Health Articles

I wanted to mention something about tick paralysis. Again, there can be a very dramatic recovery from what appears to catastrophic illness. Tick paralysis is due to a neurotoxin that is produced in the saliva of a tick. Symptoms can occur within two to seven days of exposure. Most cases from the United States have been reported from the Pacific Northwest, but they can occur anywhere in the United States. The typical mimic here is Guillain-Barre. This is someone who presents with a symmetric ascending paralysis, or weakness, with a suggestion of the diagnosis of Guillain-Barre. However, there is either something unusual about the presentation, like you can’t find an antecedent illness, or they are just in an area where they could be outdoors and have exposure. You should look for ticks and most commonly they are found in the scalp. If you remove the tick, the paralysis will respond. It doesn’t happen right away – it can take hours or even two or three days – for full recovery to occur. Full recovery usually occurs. Once every three or four years we see a case in an intensive care unit where it is presumed Guillain-Barre and if you look, you can find the tick. Again, the recovery in these cases is dramatic, whereas it is not with other causes or with primary Guillain-Barre. This is rare, but if you see it and recognize it, you can make a big impact.

When you remove a tick, you want to do it with as least trauma as possible. In general, if you are doing it carefully, tweezers can work fine. There are people who do all kinds of stuff, including Vaseline and other things. In general, the organizations that make recommendations about removing ticks say to do it with tweezers, but you want to try to remove the whole body of the tick; that is the problem. You can do this with fine forceps.

Treatment of the bite site does not decrease the risk of infection, but you can get superinfection of a tick bite, so applying something like topical mupirocin Bactroban online is generally recommended only if there is evidence of infection at the time that you see it. So if you are seeing a bite and there is purulence there, and it does happen, then it would be reasonable to treat topically. Otherwise, there is no evidence that treating topically makes a difference.

In terms of who should be vaccinated for Lyme disease, I think you need to assess who is at risk for the disease. Just living in an endemic area is probably not an indication. Living in an endemic area and spending a lot of time outdoors may well be an indication. Someone who works for a state forestry division in a state where Lyme is endemic should be considered. The thing that you always have to remember is that this is not a tremendous vaccine. So even if you vaccinate people, they still need to wear protective clothing and use repellents, so you are not making it so much easier for them. You are decreasing the risk of developing disease if they get bitten, but it doesn’t mean they can avoid doing all the other things. So I think you have to risk assess and see who is doing things outdoors.

Babesiasis is usually transmitted by tick bites although there is some non-tick transmission. This is one of the illness that can still be transmitted by transfusion from people who are infected. It is transmitted by the same tick that transmits Lyme and Ehrlichia, so you can have a triple infection with Babesia, Ehrlichia and Lyme. There is some suggestion that the ongoing fatigue in people with Lyme disease may be due to co-infection with Babesia. Most cases occur in the summer and in the Northeastern United States. One of the areas that was initially described was in Martha’s Vineyard off of Massachusetts. There are also areas in the Midwest, particularly in Minnesota and Wisconsin, where Babesia has been described. There is a newer illness in the far west, in Washington and Oregon, where a babesia-like illness has been described. This is an erythrocytic parasite. Like malaria, is likes to invade red cells.

The clinical presentation of babesiasis is that symptoms usually occur a week after the bite, people don’t recall the bite and again, it is a flu-like syndrome, but this is a flu-like syndrome like malaria. People have fevers, sweats, myalgias and headache. It can be mild and asymptomatic, but it also can lead to renal failure and death. This is one of the diseases that is more severe in splenectomized individuals. So when you see someone in the office who has had a splenectomy and you are warning them about the risks of pneumococcal disease and you should vaccinate them – preferably before their spleen is removed – one of the other things that you need to warn them about is tick bites. If they go to some high-risk area and get bitten by ticks, they can have very severe disease and probably should be evaluated and followed closely.

The diagnosis is made by demonstrating the organism in peripheral blood smear. This can look like malaria when you look at it on a blood smear. It tends to be low parasitemia, so you don’t see many of them. There are serologies for babesia, but titers can persist for months, so if you have an isolated serology, it may reflect past infection and as I mentioned, co-infection with

Lyme can occur in up to twenty percent of individuals, so in someone with Lyme disease with persistent symptoms or an unusual presentation, this is one of the things you think about.

Treatment is not incredibly well worked out for this disease, but in general the recommendations are quinine plus clindamycin. These are both anti-protozoal agents which will kill the organism. You generally treat for seven days and similar to Lyme disease, symptoms here can persist for months after treatment and it doesn’t mean that you need to re-treat them, it just means that you need to follow them over time and tell them that the symptoms may persist. In splenectomized patients with severe disease, exchange transfusion has been used to get rid of and basically lower the level of parasitemia.