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Tic Troubles - FMLH NR 6/20/19 w/ Dr. Murray

Updated: Jul 11, 2019

A patient with recent travel to the northwoods of Wisconsin presented with high grade fever, rash, and generalized lethargy for 7 dats in the setting of increasing LFTs.


The patient was originally thought to have Lyme Disease but was not treated after an EIA test came back negative. However, the low sensitivity of this test early in a course of symptoms justifies treatment based off of clinical suspicion and physical exam alone.


...seen in the "late disseminated" stage.

Lyme Disease:


- Phases:

Multiple EM lesions

1. Early localized

Onset: ≤ 4 wks

Findings: EM at site of tick attachment, fever, lymphadenopathy, myalgia

Rx: Doxycycline 100 mg PO BID x 10-21d


2. Early disseminated

Onset: 2 wks – 6 mo

Findings: multiple sites of EM, flu-like syndrome, heart block, myocarditis, facial nerve palsy, meningitis, radiculitis

Rx: depends on complication*


3. Late disseminated

Onset: ≥ 6 mo

Findings: Recurrent large joint arthritis, neurologic sx (peripheral neuropathy, encephalopathy), dermatologic sx (acrodermatitis chronica atrophicans)

Rx: depends on complication*


* Neuro cx = IV Ceftriaxone x28d,

AV Block = IV Ceftriaxone x 28d


- Testing:


No confirmatory labs are needed if EM is present.


Two-tiered serologic testing if EM is not present, or is unclear


CSF testing for intrathecal antibody production and lymphocytic pleocytosis if concern for meningitis


**See two tier testing image above**


Post-Lyme Disease Syndrome:

10% pts post-EM rx


Characterized by persisting fatigue, arthralgia, myalgia, impiared memory/cognition that can last for years.


MUST exclude Babesiosis/other tic-borne infection


Co-Infections


- Babesiosis: Intraerythrocytic protozoan

Tic: I. scapularis

Fatal disease in 10%

RF: >50 yo, immunocompromised, asplenia

Sx:Fever, fatigue, headache, myalgias, cough

PE: jaundice, hepatomegaly, splenomegaly

Labs: hemolytic anemia, elevated LFTs, AKI

Histology: Blood smear shows intraerythrocytic ring forms or tetrads resembling Maltese crosses. PCR or serology if smear is negative and suspicion is high.

Tx: mild to moderate: atovaquone + azithromycin

Severe: (requiring ICU or exchange transfusion (>10% parasitemia)): clindamycin + quinine


Two others that similarly present:

- Anaplasmosis: = Anaplasma phagocytophilium

Tic: I. scapularis


- Erlichiosis: = Erlichia chaffeensis

Tic: Lone Star Tic


- Common Sxs: febrile illness, RASH UNLIKELY

Labs: leukopenia, thrombocytopenia, AKI, transaminitis

Histology: basophilic inclusion bodies in cytoplasm of leukocytes.

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