Rickettsial diseases, caused by a variety of obligate intracellular, Gram-negative bacteria from the genera Rickettsia, Orientia, Ehrlichia, Neorickettsia, Neoehrlichia, and Anaplasma are considered some of the most covert emerging and re-emerging diseases. Scrub typhus, murine flea-borne typhus and Indian tick typhus are commonly being reported and during the last decade. Scrub typhus (ST) has emerged as a serious public health problem in India. Rickettsial infections are generally incapacitating and difficult to diagnose; untreated cases have case fatality rates as high as 30-45% with multiple organ dysfunction,if the specific treatment is delayed. Early clinical suspicion, timely diagnosis followed by institution of specific antimicrobial therapy shortens the course of the disease, lowers the risk of complications and reduces morbidity and mortality due to rickettsial diseases. Still there is large gap in our knowledge of Rickettsioses and the vast variability and non-specific presentation of these have often made it difficult to diagnose clinically. The present review describes the epidemiology, clinical manifestations, diagnostic modalities and treatment of Scrub typhus which is a vastly underdiagnosed entity and clinicians should suspect and test for the disease more often.
LYME PODCAST: 74-YEAR-OLD WOMAN WITH A TRIPLE TICK ATTACK
Welcome to an Inside Lyme case study. I find that the best way to get to know Lyme disease is through reviewing actual cases. In this case study, I will be discussing a 74-year-old woman with a triple tick attack. This case series will be discussed on my Facebook and made available on podcast and YouTube.
In this episode, I will be discussing a 74-year-old woman with a triple tick attack.
This case was described in the journal Cureus, written by Kumar and colleagues in 2019.
A 74-year-old woman had underlying medical problems. She was a smoker with chronic obstructive pulmonary disease (COPD). She also had hypertension. She was initially treated for pneumonia with ceftriaxone and azithromycin. She was also treated for Babesia.
Her red blood test contained parasites typical of Babesia. That is, they were able to see a parasite typical of Babesia under the microscope. Babesia is a disease from a parasite found in a deer tick. This is the same deer tick that carries the spirochete that causes Lyme disease. Over 9% of her red cells contained parasites typical of Babesia.
The doctors added atovaquone for Babesia. Atovaquone is marked under the name Mepron in the US. The doctors also added doxycycline over concerns that the woman might also be infected with Lyme disease. She was quite ill. She was also placed on a respirator. She required medications to raise her blood pressure.
The doctors prescribed erythrocytapheresis due to the severity of her illness and the high number of parasites in her red cells. During erythrocytapheresis, some of the red blood cells are removed and replaced with blood from a donor. The number of parasites dropped from 9 to 5.54 percent, but the woman remained in shock. Her kidneys function worsened, which was believed due to hemolysis.
The woman’s blood test was positive for Lyme disease and Anaplasmosis.
The doctor made one last antibiotic change. The doctors changed the treatment for Babesia from atovaquone and azithromycin to clindamycin and quinine. Clindamycin and quinine are still used for difficult to treat cases of Babesia. She improved enough to take her off the respirator. Her blood counts and kidney function returned to normal after 14 days of treatment.
There have been a number of studies showing three or more pathogenic infections in the same tick. “The incidence of a three pathogen infection is rare” writes Kumar. In actual practice, I have seen individuals with three pathogens who have not been published.
I support the Kumar’s call for a low level of suspicion; “A low threshold for suspicion should be held for a co-infection when patients exhibit a presentation that would be atypical for single pathogen exposure. A delay in diagnosis can lead to prolonged disease duration and increases the comorbidities associated with the infectious state.”
I agree with the doctor’s concerns with the reliability of testing for Babesia. Kumar writes, “A blood smear is the gold standard for the diagnosis of Babesiosis, however, if a patient has a low level of parasitic load, PCR is more sensitive.”
Kumar also raised concerns about the reliability of testing for Anaplasmosis. Anaplasmosis has been seen in red cells in some patients. “PCR and serological testing are also available, which are more sensitive than a thin smear.”
Finally, Dr. Kumar advised a longer course of treatment for Babesia. “In case of immunocompromised individuals who are at risk of relapsing Babesia, treatment for a total of six weeks is preferred, including a period of two weeks after parasites are no longer visible on a thin smear” writes Kumar.
What can we learn from this case?
It is important to look for a tick-borne infection even in patients with an underlying illness.
Patients can suffer from more than one tick-borne infection at the same time.
Their illness can be severe.
What questions does this case raise?
Would Babesia have been discovered without seeing the parasite under the microscope?
What is the best combination of treatment and length of treatment to prevent long-term complications?
TREATING TICK-BORNE DISEASE IN MY PRACTICE
In my practice, each individual requires a careful assessment. That is why I order tests a broad range of tests, including blood counts, liver and kidney function, thyroid disease, lupus, and rheumatoid arthritis in addition to tests for tick-borne infections. I also arrange consultations such as neurologists, rheumatologists, and ophthalmologists.
Many patients are complex, as highlighted in this Inside Lyme Podcast series.
We need more doctors with skills diagnosing and treating individuals with more than one tick-borne infection. We could use a reliable test to determine who has a tick-borne infection and when tick-borne infections have resolved. We need to determine the best course of treatment to prevent chronic illness. We hope a professional can use this case to remind them to look for more than one tick-borne infection and treat them accordingly.
We also need to give doctors the freedom to treat these difficult cases without undue interference by colleagues, insurance companies, medical societies, and medical boards.
Inside Lyme Podcast Series
This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube. As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.
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Kumar M, Sharma A, Grover P. Triple Tick Attack. Cureus. 2019;11(2):e4064.
A few details:
She was an avid gardner
It doesn’t specify if she saw a tick or not. The title is misleading because it infers she was bitten 3 separate times when in fact 1 tick bite could transmit all 3 pathogens simultaneously.
The study states that it is COMMON to be infected with 2 pathogens but that being infected with 3 is rare, but that risk increases in endemic areas (like Wisconsin).It is my experience that infection with 3 pathogens or more in WI is fairly common.
They don’t state it but ALL Lyme/MSIDS patients are immunocompromised, which means we typically need longer treatment. Mainstream medicine completely ignores this issue.
The study states: A treatment duration of a total of 10 days has been shown to be highly effective in treating both Lyme disease and human granulocytic anaplasmosis [12-13]. I couldn’t disagree more. The study in reference #12 studied 10 days of treatment to eradicate the EM rash. It’s common knowledge that the disappearance of EM rash does not mean a systemic infection is eradicated. In fact, the EM rash has been known to disappear without any treatment what so ever! The study in reference #13 is really about the increased disease severity in those with Anaplasmosis who had a delay in treatment. The study also admitted that their study may have excluded those with PCR-negative cases as well as the fact they are assuming disease course and severity doesn’t differ with different species.
CATS CARRY ALL TYPES OF TICKS AND TICK-BORNE DISEASES
Did you know the cat you may be cuddling with on your couch every evening could be infected with a host of tick-borne diseases? Unlike our canine friends, cats are typically not symptomatic when it comes to such diseases. But as researchers have found, that doesn’t mean they are free from disease.
The authors found that the cats were carrying 3 species of ticks including 83 Lone Star ticks (Amblyomma americanum), 7 American dog ticks (Dermacentor variabilis) and 70 black-legged ticks (Ixodes scapularis.)
Out of the 160 ticks, 22 (13.8%) tested positive by PCR for Bartonella spp., Borrelia burgdorferi, or Borrelia miyamotoi.However, only 25 of the 70 cats were able to be fully tested.
Nine of those cats (36%) were positive for exposure to at least one of the following tick-borne pathogens: Borrelia burgdorferi, Ehrlichia ewingii, Anaplasma phagocytophilum, Borrelia miyamotoi, Bartonella clarridgeiae and Bartonella henselae.
“We also found at least one cat blood sample to test positive for antibodies to each of the four tick-borne agents we screened for,” the authors state.
According to the authors’ review of the literature, the risk to pet owners is unclear. “Pet ownership has been implicated in vector-borne pathogen transmission and has been identified as a potential risk factor for such diseases in some studies, but not others.”
Nevertheless, screening for ticks may prove helpful, providing advanced warning of disease risk to humans “upon recognition of an uncommon or unexpected pathogen in a pet or pet-derived parasite,” Shannon concludes.
Author’s note: Keeping your cat indoors can prevent it from picking up ticks that could be passed onto you or other family members.
Shannon AB, Rucinsky R, Gaff HD, Brinkerhoff RJ. Borrelia miyamotoi, Other Vector-Borne Agents in Cat Blood and Ticks in Eastern Maryland. EcoHealth. 2017.
For some reason many people believe cats are immune to tick bites. This article clearly shows this to be a fallacy. Besides being bitten by ticks and infected with the pathogens within them, cats are known for carrying and transmitting Bartonella:
In my experience, not only do many Lyme patients also have Bartonella, it is often harder to resolve than Lyme. Testing for these coinfections is just as abysmal as Lyme testing is so knowing symptoms is a must for a clinical diagnosis as many will never test positive. This website is full of patients who had Bartonella who were negative on testing.
We investigated the effectiveness of integrated tick management (ITM) approaches in reducing the burden of infection with Borrelia burgdorferi, Babesia microti, and Anaplasma phagocytophilum in Ixodes scapularis. We found a
52% reductionin encountering a questing nymph in the Metarhizium anisopliae (Met52) and fipronil rodent bait box treatment combination as well as a
51% reduction in the combined white-tailed deer (Odocoileus virginianus) removal, Met52, and fipronil rodent bait box treatment compared to the control treatment.
The Met52 and fipronil rodent bait box treatment combination reduced the encounter potential with a questing nymph infected with any pathogen by 53%.
Compared to the control treatment, the odds of collecting a parasitizing I. scapularis infected with any pathogen from a white-footed mouse (Peromyscus leucopus) was reduced by 90% in the combined deer removal, Met52, and fipronil rodent bait box treatment and by
93% in the Met52 and fipronil rodent bait box treatment combination.
Our study highlights the utility of these ITM measures in reducing both the abundance of juvenile I. scapularis and infection with the aforementioned pathogens.
A Yarmouth, N.S., horse owner wants others to know about anaplasma, a tick-borne disease that her horse, Sloane, contracted before Halloween.
“If you see swollen legs on your horse, it means something, do something,” said Sarah LeBlanc, Sloane’s owner.
Anaplasma causes serious fevers, loss of appetite and swollen and painful limbs. If a fever is left untreated, it can lead to other complications like laminitis, which can damage a horse’s hooves. Anaplasma is rarely fatal and usually responds well to treatment.
On Monday, LeBlanc received confirmation that a blood test determined Sloane had anaplasma and Lyme disease.
LeBlanc said she first realized something was wrong with her 10-year-old barrel racing horse last Wednesday.
“If you have a horse with four swollen legs, it’s not the result of an injury, it’s got to be the result of a side effect or something,” LeBlanc said. “And so I thought I would give it 24 hours to see if it goes away on its own.”
Swollen legs aside, LeBlanc said Sloane seemed pretty normal and she was still eating.
But when a horse farrier, a person whose job it is to put horseshoes on horses, saw Sloane that night, she was advised to speak with a vet as soon as possible.
LeBlanc called Dr. Megan Crouse, a veterinarian from the South Shore Veterinary Services in Wileville, N.S., and described the symptoms. Crouse told her it could be anaplasma, a disease LeBlanc had never heard of.
Crouse told CBC News in an email that anaplasma pops up at this time of year. She said it can be treated with antibiotics, anti-inflammatory medications and supportive care.
Local vet sees uptick in anaplasma cases
Crouse said her clinic has treated between 10 to 12 cases this year and all have been in the last four weeks. She said it is spread through tick bites.
“The carrier must bite and be attached for 24 to 48 hours to spread infection,” Crouse said.
Tick prevention is key.
“Things such as keeping pastures clipped short, using fly/tick repellent daily, daily thorough tick checks are all things to help prevent exposure,” she said.
LeBlanc said she always checks Sloane and her other horse for ticks. She said there are a lot of them in her area.
“I’ve been picking hundreds of the ticks off the horses,” she said.
LeBlanc posted about the ordeal on Facebook last week and as of Monday, it has been shared about 500 times.
“It’s an illness, it’s a disease and you just can’t ignore it and let it go untreated,” she said.
The good news, LeBlanc said, is Sloane’s temperature continues to be normal and she’s responding well to the medicine.
“She seems happy and content, so she is certainly on the road to recovery,” she said.
Rickettsial diseases or rickettsioses are infections caused by various bacteria belonging to the genus Rickettsia. These bacteria are transmitted through the bites of certain hard-bodied ticks and some other arthropods. Rickettsial diseases are not to be confused with rickets, which is a condition affecting the bones and resulting from vitamin D deficiency.
The infections caused by Rickettsia bacteria have traditionally been classified into two groups: spotted fever and typhus. However, they’re sometimes divided into further categories. Either way, all groups include species of pathogens that can infect humans. Although Rickettsia bacteria can be found worldwide, the most common rickettsial illnesses are normally contracted in Africa and Asia.
Lyme disease is also transmitted to humans by ticks. It’s the most common tick-borne illness in the northern hemisphere. However, Lyme isn’t a rickettsial disease, since it’s caused by a bacterium of a different genus: Borrelia burgdorferi.
However, the same tick that carries Rickettsia bacteria might also be infected with Borrelia burgdorferi. Therefore, it’s possible to contract both illnesses via one tick bite. Therefore, the answer to question ‘is Rickettsia a Lyme co-infection?’ is that yes – rickettsiosis can be a potential co-infection of Lyme disease.
What Are The Symptoms of Rickettsia Diseases?
Some of the most common rickettsial diseases are Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis and typhus. All of these are generally difficult to diagnose. Some of them rarely cause symptoms, and most of them only cause moderate illness even when symptomatic. However, certain forms of spotted fever and typhus may be fatal if left unrecognised and untreated. The sooner these illnesses are diagnosed, the easier they are to treat using antibiotics.
The clinical presentation of rickettsial diseases varies greatly. Even infections caused by the same species of bacteria may produce different symptoms in different patients. Nonetheless, the most common symptoms include
rashes and eschar (a piece of dry and dark dead skin at the site of the bite). These tend to develop within two weeks after the bacteria have entered the body.
African tick bite fever is one of the mildest forms of rickettsiosis. Patients usually present with fever, headache, muscle pain and an eschar shortly after contracting the disease during a visit to southern Africa.
Mediterranean spotted fever is a serious and potentially life-threatening illness. It’s prevalent in the Mediterranean region, including northern Africa. In addition to fever, rashes and an eschar are typical signs of the illness.
Patients with Rocky Mountain spotted fever often experience fever, headache, nausea, and stomach pain. A rash at the site of the bite is also commonly seen, but eschars aren’t usually present.
The only common symptom of murine or endemic typhus is fever. About half of all patients also develop a rash. Scrub typhus can be contracted in Asia, and it’s characterised by a severe fever, headache and muscle pain. An eschar, cough, enlarged lymph nodes and encephalitis (inflammation of the brain) may also occur in some patients.
The symptoms of ehrlichiosis and anaplasmosis are similar to those of other rickettsial diseases. However, they’re also known to significantly reduce white blood cell count in affected people.
Is Rickettsia The Same As Lyme Disease?
Rickettsiosis and Lyme disease share several symptoms in their early stages, such as fever, headache, fatigue, malaise and muscle pain. Moreover, all of these symptoms also overlap with those of the flu and other non-specific viral infections, making diagnosis even more challenging.
The only distinctive sign of Lyme disease is the circular bull’s eye rash that develops around the tick bite within a few weeks. However, the rash can also appear elsewhere on the body, and in 20-30% of patients it’s not seen at all.
The diagnosis of Lyme and rickettsial diseases is usually based on a combination of factors, including signs, symptoms, patient history and laboratory tests. Unfortunately, currently there aren’t any completely reliable diagnostic tests available for Lyme disease: in the first weeks after infection, there’s a 60% rate of false negative results. Serological assays for rickettsiosis are more reliable, but these can take 10–12 days to provide a decisive result.
What To Do If You Think You’ve Been Infected With Rickettsia
Ticks are very tiny, and their bites aren’t painful. Many people don’t even realise they’ve been bitten.
It’s important to note that being bitten by a tick doesn’t mean you’ve contracted an illness. In fact, out of the approximately 800 different tick species in the world, less than 60 can transmit infections to humans and animals. Most types of tick also have to be attached to the host’s body for an extended period of time in order to pass on any bacteria.
Nevertheless, you must see your doctor if you have a fever and any other flu-like symptoms or a rash shortly after being bitten by a tick. You should also arrange a medical appointment if you don’t recall being bitten but you do experience some suspicious symptoms within a few weeks of returning from a high-risk area. Be sure to tell your doctor about your recent travels, so that they can evaluate the probability of a tick-borne infection and order any appropriate diagnostic tests.
According to information written in Carl Tuttle’s petition against the IDSA, he mentions an article that indicates the persistent form of Lyme disease might be caused by another organism altogether.
“The STAT article reports that both Jorge Benach and Allen Steere now say it is time to take a closer look at Rickettsia helvetica’s role in Lyme disease. Benach says the research “should be done” because public health concerns warrant a closer look.”
“Dr. Willy Burgdorfer reviewed and tested patient blood samples from Dr. Anderson for C9P09, which is a rickettsial helical Mycoplasma; P09 being a Rickettsia bellii and C9 being a Mycoplasma (FIG. 2).35 This is further supported by the theory that an endosymbiotic infection produces spirochetes that are uncultivable Mycoplasmas, which are also called spirochetes. 1, 22, 31, 32
The “Swiss Agent” is documented by Dr. Willy Burgdorfer (FIG. 3),25 who also wrote a speech on “Pandora’s Box”.5 Although the Swiss Agent paper is associated with the suspected African Swine Flu, Dr. Willy Burgdorfer appears to be famous for leaving clues throughout his work regarding Lyme disease. Upon reviewing the structure of the Lyme disease “Swiss Agent” and the “Pandora Giant Virus”, there is a striking resemblance that deserves further examination.”
I don’t think we actually know precisely what the agent(s) causing Lyme disease is. This would explain why it can’t be picked up in current testing and why many fail treatment.
While it’s true that the early stages can often yield unspecific symptoms, an experienced eye will be able to diagnose a patient with tick borne illness. Also, please remember that in some patients their only symptoms are psychological: https://madisonarealymesupportgroup.com/2015/10/18/psychiatric-lymemsids/Any acute onset behavior changes should be suspect. Please don’t mess around with mainstream medicine should this occur. Get to an experienced and recommended ILADS practitioner who understands the mental illness aspect of tick borne disease.
Lyme disease isn’t the only awful illness ticks are capable of transmitting.
Superticks can carry up to four different diseases at a time, including Lyme disease. And these insects of mass destruction are becoming especially abundant in Long Island, according to a study published this month in the journal mBio.
“They’ve kind of taken over,” co-author Rafal Tokarz tells The Post.
It means that one bite could potentially give a person Lyme disease as well as illnesses such as potentially life-threatening babesiosis and anaplasmosis. A quarter of the ticks examined in the study had the ability to transmit more than one disease.
“Most people think of Lyme disease when they think of [tick-borne illnesses], and that’s justified, but in Suffolk County alone, ticks can carry four other pathogens,” says Tokarz, an assistant professor of epidemiology at the Center for Infection and Immunity at Columbia’s Mailman School of Public Health.
“Very often, we find sometimes two, even three, of these pathogens [in the same tick],” he says.
He and his fellow researchers are also growing increasingly worried about the Lone Star tick, a species whose saliva can cause an allergic reaction to meat. The tick has migrated in recent years from the southern part of the United States up to Long Island and New England.
“It got to the point where my stomach would swell up; I was vomiting,” Kristie Downen said. “The rashes were real bad. It was getting to the point [I told doctors], ‘You’re missing something — I’m still dying.’ ”
There’s currently no treatment for the meat allergy the Lone Star tick can cause, Tokarz says. But, he adds, doctors now need to start testing people who were recently bitten for multiple tick-borne diseases.
“This tick, in particular, has become very troublesome,” Tokarz says. “Thirty, 40 years ago, you hardly ever found them on Long Island. Now they’ve become extremely abundant.”
The number of diseases currently transmitted by ticks is 20 and counting. This article states it’s 16 within the U.S. but these numbers are continually influx with new pathogens continually being discovered:
For the first time, Garg et al. show a 85% probability for multiple infections including not only tick-borne pathogens but also opportunistic microbes such as EBV and other viruses.
“Our findings recognize that microbial infections in patients suffering from TBDs do not follow the one microbe, one disease Germ Theory as 65% of the TBD patients produce immune responses to various microbes.”
The poly microbial issue isn’t even on the radar of most doctors, and this is why the CDC recommendation of 21 days of doxycycline is an absolute farce.