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Taylor-Salmon E, Shapiro ED. Tick-borne infections in children in North America. Curr Opin Pediatr 2024; 36:156-163. [PMID: 38167816 PMCID: PMC10932821 DOI: 10.1097/mop.0000000000001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Because both incidence and awareness of tick-borne infections is increasing, review of major infections and recent advances related to their diagnosis and management is important. RECENT FINDINGS A new algorithm, termed modified two-tier testing, for testing for antibodies to Borrelia burgdorferi , the cause of Lyme disease, has been approved and may replace traditional two-tier testing. In addition, doxycycline is now acceptable to use for treatment of and/or prophylaxis for Lyme disease for up to 21 days in children of any age. Borrelia miyamotoi , a bacterium in the relapsing fever type of Borrelia, is the first of this type of Borrelia that is transmitted by hard-bodied ticks such as Ixodes scapularis. SUMMARY Awareness of these infections and advances in their diagnosis and treatment is important to assure the best outcomes for affected patients. Table 1 contains a summary of infections discussed.
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Affiliation(s)
- Emma Taylor-Salmon
- Department of Pediatrics, Yale School of Medicine
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Eugene D Shapiro
- Department of Pediatrics, Yale School of Medicine
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
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Fareed A, Rohail S, Zameer U, Wahid A, Akhtar SMM, Masood W. A comprehensive neurological perspective on tick-borne flaviviruses, with emphasis on Powassan virus. Ther Adv Infect Dis 2024; 11:20499361241247470. [PMID: 38693969 PMCID: PMC11062229 DOI: 10.1177/20499361241247470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/28/2024] [Indexed: 05/03/2024] Open
Abstract
Powassan virus (POWV), a tick-borne flavivirus transmitted primarily by Ixodes ticks, poses a significant threat as it can lead to severe neuroinvasive illness. This review delves into the nuanced clinical presentation of Powassan infection, a challenge in diagnosis exacerbated by the absence of an available vaccine. Over the past decade, the prevalence of POWV has surged in North America, necessitating a thorough examination of its neurological manifestations alongside tick-borne encephalitis virus (TBEV). A comprehensive literature search conducted up to January 2024 revealed 135 cases of neurological symptoms associated with either Powassan or TBEV infection. Notably, severe occipital headache emerged as the most prevalent symptom (22.75%), followed by meningoencephalitis (10.34%), seizures (8.27%), and flaccid paresis (6.8%). Additional manifestations included poor balance, wide gait, dysarthria, facial nerve palsy, seizure, slurred speech, and absent deep tendon reflexes. Tragically, nine cases resulted in fatal outcomes attributed to POWV infection. This analysis highlights the intricate spectrum of neurological symptoms associated with Powassan infection and underscores the necessity for heightened awareness among medical practitioners, particularly in regions with a higher prevalence of the virus. The complexity of symptoms emphasizes the need for further research to unravel the factors contributing to this diversity. Additionally, exploring potential treatment avenues and vaccine development is crucial in addressing the rising threat posed by POWV, ultimately enhancing our ability to manage and prevent severe neurological outcomes.
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Affiliation(s)
- Areeba Fareed
- Department of Medicine, Karachi Medical and Dental College, Block M, North Nazimabad, Karachi 74600, Pakistan
| | - Samia Rohail
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Ushna Zameer
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | - Abdul Wahid
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Waniyah Masood
- Department of Medicine, Dow Medical College, Karachi, Pakistan
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Kakoullis L, Vaz VR, Kaur D, Kakoulli S, Panos G, Chen LH, Behlau I. Powassan Virus Infections: A Systematic Review of Published Cases. Trop Med Infect Dis 2023; 8:508. [PMID: 38133440 PMCID: PMC10747444 DOI: 10.3390/tropicalmed8120508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Powassan virus is an emerging neurotropic arbovirus transmitted by the tick Ixodes scapularis. This systematic review was conducted to aggregate data on its clinical manifestations, diagnostic findings, and complications. METHODS PubMed was searched until August 2023 using the term "Powassan", to identify all published cases of Powassan virus infections, as per PRISMA guidelines. RESULTS Among the 380 abstracts identified, 45 studies describing 84 cases (70 adult, 14 pediatric) were included. Cases were reported from the USA and Canada. Complications included paralysis in 44.1% of adult and 42.6% of pediatric cases, cognitive deficits in 33.3% of adult and 25% of pediatric cases, while the mortality rate was 19.1% and 7.1% in the adult and pediatric populations, respectively. Correlation analysis revealed an association between mortality and age (r = 0.264, p = 0.029), development of paralysis (r = 0.252, p = 0.041), or respiratory distress or failure (r = 0.328, p = 0.006). Factors associated with persistent neurological deficits were development of ataxia (r = 0.383, p = 0.006), paralysis (r = 0.278, p = 0.048), speech disorder (r = 0.319, p = 0.022), and cranial nerve involvement (r = 0.322, p = 0.017). Other significant correlations included those between speech disorders and ataxia (r = 0.526, p < 0.001), and between paralysis and respiratory distress or failure (r = 0.349, p = 0.003). CONCLUSION Powassan virus infections have significant morbidity and mortality and should be suspected in cases of encephalitis and possible tick exposure. PROSPERO registration number: CRD42023395991.
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Affiliation(s)
- Loukas Kakoullis
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA 02138, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Victor Renault Vaz
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA 02138, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Divmehar Kaur
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA 02138, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Sonia Kakoulli
- Medical School, University of Groningen, 9712 Groningen, The Netherlands
| | - George Panos
- Division of Infectious Diseases, Department of Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece
| | - Lin H. Chen
- Harvard Medical School, Boston, MA 02115, USA
- Division of Infectious Diseases and Travel Medicine, Department of Medicine, Mount Auburn Hospital, Cambridge, MA 02138, USA
| | - Irmgard Behlau
- Harvard Medical School, Boston, MA 02115, USA
- Division of Infectious Diseases and Travel Medicine, Department of Medicine, Mount Auburn Hospital, Cambridge, MA 02138, USA
- Molecular Biology and Microbiology and Ophthalmology, Tufts Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA 02111, USA
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Powassan Encephalitis: A Case Report from New York, USA. Case Rep Neurol Med 2022; 2022:8630349. [PMID: 36035550 PMCID: PMC9402360 DOI: 10.1155/2022/8630349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Powassan is a positive-sense, single-stranded, enveloped RNA virus that is a tick-borne Flavivirus, transmitted by Ixodes species, with groundhogs being the usual mammalian host. The virus is endemic to North America, with peak transmission during the summer and fall. The incubation period is 7–34 days, followed by a prodrome of flu-like symptoms. Although most infected individuals are asymptomatic, the virus can penetrate the CNS to produce a viral encephalitis. The key to the diagnosis is a positive serology. Results The patient is a 62-year-old male with a past history of a right putamen infarct, hepatitis C, hypertension, and substance abuse who presented due to acute onset altered mental status, dysarthria, and left-sided facial droop. He had several tick bites around the time of presentation in December. He was empirically treated for possible meningitis, as CSF revealed WBC 370 (80% mononuclear cells); RBC 10, protein 152 mg/dL, and glucose 59 mg/dL. An MRI scan of the brain showed a subacute left putamen stroke. MRAs of the head and neck were unremarkable. A Mayo Clinic Encephalopathy Panel was unremarkable; however, a New York State Arbovirus panel revealed Powassan IgM ELISA as well as Powassan Polyvalent microsphere immunofluorescence assay reactivity. His hospital course was complicated by critical illness myopathy and respiratory failure requiring tracheostomy. Conclusion The Powassan virus is a known etiology for encephalitis in North America. Although the peak incidence of transmission is in the summer and fall, this does not exclude transmission during other seasons. Due to the increasing prevalence of Powassan virus in Lyme-endemic areas particularly in the Midwest and Northeast, United States, patients with an unexplained altered mental status in these regions should be screened for Powassan virus, regardless of the time of year.
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Dumic I, Glomski B, Patel J, Nordin T, Nordstrom CW, Sprecher LJ, Niendorf E, Singh A, Simeunovic K, Subramanian A, Igandan O, Vitorovic D. "Double Trouble": Severe Meningoencephalitis Due to Borrelia burgdorferi and Powassan Virus Co-Infection Successfully Treated with Intravenous Immunoglobulin. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929952. [PMID: 33758161 PMCID: PMC8008974 DOI: 10.12659/ajcr.929952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Powassan virus (POWV) is an emerging tick-borne flavivirus transmitted to humans by ticks. While infection is asymptomatic in some people, others develop life-threatening encephalitis with high mortality rates. Co-infection between POWV and Borrelia burgdorferi is rare despite the fact that both pathogens can be transmitted through the same tick vector, Ixodes scapularis. It is unclear if co-infection leads to more severe clinical presentation and worse outcome. CASE REPORT A 76-year-old Wisconsin man was admitted for meningoencephalitis complicated by hypoxemic and hypercapnic respiratory failure requiring endotracheal intubation. The patient had no known tick bites but lived in a heavily wooded area. Extensive work-up for infectious, autoimmune, and paraneoplastic causes was positive for Borrelia burgdorferi and Powassan virus infection (POWV). Following treatment with ceftriaxone for neuroborreliosis and supportive care for POWV infection, the patient failed to improve. Intravenous immunoglobulins (IVIG) were started empirically, and the patient attained gradual neurological improvement and was successfully extubated. CONCLUSIONS Treatment for POWV infection is supportive, and at this time there are no approved targeted antivirals for this disease. At this time, it remains unclear if co-infection with 2 pathogens leads to a more severe clinical presentation and higher mortality. In the absence of contraindications, IVIG might be beneficial to patients with POWV infection who are not improving with supportive care.
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Affiliation(s)
- Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Bridget Glomski
- Mayo Clinic Family Medicine Residency Program, Eau Claire, WI, USA
| | - Janki Patel
- Department of Infectious Disease, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Terri Nordin
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.,Mayo Clinic Family Medicine Residency Program, Eau Claire, WI, USA
| | - Charles W Nordstrom
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Lawrence J Sprecher
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Eric Niendorf
- Department of Radiology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Amteshwar Singh
- Department of Hospital Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kosana Simeunovic
- Department of Hospital Medicine, Merit Health Wesley, Hattiesburg, MS, USA
| | - Anand Subramanian
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Oladapo Igandan
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.,Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Danilo Vitorovic
- Department of Neurology, University of Vermont, Burlington, VT, USA
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