Download - ACES: Rabies / Tick Illness
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29 JANUARY 2014
CHAPTER 129CHAPTER 132
RABIESTICK-BORNE
ILLNESSES
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1. Which of the following is true?
A. Worldwide, dogs are the most commonly rabies-infected animals.
B. Despite similarities to dogs, foxes rarely carry rabies.C. Skunks are the most common source of rabies in the
US.D. Due to efforts by the WHO, deaths from rabies have
dropped to less than 5000 cases/year.E. Rabbits and other langomorphs almost never carry
rabies because they are herbivores.
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2. Regarding clinical rabies:
A. There are three distinct stages: prodrome, acute neurological illness, death.
B. The incubation period is typically < 72 hours.C. Hydrophobia is largely mythical and is almost never
seen.D. One-quarter of patients with clinically-evident rabies
will survive, although with neurologic sequelae.E. The duration of the incubation period depends on the
severity of the bite.
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3. Post-exposure rabies prophylaxis
A. Includes gentle wound irrigation with saline only, so as not to irritate tissues and increase the risk of viremia.
B. Should include immunoprophylaxis for a pt who awakens to find a bat in her tent, even without a known bite.
C. Should include human rabies immunoglobin (HRIG) applied topically to the wound.
D. Involves the same regimen worldwide regardless of the type of exposure or country of origin.
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4. Which of the following is not commonly seen
with encephalitic, or “furious” rabies?
A. Hydrophobia – the fear of being in contact with waterB. Aerophobia – the fear of air in motionC. Hyperactivity in response to light exposureD. SeizuresE. Excessive salivation
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5. Which is true in making the diagnosis of lyme
disease?
A. Erythema chronicum migrans (ECM) is always a macular rash with central clearing.
B. 10% of patients cannot recall the tick bite.C. Arthritis of early Lyme disease is episodic,
symmetrical, polyarticular and attacks small joints.D. Common sites for ECM include ankles and skin folds.E. ECM is seen in 50% of early Lyme disease.
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6. Which of the following is the correct pair?
A. Lyme disease – caused by a virusB. Rocky Mountain Spotted Fever – Ixodes sp. ticksC. Tularemia – lagomorph reservoirD. Tick paralysis – Rickettsia rickettsiiE. Relapsing fever – parasitic (protozoal)
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7. You suspect tick paralysis (TP) in an 8-year-old boy.
A. Treatment of choice is doxycycline for 3 weeks.B. TP is an ascending flaccid paralysis 4-7 days after tick
attachment.C. TP is commonly seen in the southwest, distinguishing
it from other tick-borne illnesses.D. A single dose of antibiotics is needed to kill the
bacteria that produce the neurotoxin.E. The neurotoxin prevents acetylcholine breakdown.
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8. A 35-year-old “outdoorsy” male presents to your
ED in upstate NY after syncope. You see a HR of 40-bpm with occasional p-waves. You realize:
A. This cannot be due to Lyme disease as you see no ECM rash.
B. You should administer aspirin immediately.C. This conduction abnormality can be managed outpatient.D. This patient needs a temporary cardiac pacemaker.E. The treatment of choice is still oral doxycycline.
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9. Which of the following is true regarding Lyme
disease?
A. Cattle are the preferred hosts of Ixodes scapularisB. Culture of blood/tissue is the gold standard for
diagnosisC. Borrelia burgdorferi, a spirochete, spreads to all
tissuesD. Skin lesions on the palms and soles are commonE. Once chronic symptoms develop, antibiotics are no
longer useful
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10. Regarding Rocky Mountain spotted fever (RMSF):
A. A maculopapular rash is the most common symptom.B. It is most commonly seen in Montana, Idaho, Colorado
and Utah.C. Rickettsia rickettsii are obligate intracellular bacteria that
live in platelets. This leads to thrombocytopenia / petechiae.
D. Early RMSF mimics any self-limited febrile viral illnesses.E. A triad of fever, rash and tick bite is seen in 33% of cases.
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1. Which of the following is true?
A. Worldwide, dogs are the most commonly rabies-infected animals.
B. Despite similarities to dogs, foxes rarely carry rabies.C. Skunks are the most common source of rabies in the
US.D. Due to efforts by the WHO, deaths from rabies have
dropped to less than 5000 cases/year.E. Rabbits and other lagomorphs almost never carry
rabies because they are herbivores.
![Page 14: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/14.jpg)
2. Regarding clinical rabies:
A. There are three distinct stages: prodrome, acute neurological illness, death.
B. The incubation period is typically < 72 hours.C. Hydrophobia is largely mythical and is almost never
seen.D. One-quarter of patients with clinically-evident rabies
will survive, although with neurologic sequelae.E. The duration of the incubation period depends on the
severity of the bite.
![Page 15: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/15.jpg)
3. Post-exposure rabies prophylaxis
A. Includes gentle wound irrigation with saline only, so as not to irritate tissues and increase the risk of viremia.
B. Should include immunoprophylaxis for a pt who awakens to find a bat in her tent, even without a known bite.
C. Should include human rabies immunoglobin (HRIG) applied topically to the wound.
D. Involves the same regimen worldwide regardless of the type of exposure or country of origin.
![Page 16: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/16.jpg)
4. Which of the following is not commonly seen
with encephalitic, or “furious” rabies?
A. Hydrophobia – the fear of being in contact with waterB. Aerophobia – the fear of air in motionC. Hyperactivity in response to light exposureD. SeizuresE. Excessive salivation
![Page 17: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/17.jpg)
5. Which is true in making the diagnosis of lyme
disease?
A. Erythema chronicum migrans (ECM) is always a macular rash with central clearing.
B. 10% of patients cannot recall the tick bite.C. Arthritis of early Lyme disease is episodic,
symmetrical, polyarticular and attacks small joints.D. Common sites for ECM include ankles and skin folds.E. ECM is seen in 50% of early Lyme disease.
![Page 18: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/18.jpg)
6. Which of the following is the correct pair?
A. Lyme disease – caused by a virusB. Rocky Mountain Spotted Fever – Ixodes sp. ticksC. Tularemia – lagomorph reservoirD. Tick paralysis – Rickettsia rickettsiiE. Relapsing fever – parasitic (protozoal)
![Page 19: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/19.jpg)
7. You suspect tick paralysis (TP) in an 8-year-old boy.
A. Treatment of choice is doxycycline for 3 weeks.B. TP is an ascending flaccid paralysis 4-7 days after tick
attachment.C. TP is commonly seen in the southwest, distinguishing
it from other tick-borne illnesses.D. A single dose of antibiotics is needed to kill the
bacteria that produce the neurotoxin.E. The neurotoxin prevents acetylcholine breakdown.
![Page 20: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/20.jpg)
8. A 35-year-old “outdoorsy” male presents to your
ED in upstate NY after syncope. You see a HR of 40-bpm with occasional p-waves. You realize:
A. This cannot be due to Lyme disease as you see no ECM rash.
B. You should administer aspirin immediately.C. This conduction abnormality can be managed outpatient.D. This patient needs a temporary cardiac pacemaker.E. The treatment of choice is still oral doxycycline.
![Page 21: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/21.jpg)
9. Which of the following is true regarding Lyme
disease?
A. Cattle are the preferred hosts of Ixodes scapularisB. Culture of blood/tissue is the gold standard for
diagnosisC. Borrelia burgdorferi, a spirochete, spreads to all
tissuesD. Skin lesions on the palms and soles are commonE. Once chronic symptoms develop, antibiotics are no
longer useful
![Page 22: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/22.jpg)
10. Regarding Rocky Mountain spotted fever (RMSF):
A. A maculopapular rash is the most common symptom.B. It is most commonly seen in Montana, Idaho, Colorado
and Utah.C. Rickettsia rickettsii are obligate intracellular bacteria that
live in platelets. This leads to thrombocytopenia / petechiae.
D. Early RMSF mimics any self-limited febrile viral illnesses.E. A triad of fever, rash and tick bite is seen in 33% of cases.
![Page 23: ACES: Rabies / Tick Illness](https://reader035.vdocument.in/reader035/viewer/2022062703/555564efb4c90530208b5589/html5/thumbnails/23.jpg)
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RABIES
RABIESBackgroun
dClinical
Treatment
TICK ILLNESS
• Lyssavirus (rhabdoviridae) – RNA
• Preference for CNS tissue
• In US: • Raccoons most common carrier• Bats most common infector
• Worldwide: Dogs most common
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RABIES SYNDROME
RABIESBackgroun
dClinical
Treatment
TICK ILLNESS
• 5 stages of rabies infection:• Incubation (30-90) days• Prodrome – flu-like
syndrome• Acute neurological illness
• Excitement • Opisthotonus• Hydrophobia• Salivation, lacrimation,
unsteady gait• Coma• Death
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RABIES TREATMENT
RABIESBackgroun
dClinical
Treatment
TICK ILLNESS
• Aggressive wound washing• Virucidal agent
• Human rabies immune globulin• HRIG 20 IU/kg (local if poss)
• Human diploid cell vaccine• HDCV days 0, 3, 7, 14, 28
• In US treat: • skunk, raccoon, fox, bat
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RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
TICK-BORNE ILLNESS
Lyme Disease:• Borrelia burgdorferi• Ixodes ticks (white tailed deer)• 3 stages of disease:
1. Localized – rash Erythema migrans: annular, expanding erythematous lesion with central clearing (spares palms, soles)
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TICK-BORNE ILLNESS
Lyme Disease:• 3 stages of disease:
1. Localized – rash 2. Disseminated – neuro / cardiac
Neuro: CN VII palsy, meningitis, peripheral neuropathyCardiac: myocarditis, pericarditis, heart block
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Lyme Disease:• 3 stages of disease:
1. Localized – rash 2. Disseminated – neuro / cardiac3. Persistent – arthritis
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Lyme Disease:• Diagnosis – ELISA for screening
Western Blot to confirm• Treatment
• doxycycline• erythromycin• amoxicillin• ceftriaxone if unstable / ill
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:• Rickettsia rickettsii• Multiple tick species• Southeastern US• April – September
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:• Flu-like syndrome – fever, HA, myalgias• Rash – begins distal, spreads proximal macules petechiae purpura (d/t vasculitis)
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Rocky Mountain Spotted Fever:• Diagnosis – clinical!• Complications (vasculitis)
Confusion / sz / deliriumDICHeart failure / ARDSRenal failureLoss of digits / limbs
• Treatment – doxycycline, chloramphenicol
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Ehrlichiosis:• Similar syndrome to RMSF• Two types: HME: human monocytic HGE: human granulocytic• Pancytopenia, hypoNa++,↑ LFTs• Dx: clinical suspicion• Tx: doxy, tetracycline, chloramphenicol• Complications: DIC, renal failure, coma,
death
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Babesiosis:• Malaria-like hemolytic disease• Intra-erythrocyte protozoa• Sx: often asx, fevers, malaise hepatosplenomegaly, jaundice• Dx: peripheral smear• Tx: only immunocomp, quinine + clinda or atovaquone + azithro
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Tularemia:• Gram- coccobacillus Francisella
tularensis• Lagomorph resevoir
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
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TICK-BORNE ILLNESS
Tularemia:• Gram- coccobacillus• Lagomorph resevoir• Sx: 1. ulceroglandular
2. glandular 3. oropharyngeal 4. pneumonic 5. oculoglandular 6. typhoidal
RABIESTICK ILLNESSLyme Dis.
RMSFEhrlichios
isBabesiosi
sTularemia
Tx: doxy, gentDx: clinical, serology
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