Subject: [Tweeters] Ticks and Rocky Mountain Spotted Fever
Date: Jun 6 15:50:28 2007
From: Julia N Allen - DrJNA at comcast.net


For those interested in discussions on tick diseases and whether to
save or not to save the tick - below are comments by 2 Public Health
experts made in response to a ProMED news report concerning a fatal
case of Rocky Mountain Spotted Fever in North Carolina.

ProMED is a program of the International Society for Infectious
Diseases http://www.isid.org.

>^..^<
Cheers
Julia N Allen
Seattle
DrJNA at comcast.net


> From: ProMED-mail <promed at promed.isid.harvard.edu>
> Date: June 6, 2007 3:08:07 PM PDT
> To: promed at promedmail.org
> Subject: PRO> Rocky Mountain spotted fever, fatal - USA (NC) (02)
> Reply-To: promedNOREPLY at promed.isid.harvard.edu
>
>
> ROCKY MOUNTAIN SPOTTED FEVER, FATAL - USA (NORTH CAROLINA) (02)
> ***************************************************************
>
> [1]
> Date: Tue 5 Jun 2007
> From: Gary Greenberg <gngreenberg at gmail.com>
>
>
> This news report is in stark contrast to much more cautionary medical
> practice in our area where tickborne rickettsial infections
> (ehrlichiosis
> and Rocky Mountain spotted fever) are endemic.
>
> 1) The careful enumeration of "tick bites" is very peculiar. Most
> residents
> find many ticks per season, dozens in those who frequent the outdoors.
> Perhaps the count is of episodes of clinical RMSF and the bracketed
> editorial comment is in error.
>
> 2) The skin rash of ehrlichiosis and RMSF is a very late finding,
> potentially
> beyond the time when antibiotic therapy might reverse fatal disease.
> Tick-exposed patients in our area are encouraged to present for
> specific
> treatment (doxycycline unless pregnant or infantile) as soon as they
> develop serious systemic symptoms: fever, unusual headache, widespread
> muscle pain. Even the history of a tick bite is unnecessary if the
> patient
> spends time in outdoor settings (gardening, sports).
>
> 3) Microbiological evaluation of the assaulting tick is a waste of
> time and
> a potential danger to the laboratory workers. Laboratory-acquired
> rickettsial infections are very high risk and historically a source of
> significant occupational mortality. Even handling the potential
> vector (to
> tape it onto an evidence card) unnecessarily increases patients'
> exposure.
>
> Empiric treatment is based upon clinical findings, geographical
> exposure
> and the calendar. The delay, cost and dissemination of the pathogen
> makes
> submitting a suspect tick a gesture of unnecessary scientific rigor.
>
> For those patients whose illness seems highly likely to be
> rickettsial in
> origin, acute and convalescent antibody titers provide retrospective
> support for a successful diagnosis and treatment. No decision about
> clinical management can be made from such information.
>
> --
> Gary N Greenberg, MD MPH
> Univ N Carolina School of Public Health
> <GNGreenberg at gmail.com>
>
> ******
> [2]
> Date: Tue 5 Jun 2007
> From: David Gaines <David.Gaines at vdh.virginia.gov>
>
>
> In the recommendations for what to do in the event of a tick bite,
> I agree
> with the recommendation that the tick should be saved for
> identification by
> an expert in the event of a subsequent onset of illness. However, the
> statement that "If a rash appears, take that card [tick] to your
> doctor" is
> misleading.
>
> With Rocky Mountain spotted fever (RMSF), the onset of symptoms
> (such as
> headache and fever) always precedes the appearance of the skin rash
> by 3 to 5
> days. In fact, the rash often does not appear until the 5th day
> after the
> onset of illness, and fatalities from RMSF often occur starting 5 days
> after the onset and can occur even if antibiotic therapy is
> commenced at
> that time.
>
> Furthermore, up to 30 per cent of RMSF patients never develop the
> characteristic rash.
>
> Therefore, persons experiencing the onset of illness up to several
> weeks
> after being bitten by a tick should see a health care provider, and
> the
> health care provider should treat the patient with an appropriate
> antibiotic on the presumption of RMSF, without waiting for
> serological test
> results, tick identification or the onset of a rash.
>
> --
> David N Gaines, PhD
> State Public Health Entomologist
> Virginia Department of Health
> Division of Zoonotic and Environmental Epidemiology
> Richmond, VA
> <David.Gaines at vdh.virginia.gov>
>
> [ProMED-mail thanks Drs Greenberg and Gaines for their useful
> comments. The
> original URL did state that there were 3 other cases of RMSF (not tick
> bites), but the final product was edited after it left this
> Moderator's hands.
>
> Clearly, prompt and empiric therapy is vital here, not confirming a
> diagnosis of RMSF prior to instituting therapy. - Mod.LL]
>

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