhes. Já o número de mortes globais na fazenda caiu consideravelmente tendo em vista que a principal causa de morte era a anaplasmose bovina. Dos animais inoculados com A. centrale em torno de 15% apresentaram sintomatologia clínica da enfermidade e precisaram ser tratados com oxitetraciclina no período entre 15 e 30 dias após a imunização. O custo com tratamento empregado na propriedade posterior à imunização caiu em torno de 85% o que provocou impacto significativo economicamente na propriedade.(AU)

Bovine anaplasmosis is a major cause of production losses and deaths in Rio Grande do Sul cattle herds. Anaplasma sp. is the main causative agent of cattle disease. It causes hyperthermia, anemia, prostration, abortions and reduces milk production in affected animals. In order to control this hemoparasite on a dairy farm located in the municipality of Eldorado do Sul in Rio Grande do Sul, where the disease incidence was high, 471 animals were immunized with Anaplasma centrale in the search for cross-protectiv immunity for Anaplasma marginale. The property anaplasmosis incidence, which usually was above 30%, became 5% after the immunization. However, abortions were observed resulting from innoculaition, especially in animals that had less than 90 days of pregnancy. The global number of deaths on the farm dropped considerably given that the main cause of death was the bovine anaplasmosis. 15% of animals inoculated with A. centrale showed clinical symptoms of the disease between 15 and 30 days after immunization and had to be treated with oxytetracycline. The amount of money spent with anaplasmosis treatment decay 85% after the immunization, which caused significant economic impact on the property.(AU)

Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis - United States.

Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.

Eficácia do dipropionato de imidocarb, da enrofloxacina e do cloridrato de oxitetraciclina no tratamento de bovinos naturalmente infectados por Anaplasma marginale / Efficacy of imidocarb dipropionate, enrofloxacin and oxytetracycline chlorydrate on the treatment of cattle naturally infected by Anaplasma marginale

O agente de maior importância, em relação à anaplasmose bovina, é o Anaplasma marginale. Os principais sinais clínicos dessa enfermidade são anemia hemolítica, icterícia, dispneia, taquicardia, febre, fadiga, lacrimejamento, sialorreia, micção frequente, anorexia, perda de peso, aborto e morte. A terapia antimicrobiana é o principal protocolo terapêutico. O objetivo do presente trabalho foi avaliar a eficácia do dipropionato de imidocarb, da enrofloxacina e do cloridrato de oxitetraciclina no tratamento de bovinos leiteiros naturalmente infectados por Anaplasma marginale. Para isso, foram avaliados 48 zebuínos mestiços que apresentavam os sinais clínicos sugestivos da doença. Os animais foram submetidos à coleta de sangue para a realização de hemograma e à extração de DNA para a confirmação da presença de A. marginale, por meio da reação em cadeia pela polimerase (PCR). Os animais foram divididos em três grupos experimentais, para realização dos protocolos terapêuticos, utilizando-se dipropionato de imidocarb, oxitetraciclina e enrofloxacina. Trinta e seis animais (75%) apresentaram reação positiva ao PCR. Os animais positivos não apresentaram diferenças significativas quanto ao hemograma e ao leucograma quando comparados com os negativos, no entanto os níveis de proteínas séricas foram inferiores nos animais positivos (P<0,05). Os três protocolos terapêuticos foram capazes de reduzir a infecção ao longo do tratamento (P<0,01), porém, após cinco dias de tratamento, a enrofloxacina apresentou maior efetividade em relação aos demais (P<0,01). Após o final do tratamento, nenhum protocolo foi capaz de eliminar totalmente a infecção pelo A. marginale em bovinos naturalmente infectados e manejados a campo.

Anaplasma marginale is the most important agent regarding cattle anaplasmosis. The main clinical signs of this disease are hemolitic anemia, jaundice, dyspnea, tachycardia, fever, fatigue, lacrimation, salivation, frequent urination, anorexia, weight loss, abortion and death. Antimicrobial therapy is the main therapeutic protocol. The aim of this paper was to assess the efficacy of this therapy frequently used in field conditions. In order to do so, 48 crossbred zebu cattle presenting suggestive clinical signs of the disease were assessed. The animals were submitted to blood sample collection to perform a CBC and DNA extraction to confirm the presence of A. marginale by the polymerase chain reaction (PCR) test. The animals were divided into three experimental groups to perform the therapeutic protocols, using imidocarb dipropionate, enrofloxacin and oxytetracycline. Thirty-six animals (75%) presented positive reaction to PCR. The positive animals do not present significant differences in the CBC and WBC when compared to the negative ones. However, the serum protein levels were lower in positive animals (P<0.05). All the treatments were able to reduce the infection throughout the treatment (P<0.01). However, in time 1, enrofloxacin presented greater effectiveness in relation to the other ones (P<0.01). After the end of the treatment no protocol was able to totally eliminate the infection by A. marginale in cattle naturaly infected and handled on the field.

Recognition of and Prompt Treatment for Tick-Borne Infections in Children.

Tick-borne infections create diagnostic challenges because they tend to present with nonspecific findings. Because clinicians often fail to recognize tick-borne illnesses in early stages, therapy is frequently delayed or omitted. This is especially problematic for rickettsial infections (Rocky Mountain spotted fever, ehrlichiosis, and anaplasmosis), because the risk of long-term morbidity and mortality increases with delayed treatment. We emphasize the need for clinicians to maintain a high index of suspicion for tick-borne infections; to diagnose these illnesses presumptively, without waiting for confirmatory laboratory test results; and to promptly start therapy with doxycycline, even in young children, when rickettsial infections are suspected.

Thrombotic thrombocytopenic purpura and its look-alikes: a single institution experience.

At presentation, variant or "look-alike" conditions can resemble TTP. We reviewed charts of 26 consecutive patients treated for presumed TTP. Of 15 classic TTP patients, 11 were tested for ADAMTS13; all showed severe deficiency, and inhibitor levels correlated with probability of relapse. The variant TMA group consisted of 8 patients who had active clinical disorders which overlapped with TTP. Variant TMA patients had higher creatinine and worse prognosis than classic TTP patients. "Look-alike" disorders included ITP with intravascular hemolysis following administration of WinRho™, and human granulocytic anaplasmosis. These conditions had not been previously described as TTP look-alikes.

Human ehrlichiosis and anaplasmosis.

Human ehrlichiosis and anaplasmosis are acute febrile tick-borne diseases caused by various members of the genera Ehrlichia and Anaplasma (Anaplasmataceae). Human monocytotropic ehrlichiosis has become one of the most prevalent life-threatening tick-borne disease in the United States. Ehrlichiosis and anaplasmosis are becoming more frequently diagnosed as the cause of human infections, as animal reservoirs and tick vectors have increased in number and humans have inhabited areas where reservoir and tick populations are high. Ehrlichia chaffeensis, the etiologic agent of human monocytotropic ehrlichiosis (HME), is an emerging zoonosis that causes clinical manifestations ranging from a mild febrile illness to a fulminant disease characterized by multiorgan system failure. Anaplasma phagocytophilum causes human granulocytotropic anaplasmosis (HGA), previously known as human granulocytotropic ehrlichiosis. This article reviews recent advances in the understanding of ehrlichial diseases related to microbiology, epidemiology, diagnosis, pathogenesis, immunity, and treatment of the 2 prevalent tick-borne diseases found in the United States, HME and HGA.

[Ehrlichiosis/Anaplasmosis]. / Ehrlichióza/Anaplazmóza.

Ehrlichiosis and anaplasmosis are zoonoses caused by bacteria from the family Anaplasmataceae, including human and animal pathogens. The human pathogens are Ehrlichia chaffeensis, the causative agent of human monocytic ehrlichiosis (HME), Anaplasma phagocytophilum, the pathogen causing human granulocytic anaplasmosis (HGA), E. ewingii and Neorickettsia sennetsu, granulocytotropic and monocytotropic Ehrlichia species, respectively. Ehrlichia spp. are small, gram-negative, obligate intracellular bacteria. They replicate in the cytoplasmic vacuoles of host cells, especially granulocytes and monocytes, to form microcolonies called morulae. These agents are transmitted through the bite of infected tick. In the United States, the vectors are Amblyomma americanum, Ixodes scapularis and Ixodes pacificus ticks. The primary vector in Europe is Ixodes ricinus. Rodents, deer, roe deer, foxes, cattle, sheep, goats, horses and dogs are reservoirs of these bacteria in Europe. Peromyscus leucopus, the white-footed mouse, and Odocoileus virginianus, the white-tailed deer, are the most important reservoirs in the United States. Infection in humans is manifested as a nonspecific flu-like illness. The laboratory diagnosis is most frequently serological--evidence of antibody by indirect immunofluorescence assay (IFA) and detection of DNA by polymerase chain reaction (PCR), or microscopy evidence--Giemsa stain of blood smears (morulae in granulocytes or monocytes). Doxycycline is the drug of choice in therapy. Avoiding exposure to ticks is the best method of prevention of infection.

Clinical diagnosis and treatment of human granulocytotropic anaplasmosis.

Tick-borne rickettsiae in the genera Ehrlichia and Anaplasma are intracellular bacteria that infect wild and domestic mammals and, more recently, man. The increased desire of humans for recreational activities outdoors has increased the exposure to potential human pathogens that previously cycled almost exclusively within natural, nonhuman enzootic hosts. Anaplasma phagocytophilum causes an acute, nonspecific febrile illness of humans previously known as human granulocytotropic ehrlichiosis (HGE) and now called human granulocytotropic anaplasmosis (HGA). The first patient to have recognized HGA was hospitalized at St Mary's Hospital in Duluth, Minnesota, USA in 1990. However, the clinical and laboratory presentation of this infection remained undefined until 1994, when Bakken and collaborators published their experience with 12 patients who had HGA. By the end of December 2004, at least 2,871 cases of HGA had been reported from 13 U.S. states to the Centers for Disease Control and Prevention (CDC). A limited number of laboratory-confirmed cases have been reported from countries in Europe, including Austria, Italy, Latvia, the Netherlands, Norway, Poland, Slovenia, Spain, and Sweden. Ixodes persulcatus-complex ticks are the arthropod hosts for Borrelia burgdorferi, the agent of Lyme borreliosis, and are also the arthropod hosts for A. phagocytophilum. Most cases of HGA have been contracted in geographic regions that are endemic for Lyme borreliosis. Male patients outnumber female patients by a factor of 3 to 1 and as many as 75% of patients with HGA have had a tick bite prior to their illness. Seroepidemiologic studies have demonstrated that HGA for the most part is a mild or even asymptomatic illness. However, older individuals and patients who are immunocompromised by natural disease processes or medications may develop an acute, influenza-like illness characterized by high fever, rigors, generalized myalgias, and severe headache. Local skin reactions at the site of the tick bite have not been described, and nonspecific skin rashes have been reported only occasionally. Anaplasmosis is associated with variable but suggestive changes in routine laboratory test parameters. Most patients develop transient reductions in total leukocyte and platelet concentrations. Relative granulocytosis accompanied by a left shift and lymphopenia during the first week of illness has been reported frequently. Serum hepatic transaminase concentrations usually increase two- to fourfold, and inflammatory markers, such as C-reactive protein and the erythrocyte sedimentation rate, rise during the acute phase. Abnormal laboratory findings may return toward normal range for patients who have been ill for more than 7 days, which may obfuscate the clinical decision making. Characteristic clusters of bacteria (morulae) are observed in the cytoplasm of peripheral blood granulocytes in 20% to 80% of infected patients during the acute phase of illness. The clinical diagnosis may be confirmed retrospectively by specific laboratory tests, which include positive polymerase chain reaction (PCR), identification of A. phagocytophilum in culture of acute-phase blood, or the detection of specific antibodies to A. phagocytophilum in convalescent serum. Virtually all patients have developed serum antibodies to A. phagocytophilum after completion of antibiotic therapy, and demonstration of seroconversion by indirect immunofluorescent antibody testing of acute-phase and convalescent-phase serum samples is currently the most sensitive and specific tool for laboratory confirmation of HGA. Treatment with doxycycline usually results in rapid improvement and cure. Most patients with HGA have made an uneventful recovery even without specific antibiotic therapy. However, delayed diagnosis in older and immunocompromised patients may place those individuals at risk for an adverse outcome, including death. Thus, prompt institution of antibiotic therapy is advocated for any patient who is suspected to have HGA and for all patients who have confirmed HGA.

Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals.

Tickborne rickettsial diseases (TBRD) continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low cost, effective antimicrobial therapy. The greatest challenge to clinicians is the difficult diagnostic dilemma posed by these infections early in their clinical course, when antibiotic therapy is most effective. Early signs and symptoms of these illnesses are notoriously nonspecific or mimic benign viral illnesses, making diagnosis difficult. In October 2004, CDC's Viral and Rickettsial Zoonoses Branch, in consultation with 11 clinical and academic specialists of Rocky Mountain spotted fever, human granulocytotropic anaplasmosis, and human monocytotropic ehrlichiosis, developed guidelines to address the need for a consolidated source for the diagnosis and management of TBRD. The preparers focused on the practical aspects of epidemiology, clinical assessment, treatment, and laboratory diagnosis of TBRD. This report will assist clinicians and other health-care and public health professionals to 1) recognize epidemiologic features and clinical manifestations of TBRD, 2) develop a differential diagnosis that includes and ranks TBRD, 3) understand that the recommendations for doxycycline are the treatment of choice for both adults and children, 4) understand that early empiric antibiotic therapy can prevent severe morbidity and death, and 5) report suspect or confirmed cases of TBRD to local public health authorities to assist them with control measures and public health education efforts.

Perceived causes, diagnosis and treatment of babesiosis and anaplasmosis in cattle by livestock farmers in communal areas of the central Eastern Cape Province, South Africa.

Perceived causes, diagnosis and treatment of redwater (babesiosis) and gallsickness (anaplasmosis) in cattle by livestock farmers in communal areas of the central Eastern Cape Province were investigated by means of participatory methods, semi-structured interviews and a questionnaire survey. Most livestock owners relate the causes of these diseases to excessive grazing of lush green grass, which is thought to bring about an accumulation of bile in the body. The majority of livestock owners diagnose gallsickness and redwater on the basis of presenting signs and post mortem findings. Eighty nine percent of a total of 343 livestock owners participating in the study claimed to administer herbal remedies to treat the 2 tick-borne diseases; 75% of these combine herbal remedies with conventional medicines and 25% use herbal remedies only. Application of herbal remedies was reportedly aimed mainly at the removal of excess bile. However, some plant species used to prepare herbal remedies are reported to possess activities ranging from anti-inflammatory, analgesic, antimicrobial, anti-pyretic and purgative, and may be effective in the treatment of gallsickness and redwater. A lack of understanding of the causes and transmission of gallsickness and redwater, leading to ill-directed treatment, and widespread deviation from the directions of use when administering conventional medicines, were identified as problems that could be addressed by farmer training and the supply of appropriate information.

Integrated control of ticks and tick-borne diseases of cattle in Africa.

The problems caused by tick and tick-borne diseases for livestock particularly cattle on the African continent are described and discussed. The control of ticks and tick-borne diseases must receive high priority in Africa with regard to both research and control application because of their widespread distribution in areas of high livestock potential and productivity. The conventional methods of tick and tick-borne disease control are discussed and are found to be inadequate in the conditions prevailing in Africa. Methods of integrated control are suggested and discussed in light of recent development in control methods and those still under development. Any one of these methods may not be adequate to control the problem on its own but when several of the methods are combined an economic and robust integrated control is likely to result. Encouragement is given to attempt this approach in Africa to solve what must be the largest animal health problem of livestock remaining in the world.

Epidemiology and control of anaplasmosis in Australia.

Anaplasmosis occurs in those areas of northern and eastern Australia infested by the cattle tick Boophilus microplus but it has been studied intensively only in Queensland. Anaplasmosis is predominantly a disease of autumn and winter and of cattle greater than 1 year of age. The complement fixation test has been used in serological surveys of the tick-infested areas of the state. Both clinical and subclinical infections occur only in tick-infested areas and they are both more frequent in Bos taurus than in Bos indicus cattle probably due to the greater susceptibility of the former to ticks. Prevalence of infection is significantly greater in cattle exposed to heavy tick infestations than it is in cattle exposed to light tick infestations. B. microplus is considered to be the main vector with transmission being effected by transtadial and intrastadial but not transovarial means. Transtadial transmission by Rhipicephalus sanguineus has been demonstrated but attempts to demonstrate transmission by Haemaphysalis longicornis were unsuccessful. Vaccination with Anaplasma centrale is employed either as a routine preventative measure in young cattle or in the face of an outbreak. Attempts to attenuate a strain of A. marginale by adapting it to sheep were unsuccessful. Oxytetracycline and imidocarb have been used successfully to control the clinical disease.