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

Susan.schedler@shawneemission.org

913-632-2368