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.

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.