early treatment of tick Borne illnessesby Edwin J. Masters, MD†Both doxycycline and azithromycin are generally well tolerated, have long track records and low incidences of true allergy, are excreted through the G. I. tract, and available as generics.
illness,4,5 Lyme disease, Ehrlichia chaffeensis, Ehrlichia ewingii, Human Granulocytic Anaplasmosis, Babesiosis
sensible combination of relatively safe Coxiella burnettii (Q fever) tularemia, acne medications to prevent serious
Rickettsia amblyommii, Rickettsia rickettsii.
etc. Tick transmission of Bartonella
very helpful. Ixodes scapularis, (deer
tick) Amblyomma americanum, (Lone
star tick) and the dermacentor, (dog
a specific tick, he may not have a clear triad of the Human Granulocytic recollection of its appearance. Many
Babesiosis in the northeast vectored by
Also, geography helps in deducing the Ixodes scapularis (deer tick),and Human tick species, but it is not absolute.
Monocytic Ehrlichiosis, due to Ehrlichiachaffeensis, and STARI, are vectored
by the Amblyomma americanum (Lone
tick is expanding its territory into the
northeast, and has even been found in star tick) in the Midwest and south.
the state of Maine. (Keirans, Means)1, 2 Delayed diagnosis and treatment can
Human Monocytic Ehrlichiosis (HME) early diagnosis, when symptoms may
250 w July/August 2009 w 106:4 Missouri Medicine
The problem is that the tick is usually not saved and even though the patient may have removed a specific tick, he may not have a clear recollection of its appearance.
evidence of recovery or 48 hours post inhibiting bacterial but not human
sensitivity and specificity. Polymerase available as generics this tends to
widely used for the treatment of acne. for many of the previously listed tick
are the rickettsial diseases, Rocky
provides therapeutic continuity in the ages.10,12-13 It has the best outcome
106:4 Missouri Medicine w July/August 2009 w 251
other antimicrobials.Intl Journ of Antimicrobial Agents
1. Keirans JE, Lacombe EH. 1998. First Records
(31) 2008 Pgs. 235-239. 10. Masters EJ, Olson OS, Weiner SJ, Paddock
of Amblyomma americanum, Ixodes dentatus, and Ixodes (Ceratixodes) uriae (Acari: Ixodiae) from Maine.
CD, Rocky Mountain Spotted Fever - A Clinician’s
The Journal ofParasitology, Vol. 84, No.3.
Dilemma. Arch Intern Med. 2003; 163:769-774.
2. Means RG, White DJ. New distribution records
11. Olano JP, Masters EJ, Hogrefe W, Walker DH.
of Amblyomma americanum (l) (Acari: Ixodidae) in New
Human Monocytotropic Ehrlichiosis, Missouri.
York State. J Vector Ecol. 1997 Dec. 22(2):133-45
Emerging Infectious Diseases, Dec., 2003;Vol. 9:
3. Kirkland KB, Wilkinson WE, Sexton DJ,
no. 12/02-0733. 12. Centers for Disease Control and Prevention.
Therapeutic delay and mortality in cases of Rocky Mountain spotted fever. Clin Infect Dis. 1995;20:
Consequences of delayed diagnosis of Rocky
Mountain spotted fever in children—West Virginia,
4. Masters EJ, Grigery CN, Masters RW, STARI, or
Michigan, Tennessee, and Oklahoma. May-July 2000. MMWR Morb Mortal Wkly Rep. 2000; 49:
need for tick identification or knowing Masters Disease: Lone Star Tick-Vectored Lyme-
Like Illness. Infectious Disease Clinics of North America
13. American Academy of Pediatrics. Rocky
5. Masters EJ. Lyme-Like Illness Deserves Lyme-
Like Treatment [Correspondence] or not? Clin
In: 2006 Red Book: Report of the Commission on
Infect Dis. 2006; 42:580-581.
6. McCants-Carr, R., Mohrman, L., Arelli,V.,
14. Holman RC, Paddock CD. Analysis of risk
Masters, E., “Cat Scratch Controversies”, Infection in
factors for fatal Rocky Mountain Spotted Fever: evidence for superiority of tetracyclines for therapy.
Med. May 20087. Gilbert DN, Moerllering RC, et. al. The Sanford
J Infect Dis 2001 Dec 1;184(11):1437-44. Epub
Guide to Antimicrobial Therapy 2008, 38th edition
15. Lochary ME, Lockhart PB, Williams WT Jr.
8. Rakel, and Bope, Conn’s Current Therapy 2008.
Doxycycline and staining of permanent teeth.
9. Lee J, Wormser GP, Pharmacodynamics of
Pediatr Infect Dis J. 1998;17:429-431.
doxycycline for chemoprophylaxis of Lyme disease:
preliminary findings and possible implications for
Tetracyclines and permanent teeth: the relation between dose and tooth color. Pediatrics. 1971; 47:
567-570. 17. Purvis JJ, Edwards MS. Doxycycline use for rickettsial disease in pediatric patients. Pediatr Infect Dis J. Sep 2000;19(9):871-4. 18. Forti G, Benincori C., Doxycycline and the teeth. Lancet 1969;1:782. 19. Abramson JS, Givnar LB, Should Tetracycline be contraindicated for therapy of presumed Rocky Mountain spotted fever children less than 9 years of age? Pediatrics. 1990;86: 123-124. 20. Product info and Pers Comm from Pfizer Pharm.for Vibramycin and Azithromax, July 2008. 21. Freidank HM, Losch P, Vögele H, and Wiedmann-Al-Ahmad M. In Vitro Susceptibilities of Chlamydia pneumoniae Isolates from German Patients and Synergistic Activity of Antibiotic Combinations. Department of Bacteriology, Institute for Medical Microbiology and Hygiene, University of Freiburg, D-79104 Freiburg, Germany Received 23 November 1998/Returned for modification 8 March 1999/Accepted 10 May 1999. 22. Halperin JJ, Shapiro ED, et. al. Practice Parameter: Treatment of Nervous System Lyme Disease (an evidence-based review) Report oft hr Quality Standards Subcommittee of the American Academy of Neurology. American Academy of Neurology. May 2007. 23. Jaruratanasirikul S., Horttwakul R., Tantisarasart T., et.al. Distribution of azithromycin into brain tissue, cerebrospinal fluid, and aqueous humor of the eye. J. Antimicrobial agents and chemo 1996 vol. 40, pgs.825-826.
252 w July/August 2009 w 106:4 Missouri Medicine
santa, cattolica ed apostolica . Professo un bene e di attuare in noi la volontà del solo battesimo per il perdono dei peccati. Padre, abbi pietà di noi. Cristo, pietà . Aspetto la risurrezione dei morti e la vita guidata dal tuo Spirito aderisca a lui con Signore, che perdoni sempre a chi viene a del mondo che verrà. Amen . te col cuore pentito, abbi pietà di noi. Signore,