susan r. schedler msn, aprn, acns-bc, cmsrn
TRANSCRIPT
Susan R. Schedler
MSN, APRN, ACNS-BC, CMSRN
The Vexing Variables of Vector Borne
Illness: Differential Diagnosis,
Treatment, Prevention, and Outcomes
Disclosure
• I do not have a potential or real
conflict of interest with this
presentation and any organization.
A Little Bit About Me
• Graduated with BSN in 1986
• Graduated with MSN- Adult Health Clinical Nurse Specialist – 1996
• Cardiovascular CNS
• Cardiac Unit Manager
• Founding Outpatient Provider for Anticoagulation Clinic- grew to 500 pts.
• Current role- 7 years- CNS for MSU/Oncology units
• Co-president MO-KAN CNSswww.mo-kancns.org
A Little About My Hospital
• Shawnee Mission Medical Center is a
not-for-profit community hospital located
in Johnson County, Kansas
• The hospital opened in 1962 on 54 acres
• Became part of Adventist Health System-
46 hospitals campuses in 9 states
A Little About My Hospital
• The hospital has grown to a 504 bed hospital, outpatient surgery center, community education building, and a child care center for SMMC associates.
• Recent expansion includes Emergency Department and outpatient services west and south of the main campus.
• SMMC Emergency Department is one of the two busiest in the Kansas City area-over 70,000 ED visits/year
A Little About My Hospital
• SMMC is one of the few hospitals in the
area that offers addiction recovery
and mental health services on an
inpatient and outpatient basis- serves
more that 25,000 patients per year.
• SMMC Center for Women’s Health
serves more than 42,000 women per
year– 5300 babies last year!!
A Little About My Hospital
• 4 Joint Commission Disease Specific
Certifications
1. Stroke
2. Sepsis
3. Diabetes
4. Joints
A Little About Our CNSs
• CNS- Executive Director of Evidence
Based Practice
• CNS- Magnet Director
• Critical Care CNS
• 2- Acute Care CNSs
• CNS Stroke Coordinator
Disclosure
• I am not an expert in vector borne illness
BUT
• I am becoming an expert
Outcome Goal:
begin with the end in mind
• The primary outcome goal is that the Advanced Practice Nurse (APN) will gain a greater knowledge and understanding of the challenges of caring for patients with a Vector Borne Illness.
• The increase in knowledge will lead to improved outcomes for patient with a Vector Borne Illness
World Health Organization
Quick Facts
• Vector-borne diseases account for
more than 17% of all infectious diseases,
causing >700,000 deaths/year
• More than 3.9 billion people over 128
countries are at risk of contracting
dengue- 96 million cases/year
Case Study• 49 yr. old female.
• PMH: hypothyroid, c-section,
• Medications: Synthroid 88mcg p.o. daily
• Social History: non-smoker, no ETOH, married, one child, full time RN
• Presents to the Urgent Care Clinic with 48 hour fever- 102 to 103, fatigue, headache, no other pain--- late June
• Home tx. Tylenol 1000mg q 12 hours alternate with Ibuprofen 800mg q 12 hours.
Case Study- cont.
• Urgent Care MD performed UA:
+ for trace blood, otherwise negative
• Urgent Care MD diagnosis a “presumed”
UTI and prescribes Levaquin.
• Patient continues to experience fever
102-103 with headache, fatigue, despite
48 hours of Levaquin treatment
• Continues Tylenol alt/w Ibuprofen for
fever
Case Study- cont.
• Pt. presents to primary care clinic –now with 4 days of fever 102-103, headache, fatigue.
• Dr. performs CBC, chemistry panel, and reveals: WBC 1.6, Platelet count 60,000, LFT’s elevated, low sodium, low potassium
• Dr. indicated to pt. “ I do not think you have leukemia, however, the blood work is suggestive of leukemia.”
*Recommended hospitalization for further testing.
Case Study- cont.
• Pt. hospitalized on day 4 of continued
fever 102-103 and fatigue
• Treatment in hospital: IVF’s at 125/hour
• Tylenol 650 mg p.o. q 8 hours.
• Pt. seen by hospitalist #1- diagnosis:
“viral syndrome” with prescribed
treatment to “watch” fever overnight
Case Study- cont. • Day 2 of hospitalization- day 5 of continued
fever 102-103, headache, fatigue
• Hospitalist #2- indicates believes diagnosis is
“viral syndrome”- continue IVF and Tylenol-
• Husband of pt. asks “could this be a tick bite
disease?”
• Hospitalist #2 replies: possibly however no
evidence of a tick bite but will consult
Infectious Disease Doctor.
Case Study- cont.
• Infectious Disease doctor sees pt. on
Day 6
• Pt. remains febrile- 102-103, chills,
WBC=1.2, Platelet count 40,000, LFTs
increased from admission.
• Infections disease doctor walks into
room and tells pt. “You have
Erlichiosis!”
Case Study- cont.
• Infectious Disease doctor prescribed
Doxycycline 100mg p.o. BID
• Pt.’s became afebrile 48 hour after
doxycycline initiated.
• Abnormal labs begin to normalize
Vectors
• Tick
• Mosquito
• Flea
Ticks
Ticks
Ticks
Mosquitos
Culex pipens- Eastern U.S.
Culex Tarsalis- West and Midwest U.S.
Only the female mosquito feeds on blood and is
responsible for the transmission of WNV
Mosquitos
Aedes Species is responsible for the
transmission of the Zika Virus & Dengue Virus
Flea
Xenopsylla cheopis- feeds on rats or other rodents
that carry the plaque
Diseases
• Lyme disease
• Anaplasmosis
• Erlichiosis
• Heartland Virus
• Spotted Fever Rickettsia
• Babesiosis
• Tuleremia
• Powassam
• West Nile Virus
• Zika
• Plaque
Prevalence 2004-2013
C= acquired outside of US
Prevalence- 2015
Lyme Disease
West Nile Virus
Heartland Virus
Zika
Lyme
• The most commonly reported vector
borne illness in the U.S.
• In 2013, 95% of Lyme cases were
reported fro 14 states: Connecticut,
Delaware, Maine, Maryland,
Massachusetts, Minnesota, New
Hampshire, New Jersey, New York,
Pennsylvania, Rhode Island, Vermont,
Virginia, Wisconsin
Lyme
• Agent- Borrelia burgdorferi- bacterium
• Incubation- 3-30 days
• Lab serology tests
• Erythema migrans -Red ring like rash
70-80% of cases
• Flu-like symptoms- fever, malaise,
headache, arthralgia, myalgia
Lyme
• Drug of Choice-
Adult: Doxycycline 100 mg Bid 14-21 daysCefuroxime Axetil 500mg BID 14-21daysAmoxicillin 500mg TID 14-21 days
Children: Amoxicillin 50mg/kg 3 divided doses Doxycycline 4mg/kg 2 divided dosesCefuroxime Axetil 30mg/kg 2 divideddoses
Erlichiosis
• Three states account for 35% of all
reported cases: Oklahoma, Missouri,
and Arkansas
• Agent- Erlichia Chaffeensis, Erlichia
ewingii, Erlichia muris- bacterium
• Incubation - 1-2 weeks
• Lab serology tests
Erlichiosis
• Fever, headache, chills, malaise, muscle
pain, confusion, rash in children
• Drug of choice:
Adults: Doxycycline 100m BID
Children <100lbs: Doxycycline 2.2mg/kg BID
Treat 3 days after fever subsides
*Diagnosis confirmed by lab serology but
treatment with doxycycline should not be
delayed
Babesiosis
• Most frequently reported in Northeast
and upper Midwestern states
• Babesiosis is caused by parasites that
infect red blood cells
• Agent- Babesia microti
• Incubation- 1-9 weeks
• Fever, chills, sweats, malaise, myalgia
Babesiosis• Decreased Hematocrit due to hemolytic
anemia
• Thrombocytopenia, elevated BUN, CR,
LFT
• Parasite seen on blood smear
• Drug of Choice:
Atovaquone(Mepron)
antifungal/antiparasite-750 mg BID with
Azithromycin 500-1000mg/day 7-10 days
Babesiosis
• OR- Clindamycin 300- 600 mg IV q 6
hours or orally q 8 hours with/ Quinine
650mg p.o. 6-8 hours for 7-10 days
West Nile Virus
• Mosquitos become infected when feed
on dead birds
• Most people do not develop symptoms
• 1 in 5 will develop febrile illness
associated with headache, body aches,
joint aches, rash
• Lab test- serum or cerebral fluid for
presence of WNV specific IgM antibodies
West Nile Virus
• No vaccines or specific antiviral
treatment
• Meds for fever, IV fluids, pain relief
Zika• Mosquito borne flavivirus
• First identified in Uganda in 1947- monkeys
• Identified in humans in Uganda in 1952
• Blood or urine test can confirm Zika
• There is no medicine to treat nor vaccine to prevent
• Zika can cause birth defects
• Zika can be spread through sex
• Symptoms- fever, rash, headache, joint pain, muscle pain, red eyes
Plaque
• Transmitted by flea bites or contact
with food or fluid of infected animals or
droplets from person with plaque
pneumonia that coughs
• Agent- Yersinia pestis- bacterium
• Animals affected by Yersinia pestis are
squirrels, rabbits, rats, mice, prairie
dogs, chipmunks
Plaque
• Symptoms- fever, chills, swollen lymph
nodes, headache
• Treatment- Gentamicin and
flouroquinolones are first-line treatments
• When recognized and appropriate
treatment started- patient recovers
• Post-exposure prophylactic treatment with
Doxycycline and Ciprofloxacin
Differential Diagnosis
• Viral Syndrome
• Leukemia
• Neurologic disease
• Fever of origin– common for all
• Ankylosing spondylitis and rheumatoid
arthritis
• Cellulitis- lyme
• Contact dermatitis-lyme
Treatment
• Antibiotics
• Antiretroviral agents lopinavir-ritonavir
have been shown to reduce the
incidence of malaria by 41%
• Anti-fungal/parasite
• Antipyretics
• Fluids
• Rest
Prevention• Vaccinations- “the epicenter for the fight
against viral vector borne disease” (Javed, et. al. 2013)
• Yellow-fever vaccine- more than 500 million people have been vaccinated and over 98% are believed to be protected for at least 10 years. A live-attenuated vaccine
• Vaccines are in clinical trials for Dengue fever
• Vaccine is available for Japanese encephalitis virus 76%-95% effective- vector is mosquito
Prevention• Repellents
Vaughn & Meshnick (2011) assessed the effectiveness of long-lasting permethrin-impregnated clothing for the prevention of tick bites and found a 93% reduction in incidence of tick bites.
*Permethrin on clothing- 0.5%
*N,N-diethyl-meta-tolumide (DEET)- 20% or more
*Natural repellents: Nootaktoone- Clove oil, Grapefruit (ticks only)
Prevention
• Clothes- cover arms/legs
• Stay away from stagnate water
• Timing of outdoor activity- stay inside between sunset and sunrise
• Check after outdoor activities- before bed again in the am
• Consider shower after outdoor activity
• If tick removed w/in 24 hours, chance of exposure to illness significantly less.
• Treat and check pets!
Outcome Goal-
take home points
• Fever of unknown origin “think vector
borne disease”.
• Late spring- early fall health care and
public health professionals must be “on
the lookout” for vector borne diseases.
• Proper identification, timely treatment
can prevent poor outcomes.
References• Huntington, et. al.(2016). Emerging Vector Borne Diseases.
American Family Physician, 94(7), 551-557.
• Javed, et al. (2013). Bites and mites: prevention and protection of vector-borne disease. www.co-pediatrics.com
25(4), 488-491.
• Simon, B. (2013). Hidden Dangers: non-lyme tick-borne
diseases. Nursing2013, September, 48-54
• Biggs, et. al. (2016). Diagnosis and Management of Tickborne
Rickettsial Diseases: Rocky Mountain Spotted Fever and Other
Spotted Fever Group Rickettsioses, Erlichilosis, and
Anaplasmosis- United States: A Practical Guide for Health Care
and Public Health Professionals. Morbidity and MortalityWeekly Report, 65(2), 1-44.
• Tickborne Diseases of the United States: A Reference Manual
for Health Care Providers, 4th Edition, 2017. CDC
References
• Vaughn, M. & Meshnick S. (2011). Pilot Study Assessing the Effectiveness of Premethrin-impregnated Clothing for the Prevention of Tick Bites. Vector Borne Zoonotic Disease, 11, 869-875.
• Websites:
www.cdc.gov
www.who.int
National pesticide information center-www.npic.orst.edu
Contact Information
Susan R. Schedler
MSN, APRN, ACNS-BC, CMSRN
913-632-2368