TIme to Get Ticked Off...

http://www.cdc.gov/mmwr/PDF/rr/rr5504.pdf

Thanks to the above link from Dr. Fuller for an excellent summary of Rocky Mountain Spotted Fever and Ehrlichiosis. The article is slightly dated at 2006, but it still forms a bedrock of knowledge that will serve any urgent care clinician well.  I wanted to highlight a few interesting points:

1. As the graphs show, North Carolina typically leads the nation in RMSF. For some reason, past CDC reviews typically list us or Oklahoma as the usual top getters. Most patients focus on Lyme, but again, the main, proven enemy in this state is RMSF.

2. On page 8, the article cites the useful tip that one should not assume that in the event of a family outbreak of illness, that the disease is not a tick borne disease and instead the fever is likely a viral illness. The literature is peppered with well confirmed "group outbreaks" of tick borne disease among golfing communities, families on camping trips, or a family pet leading to family wide tick disease.

3. Most people present on day 2-3 of a suspected tick bite or disease. Most cases of RMSF that have a rash first develop  the rash on days 2-4, so keep in mind you could be confronting " Rocky Mountain Spotless Fever". The rash usually starts on the ankles, wrists and forearms. As such, I often document in a febrile patient "normal wrists and ankles" to show I was looking for tick disease/rash.

4. Useful lab hints at the clinical diagnosis of RMSF ehrlichiosis are leukopenia, thrombocytopenia, mild hyponatremia, and mildly elevated hepatic transaminases. So, a CBC and CMP may augment your CLINICAL suspicion.....but note the lab titers should not, as even the earliest IgM does not start to rise until day 7.    

5. If you or someone else orders titers, the article mentions that titers can be elevated up to 3.5 years after infection. As such, it is easy to generate false alarm in a febrile illness you are investigating, since suddenly you have a "positive lab", but you are actually being misled by an old finding of elevated titers.

6. The article bluntly says on page 12, " doxycycline is the drug of choice for treatment of all tick disease in children and adults." THE END. The article further explains that the 1960s studies showing tooth staining in children less than 7 involved multiple, extended courses of doxycycline for otitis media. As such, a comparatively short (7-10 day) course of doxycycline should not harm the teeth of any child, regardless of age.  The American Academy of Pediatrics Committee on Infectious Diseases revised its guidelines in 1997 to say that doxycyline is the drug of choice for presumed or confirmed RMSF and ehrlichial infections in children of ANY age. I would use this CDC, standard of care paper as your reference in any legal accusations or conversations with parents on tooth stain risks. Remember you will get the call after the parent fills the prescription and reads the mandatory included drug summary and side effect pamphlet.

Again, I highly encourage all to peruse the article. You will be a better beacon of knowledge for it!