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Differential Diagnosis
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The differential diagnosis includes other causes of aseptic meningitis such as enteroviral infections, herpes simplex encephalitis, and a variety of tick-borne pathogens including tularemia, the rickettsial diseases, babesiosis, Lyme disease, poliomyelitis (no longer reported from Eastern Europe) and other flaviviral infections
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Clinical Findings
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A Symptoms and Signs
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The incubation period is 3 6 days The onset is usually abrupt with fever (to 389 406 C), sometimes with chills Severe myalgia, headache, photophobia, anorexia, nausea and vomiting, and generalized weakness are prominent symptoms Physical findings are limited to an occasional faint rash The acute symptoms resolve within a week The remission is followed in 50% of cases by recurrent fever and a full recrudescence lasting 2 4 days In an occasional case there may be three bouts of fever The differential diagnosis includes influenza, Rocky Mountain spotted fever, numerous other viral infections and, in the right setting, relapsing fevers
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Prevention
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Prevention is based on vaccination Although a vaccine has not been approved in the United States, a variety of vaccines are in current use, with the most popular and most effective being a formaldehyde-inactivated whole virus vaccine from Austria Alternative effective vaccines have been developed in Germany and Russia The initial vaccination schedule requires 1 year with boosters every 3 years Other prevention recommendations include avoidance of tick exposure, pasteurization of milk, and passive immunization with immunoglobulin within 4 days of exposure (disease exacerbation from exposure to immunoglobulin is not substantiated)
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B Laboratory Findings
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Leukopenia (2000 3000/mcL) with a shift to the left and atypical lymphocytes occurs, reaching a nadir 5 6 days after the onset of illness Thrombocytopenia may occur Viremia may be demonstrated by inoculation of blood into mice or by fluorescent antibody staining of the patient s red cells (with adsorbed virus) Complementfixing antibodies do not appear until the third week of disease but are the most frequently used tool to document an infection An RT-PCR assay may be used to detect viremia
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Therapy is largely supportive Some clinicians believe corticosteroids or other nonsteroidal anti-inflammatory drugs may be useful, although no controlled clinical trials exist
Bratton RL et al Tick-borne disease Am Fam Physician 2005 Jun 15;71(12):2323 30 [PMID: 15999870] Charrel RN Tick-borne virus diseases of human interest in Europe Clin Microbiol Infect 2004 Dec;10(12):1040 55 [PMID: 15606630] Kunze U et al Tick-borne encephalitis in childhood consensus 2004 Wien Med Wochenschr 2004 May;154(9 10):242 5 [PMID: 15244050] Zent O et al Protection against tick-borne encephalitis with a new vaccine formulation free of protein-derived stabilizers J Travel Med 2005 Mar Apr;12(2):85 93 [PMID: 15996453]
Complications
Aseptic meningitis (particularly in children), encephalitis, and hemorrhagic fever occur rarely Malaise may ensue, but fatalities are very rare
6 Colorado Tick Fever
Treatment
No specific treatment is available Ribavirin has shown efficacy in an animal model Antipyretics are used, although aspirin should be avoided Tick-avoidance measures may be effective in preventing the disease
ESSENTIALS OF DIAGNOSIS
Onset 1 19 days (average, 4 days) following tick bite Fever, chills, myalgia, headache, prostration Leukopenia, thrombocytopenia Second attack of fever after remission lasting 2 3 days
Prognosis
The disease is usually self-limited and benign
Bratton RL et al Tick-borne disease Am Fam Physician 2005 Jun 15;71(12):2323 30 [PMID: 15999870] Klasco R Colorado tick fever Med Clin North Am 2002 Mar; 86(2):435 40 [PMID: 11982311]
Viral & Rickettsial Infections
CMDT 2008
COMMON VIRAL RESPIRATORY INFECTIONS 1 Respiratory Syncytial Virus & Other Paramyxoviruses General Considerations
Respiratory syncytial virus (RSV) is a paramyxovirus that causes annual outbreaks of pneumonia, bronchiolitis, and tracheobronchitis, with the majority of cases occurring in the very young Premature infants with bronchopulmonary dysplasia are at highest risk Other risk factors in children include male gender, age less than 6 months, and day care exposure Incomplete immunity commonly leads to reinfection manifested typically as an upper respiratory tract infection and tracheobronchitis in older children or adults Serious pulmonary RSV infections have been described in elderly and immunocompromised adults Outbreaks with a high mortality rate in bone marrow transplant and pediatric liver transplant patients are reported Annual epidemics occur in winter and spring The average incubation period is 5 days Inoculation may occur through the nose or the eyes RSV is an increasingly recognized as contributing to recurrent otitis media in children and upper respiratory tract infections Among hematologic adult cancer patients with upper respiratory tract infections, the isolation of RSV is a significant marker for progression to pneumonia and concomitant bacterial pneumonia is reported in at least 40% of children under intensive care with RSV bronchiolitis
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