A Favorite magazine- Wilderness Medicine Newsletter

From “Ticks are Little Cesspools”
e trust (funded by Newmont) and creation of a recreational lakeGoodies from the Wilderness Medicine Newsletter (published by TMC Books - to get an online subscription, write to info@tmcbooks.com ).  Paraphrased from Sept/Oct 2010 issue.

Ticks are the leading insect-borne disease vector in the US, and second in the world (after mosquitos).  95% of insect-borne diseases in the US are caused by ticks.  All tickborne diseases are parasitic. 

Here are all the North American tick bourne diseases (DOCs listed are for adults):

Lyme Disease
Anaplasmosis - bacteria that attacks white blood cells  Vague flulike symptoms.  Treatment is doxy 100mg             7-14 days.  E and Central US.
Human Monocytic Ehrlichiosis - bacteria that attacks white blood cells  Vague flulike symptoms, maybe rash and joint pain.  Treatment is doxy 100mg 7-14 days.  Southern half US.
Human Ewingii Ehrlichiosis - bacteria that attacks white blood cells  Vague flulike symptoms.  Treatment is doxy 100mg 7-14 days. 
Cat Scratch Fever - uncommon, usually pediatric.  Swollen lymph nodes, flulike symptoms.  Reservoir is the domestic cat.  Doxy, or pt will recover without treatment in time.
Rocky Mountain Spotted Fever - see below
Colorado Tick Fever - attacts RBCs.  Self-limiting and not dangerous.  Start-stop fever and dengue-like symptoms. 
Tularemia - see below
STARI (Southern Tick- Associated Rash Illness) - similar to Lyme disease, SE and South US.  Treat with doxy 100mg for 2-3 weeks.
Tickborne Relapsing Fever - Western US, attacks blood vessels, mortality 1% treated, 30-70% without treatment.  Abrupt onset, relapsing high fever, shaking rigors, flulike symptoms.  Treat with doxy 100-200mg for 7 days.
Babes iosis - rare malaria-like illness, attacts RBCs.  Treatment is malaria drugs or clindamycin/other.
Tick Paralysis - caused by a neurotoxin in the saliva of the gravid female tick.  Usually peds.  Treat by removing tick (often hidden at hairline).
Q Fever - see below
Tickborne Encephalitis (Deer Tick Virus) - virus, causes headache, neck and back pn, etc.  Supportive treatment only.

Yikes-! one more reason to live every day to its fullest… you never know… (although I guess an alternative argument for sitting inside on the couch all day could be made here). 
Ticks are small arachnid ectoparasites that feed on mammals, birds, and occasionally  reptiles or amphibians.  It is estimated that ticks transmit a greater number and variety of diseases than any other arthropod.  Female ticks lay about 3000 eggs on the ground in late spring.  Once hatched, ticks take blood meals from 3 different hosts at successive stages of their life cycle- as a larvae, nymph, and adult.  This is important because nymphs are small and hard to detect but can still pass on disease.  Ticks live 1-2 years.  Disease is spread between hosts when the tick’s contaminated saliva is injected into the host as an anticoagulant. 

A little detail on a few of the diseases caused by ticks:
Lyme Disease - caused by a bacterial spirochete spread by the deer tick in the east and the blacklegged tick in the west.  Is relatively common and can cause lifelong morbidity.  Fortunately a deer tick must be attached for at least 24 hours to transmit the disease, so a thorough search after outdoor activities may detect a vector in time.  Lyme disease is most commonly spread by small, easy-to-miss nymphs.  Reservoirs are white footed mice, meadow voles, whitetail deer, and some species of birds. 
By the time symptoms appear, the disease has disseminated throughout all body systems.  There are three stages:
1) Early localized disease: After incubation of 3-30days.  The classic sign is erythema migrans - a red bullseye rash which can be present anywhere on the body, not just the bite site, and is diagnostic if >5cm.  Occurs in 50-80% of cases.
Fever, headache, muscle pain, joint pain, swollen lymph nodes near bite.  Victim may be asymptomatic.
2) Early Disseminated Disease: 2-6 weeks or more:
Multiple erythematic migrans, secondary annular lesions, cranial neuropathies in 15% cases, lymphcytic or aseptic meningitis, cardiac manifestations in 8%, orchitis, hepatitis, hepatosplenomegaly, conjunctivitis, migratory joint pains, swollen throat
3) Late or Chronic Disease - 2-4 months or more.  Arthritis, synovitis, tendonitis, bursitis - 50% cases, neuropsychiatry behaviors: psychosis, dementia, memory loss, depression.  Encephalopathic symptoms: headaches, confusion, fatigue, memory loss.  May mimic other CNS diseases: Parkinsons, MS, stroke-like, neuronitis.
Tickbite prophylaxis is a single 200mg dose of doxycycline.  Treatment is doxy 100mg/day for at least 28 days.  An estimated 20% of people with Lyme disease have a second tick-borne illness as well.

Rocky Mountain Spotted Fever is rare, with about 1000 cases/year, mostly in children.  It causes disseminated small blood vessel damage that can be fatal without treatment. 
Incubation is 2-14 days.  Symptoms include fever, chills, severe headache, muscle pain, mental confusion, followed by the rash.  The rash looks like small flat red spots that start at the wrists and ankles and move up centrally, usually sparing the face.  The rash gets bumpier over time.  10% of pts do not get the rash. 
Treatment is doxy 200mg for 7-14 days.

Tularemia is a hardy bacteria that survives well in cold dry environments.  It is capable of passing through healthy undamaged skin.  Spread by ticks, deer flies, handling infected pelts, eating infected meat, or drinking infected water.  Reservoir is rabbits, hares, pikas.  Occurs in North America and Europe.  Worldwide there are 500,000 cases/per, but only 150-300 in the US. 
There are 6 forms of tularemia, depending on transmission mode:
70-80% Ulcero glandular - caused by insect bite or contamination of open wound
Glandular- rare, no ulcerations, bacteria gained access direct into bloodstream
Oculoglandular - from contaminated fluids splashed into eye
Oro  pharyngeal - from ingestion contaminated meat
Pneumonic- from inhalation contaminated droplets
Typhoid al - from ingestion contaminated meat
Incubation 1-21 days, then swollen skin papules at site of bite which progress to ulceration with fever and swollen lymph nodes in groin and armpits.  Flulike symptoms, conjunctivitis, sweating, dyspnea, weight loss, joint stiffness. 
Streptomycin is the DOC: 1-2 gm/day for 7 days, or doxy 100 mg for at least 14 days.

Q fever is usually contracted via infected droplets from cattle, sheep, or goats in stockyards across America, but ticks can also be a vector.  It is highly virulent- 1 bacterium can cause disease, and it resists drying for long periods. 
Incubation is 20 days, then acute illness is flu-like and can last 3 weeks.  1/3 of all cases develop into hepatitis or pneumonia.  If untreated it can turn into chronic Q fever with long-term heart, lung, and liver damage. 
Responds best if treatment started within 3 days.  Doxy 100 mg 2-3 weeks.

Elsewhere in the world:
Lyme Borreliosis - the European and Asian version of US Lyme disease
Crimean- Congo Hemorrhagic Fever - a virus in the Yellow Fever/dengue family- attacts blood vessels.  Spontaneous bruising and internal bleeding, supportive care only, cab be fatal. 
Kyasunur Forest Disease - similar to above
Omsk Hemorrhagic Fever - similar to above
Boutonneuse Fever -
African Tick Fever - similar to Rocky Mountain Spotted Fever
And Australia has 4 diseases that are similar to Rocky Mountain Spotted Fever: Queensland Tick Typhus, Flinders Island Spotted Fever, Murine Typhus, Scrup Typhus.  (yet another fun discovery for the Aussie settlers)
And more………

So wear insect repellent, sleep under netting, and do frequent tick checks!

BTW, I love this Wilderness Medicine Rag:
The Wilderness Medicine Newsletter (published by TMC Books - to get an online subscription, write to info@tmcbooks.com
A 3 yr subscription to this bi-monthly electronic magazine aimed at outdoorsmen, EMS providers, and healthcare workers costs $30.  I only wish they included a CEH credit option for my state in each issue!
These are their topics over the years: 
1 May 1988 Head Injury, Headache
2 June 1988 Feet, Sprains & Strains, Blisters
3 July 1988 Heat Injury, Heat Cramps
4 August 1988 Lyme Disease, Insect Bites
5 September 1988 Wound Management, Wound Infection, Giardia
6 October 1988 Hypothermia, Immersion Foot
7 November 1988 Legal Aspects, Major Wound Care, Epistaxis
8 December 1988 Hx of Wild Med, Snakebite, Hyperventilation
9 January 1989 Frostbite, Cervical Spine
10 February 1989 Altitude Illness, Yeast Infections, Spinal Assessment
11 March 1989 Neck Pain, Altitude, Rashes, Poisoning
12 April 1989 Dental Emergencies, Poisoning Chart, Otitis Externa
13 May 1989 Backache, Poisoning, Heartburn
14 June 1989 Rabies, Cocaine, Anaphylaxis
15 July 1989 Dysbarism, Lyme, Sunburn
16 August 1989 Lightning, Common Cold, Altered LOC
17 September 1989 Malaria, Healing, Fractured Clavicle, Asthma, Peter Hackett, MD
18 October 1989 Feet, Fractures, Mushrooms
19 Nov/Dec 1989 Toxic Shock Syndrome, Spider Bites, Femur, Frostbite
20 Jan/Feb 1990 Optic Injuries, Pain, Rescue Tobaggan, Hand Injuries
21 Mar/Apr 1990 Naegleria, Panic, Hypothermia, Red Tide, Cold Sores
22 May/June 1990 Insects, Allergies, Water, Fishhooks, Water Disinfection
23 July/Aug 1990 Violent Behavior, SCIM, SOAPnote, Poison Ivy, Patellofemoral
24 Sept/Oct 1990 Immersion, Bears, Hearing, Carpal Tunnel, Femur
25 Nov/Dec 1990 Tendonitis. Tetanus, Asthma, Hobo Spider, Shin Splints
Vol. 2, 1 Jan/Feb 1991 Fever, Hypothermia, Leptospirosis
2 Mar/Apr 1991 Fractures, Hypothermia,
3 May/June 1991 Infectious Disease, Hypothermia, Amputation
4 July/Aug 1991 Dehydration, Dogs, Leeches, Facial fractures
5 Sept/Oct 1991 SAR Basics, Cervical Spine, Raynaud’s Syndrome
6 Nov/Dec 1991 BP, Hand Injuries, Arthritis
Vol. 3, 1 Jan/Feb 1992 HBV, Socks, Snakebite
2 Mar/Apr 1992 Med Hx, Fibromyalgia, Appendicitis
3 May/June 1992 Drugs, Activated Charcoal, Vapor Barriers
4 July/Aug 1992 Ankle Injuries, Knee Injuries, Vapor Barriers
5 Sept/Oct 1992 Psych Assessment, NOLS
6 Nov/Dec 1992 Deep Wounds, Burn Care
Vol 4, 1 Jan/Feb 1993 Anaphylaxis, Puma Attacks
2 Mar/Apr 1993 Helicopter, Ailing Nails, Insects
3 May/June 1993 Diving Emergencies, Suicide, UTI
4 July/Aug 1993 Water Disinfection, Cryptosporidium, Hantavirus, Hygiene
5 Sept/Oct 1993 Book Review Issue
6 Nov/Dec 1993 Asthma, Seizures, Diabetes
Vol. 5, 1 Jan/Feb 1994 Legal Issues
2 Mar/Apr 1994 Wild Pediatrics
3 May/June 1994 Zoonoses
4 July/Aug 1994 Ozone & UV light
5 Sept/Oct 1994 The 5 Commandments of First Aid Kits
6 Nov/Dec 1994 Principles of Wild EMS, Newsletter moves back to SOLO
Vol. 6, 1 Jan/Feb 1995 Can I Do That, Legally?, Cellulitis, William Forgey, MD
2 Mar/Apr 1995 Outdoor Leadership—Past and Present, Diamox
3 May/June 1995 Parasitology, HAV, Warren Bowman, MD
4 July/Aug 1995 Wilderness Pediatrics, Allerigies
5 Sept/Oct 1995 Hypothermia, Keith Conover, MD
6 Nov/Dec 1995 Chest Injuries, Cardiac Risk, Anaphylaxis, Frank Hubbell, DO
Vol. 7, 1 Jan/Feb 1996 Hello, 911? Murray Hamlet, DVM
2 Mar/Apr 1996 Eating disorders, Bill Herring, MD
3 May/June 1996 Immersion Foot, Robert Rose, MD
4 July/Aug 1996 Musculoskeletal system I
5 Sept/Oct 1996 Lightning
6 Nov/Dec 1996 Potpourri: Frostbite, chilblains, Avalanche, David Kuhns, PAC
Vol. 8, 1 Jan/Feb 1997 Musculoskeletal system II
2 Mar/Apr 1997 Drowning, Ask the Experts
3 May/June 1997 Rabies, Ask the Experts
4 Jul/Aug 1997 Women’s Health Issues, Ask the Experts
5 Sept/Oct 1997 Water, Water, Everywhere…Death in the Backcountry
6 Nov/Dec 1997 Medecine Sans Frontieres
Vol. 9, 1 Jan/Feb 1998 Avalanche Awareness
2 Mar/Apr 1998 ALS in the Backcountry
3 May/June 1998 The Charcoal Vest – hypothermia
4 July/Aug 1998 ISMM – Case, Summer Review – Heat Injuries
5 Sept/Oct 1998 What’s Your Position – GPS, Trenchfoot
6 Nov/Dec 1998 Gender Specific Emergencies, Hypothermia
Vol. 10, 1 Jan/Feb 1999 Tendonitis, Musculoskeletal problems
2 Mar/Apr 1999 Anaphylaxis, Clearing the Cervical spine
3 May/June 1999 Wild – Critical Incident, Kayaking injuries
4 July/Aug 1999 Children in the Mountains
5 Sept/Oct 1999 Oh, My Aching Feet, Joy of Socks,
6 Nov/Dec 1999 Breathing Hard in the Backcountry, Pre-Existing Conditions
Vol. 11, 1 Jan/Feb 2000 Lions & Tigers & Bears, Oh My,
2 Mar/Apr 2000 Unraveling Abdominal Pain, Oral fluids, cave rescue
3 May/June 2000 Sunscreen Controversy, Dehydration & Heat Injury
4 July/Aug 2000 Leadership in Prevention, Lost Proofing
5 Sept/Oct 2000 Stonefish, Sea snakes, & Jellyfish, Shark bites
6 Nov/Dec 2000 Got the Travel Bug, Bugs in Bed
Vol. 12, 1 Jan/Feb 2001 Have You Ever Wondered Why?
2 Mar/Apr 2001 Don’t Blame Montezuma
3 July/Aug 2001 Contact Dermatitis
4 July/Aug 2001 Diabetes in the Wilderness, Answers to Common Wild ?
5 Sept/Oct 2001 Wilderness Rescue in the Winter Environment
6 Nov/Dec 2001 Survey of Backcountry Drugs
Vol. 13, 1 Jan/Feb 2002 Brief History of Wilderness Med Outside the Golden Hour
2 Mar/Apr 2002 Managing a Backcountry Fatality
3 May/June 2002 The World of Infectious Disease
4 July/Aug 2002 Preventing Infectious Disease, Schistosomiasis
5 Sept/Oct 2002 Cardiac Disease, Aspirin, West Nile Virus
6 Nov/Dec 2002 Risk Management Briefing, Psychotropics, smallpox
Vol. 14, 1 Jan/Feb 2003 Weather, Psychotropics, Giardia
2 Mar/Apr 2003 Musculoskeletal Trauma I, Psychotropics part 2
3 May/June 2003 Musculoskeletal Trauma II
4 July/Aug 2003 Lightning, Beauty & the Beast
5 Sept/Oct 2003 Musculoskeletal Trauma III, Pain Control
6 Nov/Dec 2003 The Performance Triad, H2O, Water purification
Vol. 15, 1 Jan/Feb 2004 When Jack Frost Bites, Mike Lynn
2 Mar/Apr 2004 Changes in Level of Consciousness, part 1
3 May/June 2004 Changes in Level of Consciousness, part 2
4 July/Aug 2004 The Heart of the Problem, Acute MI, Giant Hogweed
5 Sept/Oct 2004 Dental Emergencies, STARI, dislocated patella
6 Nov/Dec 2004 Frozen Mythbusters
Vol. 16, 1 Jan/Feb 2005 Non-Freezing Cold Injuries, Free Radicals
2 March/April 2005 Self-Preservation – Disaster Response
3 May/June 2005 Heat-Related illness
4 July/Aug 2005 Malaria
5 Sept/Oct 2005 Eye Injuries
6 Nov/Dec 2005 Burns
Vol. 19, 1 Jan/Feb 2006 Soft Tissue Injuries: Part 1
2 March/April 2006 Soft Tissue Injuries: Part 2
3 May/June 2006 First Aid Kits, Crush Injuries
4 July/August 2006 Poisonous Pearls (of wisdom)
5 Sept/Oct 2006 SNAP! Crackle Pop: Orthopedic Emergencies
6 Nov/Dec 2006 High Altitude Illness
Vol. 20, 1 Jan/Feb 2007 20 Years of Wilderness Medicine—a retrospective
2 Mar/April 2007 The First Five Minutes—the Patient Assessment System
3 May/June 2007 The First Five Minutes—Critical Care
4 July August 2007 Barotrauma—Deep Trouble
5 Sept/Oct 2007 Allergies—Runny Nose to Anaphylaxis
6 Nov/Dec 2007 The Rist of Caring
Vol. 21, 1 Jan/Feb 2008 Disaster, TB, Nausea, Tib-Fib splint, WMN Extreme Makeover
2 March/April 2008 Navigation, Dengue, Constipation, Laxatives, Traction Splint
3 May/June 2008 Diabetes, Yellow Fever, Fever, Pelvic Sling
4 July/August 2008 Facial Trauma, Water-Borne Disease, Spine, Water, Pain, Blisters
5 Sept/Oct 2008 Shortness of Breath, giardiasis, inhalers, eye abrasions/impalements
6 Nov/Dec 2008 Respiratory trauma, cholera, fishhooks, bugs in ear, antihistamines
Vol. 22, 1 Jan/ Feb 2009 A Winter Primer
2 March/April 2009 Summer Primer, influenza, rhinitis, dermatology, boot bash, Africa Prt I
3 May /June 2009 Summer Primer, influenza, rhinitis, dermatology, boot bash, Africa Prt II
4 July/August 2009 Principles of Long-Term Patient Care-Part I
5 Sept/Oct 2009 Principles of Long-Term Patent Care -Part II
6 Nov/Dec Special Haiti edition: Disaster Management Revisited
Vol. 23, 1 Jan/Feb 2010 Celiac Disease
2 March/April Abdominal Trauma
3 May/June Abdominal Emergencies
4 July/August Marine Bites and Stings
5 Sep/Oct Tickborne Diseases
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