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    Old 04-29-2001, 06:55 PM   #1
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    Post San Francisco Chronicle: "Heard of Lyme? Three newly recognized diseases mean you sh



    Heard of Lyme? Three newly recognized diseases mean you should take extra precautions against tick bites

    Claudia Morain, Special to The Chronicle Sunday, April 29, 2001

    Loretta Goudie blames Frrt the cat. One evening the dowager feline was purring on her mistress' lap. The next morning Goudie had a tick the size of a large freckle sucking blood from her neck.

    "That cat is a tick taxi," says Goudie, 48, of Aptos. "I figure she carried the tick in, the tick didn't like the taste of her and, when she sat down on me, the tick must have smelled me and thought I seemed like a better meal."

    Goudie wasted no time prying the engorged tick from her flesh, but four days later she developed an angry red rash, right where the tick had feasted on its final blood meal.

    Goudie came down with Lyme disease -- and two lesser-known but potentially more dangerous tick-borneinfections: human granulocytic ehrlichiosis (HGE) and babesiosis. Ticks, because they can harbor more than one disease-causing agent at a time, can transmit multiple illnesses to their human hosts. Such co- infections are more challenging to diagnose and treat -- and can make sufferers much sicker. Goudie, a manager at a Web software firm in Santa Cruz, was wiped out for two years, unable to work. "Just lifting my arm was a chore, " she recalls. "I didn't have the energy to think."

    "Ehrlichiosis and babesiosis are fairly newly described tick-borne illnesses in California," says Anne Kjemtrup, a veterinary epidemiologist at the state Department of Health Services. "We would like to put the information out that these diseases are here in California, and no matter where you go, you should be careful."

    As warmer weather beckons Bay Area residents to parks, campgrounds and other favored tick haunts, Kjemtrup's warning takes on added urgency.

    Lyme disease, first recognized in Connecticut in 1975, is the most common tick-borne illness in the United States. But HGE and a second ehrlichiosis infection, human monocytic ehrlichiosis (HME), may not be far behind. And babesiosis is turning up in more new places every year.

    On the East Coast, the deer tick, Ixodes scapularis, transmits the three bacteria responsible for Lyme disease, HGE and HME, as well as the parasite that causes babesiosis. Here on the West Coast, the Western black-legged tick, Ixodes pacificus, spreads Lyme and HGE bacteria. Scientists are still working out which tick species transmits the HME bacteria and the babesiosis parasite. (The Western black-legged tick is a top suspect.)

    For hikers and bird-watchers, golfers and gardeners, the newly recognized infections mean that safe-tick behavior is needed year-round. Prime Lyme season runs from late spring through early summer, months when the Western black-legged tick is in its adolescent, nymphal stage and most likely to spread Lyme disease. Prime HGE season, in contrast, stretches from November through early spring, when the tick is in its adult phase and most likely to spread that infection. Because scientists aren't sure which tick harbors the HME and babesiosis organisms here, they can't yet say when risk is highest for those infections.

    The Western black-legged tick has been found in 56 of California's 58 counties, according to the state Department of Health Services. But the little arthropod is most likely to hang out in woodsy areas of the coastal range north of San Francisco, the western Sierra foothills of northern California, and the Bay Area, especially Santa Cruz County. The ticks are less common in the Central Valley and south of the Tehachapi Mountains.

    Lyme disease may be better known and more feared, but ehrlichiosis and babesiosis are potentially more serious. Babesiosis, a malaria-like illness caused by a parasite that attacks red blood cells, weakens the immune system and can be fatal, especially in elderly people, those with already weakened immune systems and anyone who has lost a spleen due to an injury or illness. HGE, the more serious of the two human ehrlichiosis infections, can cause overwhelming infection, toxic shock and death.

    HGE is caused by a close cousin of a bacteria first identified in the 1960s as the source of a horse illness in California. The human disease was first recognized in 1994, in a cluster of patients in Minnesota and Wisconsin. Two Californians, both from Santa Cruz County, turned up with the infection the following year. By 1997, health departments in eleven states had reported 449 cases of the previously unknown illness, according to the most recent published statistics from the U.S. Centers for Disease Control and Prevention. Today, California's official tally stands at six HGE cases; the latest four all occurred in Humboldt County.

    HME first appeared in 1986 in a 51-year-old man bitten by a tick while in Arkansas. Since then, health departments in 19 states have reported 740 cases, including three in California -- one in Marin County and two in Humboldt County.

    Babesiosis, a scourge of cows worldwide for decades, made its human debut in 1969 on Nantucket Island. More than 450 cases of the illness have been reported in at least a dozen states since then, most frequently in the Northeast during the summer. The first Californian came down with the bovine bug in 1993. Today the state's total is six. Mono, Monterey, San Bernardino and Sonoma counties each have had one case; Alameda County has had two. The Sonoma County patient, a 36-year-old man whose spleen had been removed, died of the illness.

    But it's likely these case numbers are low. Robert S. Lane, professor of entomology at the University of California at Berkeley, says the true incidence of tick-borne illnesses may be 10 times higher. "A lot of doctors -- the vast majority, I'd say -- don't report the infections," Lane said.

    And many doctors may not know what to look for. "There are a lot of sick people around without anyone to treat them," says Dr. Raphael Stricker, a San Francisco internist specializing in immunology and hemotology who represents the California Medical Association on Gov. Gray Davis' nine-member Lyme Disease Advisory Committee.

    Lyme, ehrlichiosis and babesiosis all start with similar, flu-like symptoms -- fever, headache, muscle aches, joint pain, fatigue, usually within seven to 21 days of the tick bite. A skin rash shows up at the same time in 1 in 5 behrlichiosis cases, and in 1 in 2 Lyme cases. No rash occurs with babesiosis, but drenching sweats do. Ehrlichiosis, on top of the flu-like symptoms, also may cause nausea, vomiting, diarrhea and appetite loss.

    If treated early, all of the infections are easily cured. But there's the rub: Laboratory tests to rapidly diagnose tick-borne diseases still leave much to be desired. Because of this, and because the consequences of doing nothing can be so severe, the National Institute of Allergy and Infectious Diseases, in a fact sheet for physicians, urges doctors to consider treatment based on symptoms alone.

    Antibiotics eradicate Lyme and ehrlichiosis infections. Antibiotics plus medication used to treat malaria can cure babesiosis.

    Without treatment, early Lyme symptoms go away on their own within three to four weeks, but the illness can return weeks or months later with a vengeance. Late-stage Lyme disease causes a host of debilitating symptoms, from arthritis to memory, thought and mood disturbances, troubles that may persist for many years.

    Without treatment, most people with ehrlichiosis also recover on their own without long-lasting problems. But some people develop life-threatening complications, and up to 5 percent die.

    In most people, babesiosis also tends to be fairly mild, even without treatment. But some people with the infection develop severe anemia, kidney failure and other life-threatening complications. Occasionally the illness is fatal.

    "After you've been in a tick area, monitor yourself for the next 30 days for flu-like symptoms such as fever, chills and non-specific aches and pains," Kjemtrup advises. "If you develop any of these symptoms within the month, see your physician and tell him or her that you've been bitten by a tick."

    Goudie saved her tick. When the rash appeared on her neck, she reported to an urgent care center. The dead tick was identified as an adult female Western black-legged tick. Goudie went home on antibiotics.

    But the treatment, while prompt, wasn't enough. Several months later Goudie broke out in a rash all over her body. She had a killer headache, crippling fatigue and joint pain. Intravenous antibiotics kept the symptoms in check, but Goudie relapsed every time she stopped therapy.

    The turning point was an October 1998 conference in Chico, sponsored by the Northern California Lyme Disease Resource Center based in Sonoma. Still wearing a portable IV, Goudie sat in on the conference and for the first time suspected co-infection with ehrlichiosis and babesiosis. When she got back home, she asked her doctor to test for both. She was positive for HGE and babesiosis.

    Goudie started on a regimen that included, at various times, Mepron, an anti-protozoal drug; doxycycline, azithromycin and trimethoprim- sulfamethoxazole, all oral antibiotics; and Rosephin, an IV antibiotic. After more than a year of aggressive combination therapy, she was able to return to work full-time, and today feels "reasonably human again."

    Goudie has tried weaning herself off the drugs three times, but relapsed each time. At one point, she managed to get down to just one antibiotic, and she hopes that some day she won't need any.

    "I've been lucky," she says. "I was able to fight my way back out of the pit."

    Lane, one of the world's leading experts on Lyme disease transmission, is also a student of ehrlichiosis and babesiosis. The UC Berkeley professor says it's likely that all of these tick-borne illnesses have been affecting humans for millennia. Only with the development of modern molecular medicine, however,

    have scientists been able to detect the organisms responsible for the suffering.

    The bacteria responsible for Lyme disease, Borrelia burgdorferi, wasn't identified until 1981. And the bacteria that causes HGE in California wasn't isolated until 1996.

    "I think many Californians have gone to their graves with these diseases, not knowing what they had," Lane says. "With emerging and re-emerging infectious diseases, we still have a lot to learn. And there are probably some out there that we still don't know about."

    Goudie knows all this now. But she still enjoys the outdoors, and still welcomes Frrt the cat into her lap.

    "I don't feel like I should let ticks rule my life,'' she says.

    Goudie and her husband do, however, check each other for ticks every time they shower.

    When hiking, gardening or golfing in tick-infested areas:

    Wear light-colored clothing so you can see ticks crawling on your clothes.

    Tuck your pant legs into your socks so ticks can't crawl up the inside of your pant leg.

    Spray tick repellent containing permethrin on your shoes and clothing; this will kill ticks for several days.

    Apply repellents containing DEET to your skin; these repellents must be reapplied every few hours. (Use DEET with caution on children; application of large amounts on kids has been associated with adverse reactions.)

    Ask your vet for medication that can kill ticks on your dogs and cats.

    Do a full-body check for ticks after returning from a potentially tick- infested area. Ask someone else to check your back and scalp, or use a handheld and full-length mirror to view all parts of your body. The Western black-legged tick is the size of a speck of dirt in its nymphal stage. Adult ticks are larger and easier to spot.

    Check your kids thoroughly for ticks and examine clothing and pets. Ticks can be carried into your home on all three.

    Lyme disease vaccine is available, but the state Department of Health Services does not recommend it for routine use anywhere in California. The vaccine is at best about 75 percent effective and does not protect against ehrlichiosis or babesiosis. In a class-action suit against the vaccine's manufacturer, some people are charging that the immunization triggers a nontreatable, degenerative form of arthritis.

    Talk with your vet about the pros and cons of the canine Lyme disease vaccine for your dog.

    If you find an attached tick:

    Remove it as soon as possible. Studies suggest it takes at least 24 hours, and perhaps as long as 36 to 48 hours, for a tick to transmit an infection. The less time a tick feeds on you, the less the risk of infection.

    Shield your fingers with a tissue, paper towel or rubber gloves. Then, using fine-tipped tweezers, grasp the tick as close to the skin surface as possible and pull upward with steady, even pressure.

    Don't twist or jerk the tick; this may cause the mouth parts to break off and remain in the skin. (If this happens, remove mouth parts with tweezers. Consult your health care provider if infection occurs.) Don't squeeze, crush or puncture the tick's body. This can squeeze tick fluids, which may contain infectious organisms, into your bloodstream.

    Don't use petroleum jelly, hot matches or other folklore techniques to remove a tick. The methods do little to encourage a tick to detach from skin, and may make matters worse by irritating the tick and provoking it to release additional saliva or regurgitate its gut contents, increasing the chances an infection will be transmitted.

    Thoroughly disinfect the bite site after removing the tick. Wash your hands with soap and water.

    Save the tick for identification in case you become ill. Having the tick may aid your doctor in diagnosis. Place the tick in a plastic bag and put it in your freezer. Label the bag with the date of the bite.

    Sources: Centers for Disease Control and Prevention, California Department of Health Services

    Claudia Morain is a writer and editor in Davis.

    2001 San Francisco Chronicle Page C - 4

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