RICKETTSIAL DISEASES

● Arthropods

- organisms responsible for a number of disorders are transmitted to human beings

- mammals become infected only through the bites of infected lice, fleas, ticks, and mites,
all of which serve as both infectors and reservoirs

● Rickettsiae
- are intracellular parasites, similar in size to bacteria that inhabit the alimentary tract of a
wide range of natural hosts
● Rickettsial diseases

- are more common in temperate and tropical climates where humans live in association
with arthropods
- infection in humans is incidental (except epidemic typhus) and not necessary for the
survival of the rickettsial species
➔ after the organism invades a human, it causes a disease that varies in intensity
from a benign, self-limiting illness to a disease that is fulminating and fatal

LYME DISEASE

● most common tickborne disorder in the US

● caused by the spirochete Borrelia burgdorferi, which enters the skin and
● bloodstream through the saliva and feces of ticks, especially the deer tick
● commonly occur in children 5 to 15 years of age and adults 45 to 55 years of age

Clinical Manifestations

disease may be initially seen in any of three stages

● first stage

❖ early localized disease

❖ consists of the tick bite at the time of inoculation
❖ followed in 3 to 30 days by the development of erythema migrans at the site of
the bite
❖ lesion begins as a small erythematous papule that enlarges radially up to 30 cm
(12 inches) over a period of days to weeks
❖ . it results in a large circumferential ring with a raised, edematous doughnut-like
border resulting in a bull’s-eye appearance
➔ thigh, groin, and axilla are common sites
❖ lesion is described as “burning,” feels warm to the touch, and occasionally is
pruritic
❖ single annular rash may be associated with fever, myalgia, headache, or malaise

● second stage

❖ early disseminated disease, occurs 3 to 10 weeks after inoculation

❖ patients develop multiple smaller, secondary annular lesions without the
indurated center
➔ may occur anywhere except on the palms and soles, and in untreated patients they disappear in
3 to 4 weeks

❖ Constitutional symptoms
● fever
● headache
● malaise
● fatigue
● anorexia
● stiff neck
● generalized lymphadenopathy
● splenomegaly
● conjunctivitis
● sore throat
● abdominal pain
● cough
➢ focal neurologic finding of cranial nerve palsy (seventh nerve palsy) occurs in 3%
to 5% of cases

❖ Additional manifestations
● optic neuritis
● uveitis
● conjunctivitis,
● keratitis
 ● third stage

❖ the most serious stage of the disease

❖ characterized by systemic involvement of
➔ neurologic, cardiac, and musculoskeletal systems that appears 2 to 12
months after inoculation

➔ Lyme arthritis is the most common manifestation with pain, swelling, and effusion

➔ In children the arthritis is characterized by

● intermittently painful swollen joints (primarily the knees), with spontaneous
remissions and exacerbations

❖ Rare neurologic features of pediatric Lyme disease

● meningitis
● encephalitis
● polyneuritis

❖ Cardiac complications (may appear in a small percentage of persons during the early
phase of the infection
● commonly acute atrioventricular conduction abnormalities
● less commonly pericarditis or mild left ventricular dysfunction

Diagnostic Evaluation

● Diagnosis is based primarily on the history, observation of the lesion, and clinical
manifestations
● Serologic testing for Lyme disease at the time of a recognized tick bite is not
recommended because antibodies are not detectable in most persons
● Laboratory diagnosis can be established in later stages with a two-step approach that
includes
➔ screening test enzyme immunoassay or immunofluorescent immunoassay
➔ if the results are equivocal or positive, with Western immunoblot testing

Therapeutic Management
● Early and appropriate treatment is essential to prevent complications
● Children older than 8 years of age are treated with oral doxycycline
● amoxicillin is recommended for children younger than 8 years of age
● patients who are allergic to penicillin
➔ alternative drugs: cefuroxime or erythromycin
 ● length of treatment depends on the clinical response and other disease manifestations,
but it usually lasts from 14 to 21 days
● treatment is effective in preventing second-stage manifestations
● Persons who have removed ticks from themselves should be monitored closely for signs
and symptoms of tickborne diseases for 30 days
➔ should be monitored for erythema migrans, a red expanding skin lesion at the
site of the tick bite that may suggest Lyme disease
● Neurologic, cardiac, and arthritic manifestations are managed with
➔ oral or IV antibiotics such as
❖ ceftriaxone
❖ cefotaxime
❖ penicillin G.
● follow-up care is important in ensuring that treatment is initiated or terminated as
needed

Nursing Care Management

● major emphasis of nursing care should be educating parents to protect their children
from exposure to ticks
● children should avoid tick-infested areas or wear light-colored clothing
➔ tuck pant legs into socks
➔ wear a long-sleeved shirt tucked into pants when in wooded areas
● after the tick is removed, wash the bite area with an iodine scrub, rubbing alcohol, or
plain soap and water
● insect repellents containing diethyltoluamide (DEET) and permethrin can protect against
ticks (should use these chemicals cautiously)
● plant essential oils, such as juniper and Chinese weeping cedar essential oil, have been
reported as being safe and effective as an insect repellent without the effects of
chemicals
● permethrin treated clothing has also been shown to be effective in repelling ticks

PET BITES

● animal bites are common in childhood

● most animal bites to children are caused by dogs
● cat bites are less frequent; cat scratches (common)
● most injuries caused by dogs or cats are to the upper extremities
● small children are likely to be bitten or scratched on
➔ head, face, neck
 ❖ injuries vary in intensity from small puncture wounds to complete evulsion of
tissue that is associated with significant crush injury
➢ animal bites are potentially serious because of the likelihood of significant infection

Therapeutic Management

● General wound care consists of

➔ rinsing the wound with copious amounts of saline or lactated Ringer solution
under pressure via a large syringe and of washing the surrounding skin with mild
soap
➔ clean pressure dressing is applied, and the extremity is elevated if the wound is
bleeding
● medical evaluation is advised because of the danger of tetanus and rabies
● bites from wild animals such as
➔ squirrels, bats, raccoons, foxes, and skunks, are potentially dangerous
● prophylactic antibiotics are indicated for puncture wounds and wounds in areas that
may prove to be cosmetically or functionally impaired if infected
● extensive lacerations are debrided and loosely sutured to allow drainage in the event of
infection
❖ Tetanus toxoid is administered

Nursing Care Management

● most important aspect related to animal bites is prevention

● parents should monitor their children’s behavior with dogs and instruct them not to
tease or surprise dogs, invade their territory, interfere with their feeding or sleeping,
take their toys, or interact with sick or injured dogs or dogs with pups
● considering getting a pet, especially a dog should select a dog that has a high level of
sociability with, and is unlikely to be a danger to, children

HUMAN BITES

● Children often acquire lacerations from teeth of other humans in

❖ rough play
❖ during fights
❖ or as victims of child abuse
● some young children bite others out of frustration or anger
➔ human dental plaque and gingiva harbor pathogenic organisms, all human bites
should receive attention
➔ delayed treatment increases the risk of infection
 ● the wound is washed vigorously with soap and water, and a pressure dressing is applied
to stop bleeding
● ice applications minimize discomfort and swelling
➔ increased pain or redness at the wound site is an indication that the child should
receive medical attention for antibiotic therapy
❖ Tetanus toxoid is needed if the child is insufficiently immunized
● wounds larger than 6 mm should receive medical attention

CAT SCRATCH DISEASE

● the most common cause o regional lymphadenitis in children and adolescents

● usually follows the scratch or bite of an animal (a cat or kitten in 99% of cases) and is
caused by Bartonella henselae, a gram-negative bacterium
● disease is usually a benign, self-limiting illness that resolves spontaneously in about 4 to
6 weeks
❖ usual manifestations are
● painless, nonpruritic erythematous papule at the site of inoculation,
followed by regional lymphadenitis
➔ lymph nodes most commonly involved are
● axillary epitrochlear
● cervical
● submandibular
● inguinal
● preauricular

● the disease may persist for several months before gradual resolution
● some children, especially those who are immunocompromised, the adenitis may
progress to suppuration
❖ children may develop serious complications that include
● ncephalitis
● hepatitis
● parinaud oculoglandular syndrome
➔ this syndrome is characterized by granulomatous lesions on the palpebral conjunctiva
associated with swelling of the ipsilateral preauricular nodes

Diagnosis is made on the basis of

1. history of contact with a cat or kitten
2. the presence of regional lymphadenopathy for several days
3. serologic identification of the causative organism by indirect fluorescent antibody assay or
polymerase chain reaction test
 ● treatment is primarily supportive
● experts recommend a 5-day course of oral azithromycin to hasten recovery
➔ Antibiotics do not shorten the duration or prevent progression to suppuration
but may be helpful in severe forms of the disease
❖ drugs have shown some benefit in uncontrolled clinical studies
● trimethoprim-sulfamethoxazole
● ciprofloxacin
● gentamicin
● rifampin
● enlarged painful nodes may be treated by needle aspiration
● children should be cautioned about playing with aggressive kittens that bite or scratch
● wounds should be washed with soap and water

SKIN DISORDERS ASSOCIATED WITH SPECIFIC AGE-GROUPS

➔ conditions include
● diaper
● atopic
● andseborrheic dermatitis
➔ which occurs predominantly in infants, and acne, which is most common in adolescence