Tick-Borne Diseases with Dr. Nicole Baumgarth

In this episode, we interview Dr. Nicole Baumgarth about the increasing spread of tick-borne diseases. 

Nicole Baumgarth is an immunologist and the director of the Lyme and Tickborne Diseases Research and Education Institute at the Johns Hopkins Bloomberg School of Public Health. Following a DVM and PhD degree obtained in Germany and post doctoral training in Australia and at Stanford University, she started her own research program at the University of California Davis, where her lab studied immune responses to infections, among them Borrelia burgdorferi, the causative agent of Lyme disease. In 2022 she moved her lab to Johns Hopkins, where she
now working to establish a broad research program that works on solutions towards better preventions and prophylaxes, diagnoses, and cures for tickborne illnesses.

Transcript

Unknown: 1:02

Hello, I'm Captain Matthew Turner, and welcome to another episode of the GSASEP podcast. In this episode, we interview Dr. Nicole Baumgarth. Dr. Baumgarth is the immunologist and the director of the Lyme and Tick-Borne Diseases Research and Education Institute at the Johns Hopkins Bloomberg School of Public Health. Following a DVM and PhD degree obtained in Germany and postdoctoral training in Australia and at Stanford University. She started her own research program at the University of California, Davis, where her lab studied immune responses to infections, among them Lyme disease. In 2022, she moved her lab to Johns Hopkins, where she is now working to establish a broad research program that works on solutions towards better preventions and prophylaxis diagnoses and cures for tick-borne illnesses. So, can you tell me why ticks and tick-borne diseases are becoming increasingly important for EM clinicians? Yeah, we see, we have seen over the last 25 or 30 years a constant and continued rise of tick-borne diseases in this country, this has to do with changing climate. Ticks who transmit 17 known pathogens or 17 different kind of diseases are increasing in numbers due to a warmer climate and like a warmer, like a humid, and we also have changed the way you use land. We live closer to forest and forested areas, which are areas where ticks like to hang out. Overall, what sort of trends are you seeing regarding tick populations across North America? Of course, the the sort of elephant in the room is this very tiny tick called Exodus ticks, black legged ticks. They are the carrier of the Lyme disease agent Borea bactophori. They also are the agent that carries a little parasite called Babesia that can induce babesiosis and another one causing anaplasmosis. So they are really dangerous because they cause most of the infections, and they are very prevalent in the upper northeast, and they are expanding and reach Ohio is now sort of ground zero for an expansion of ticks that we see. The more recent changes that we have seen is that areas where these blacklegged ticks were very abundant, for example, here in Maryland, we are seeing that another tick population called amblyoma, or the lone star tick, sort of moving very rapidly, and we don't know yet whether they are replacing the blacklegged ticks or whether they're in addition to the blacklegged ticks. Those ticks don't carry the Lyme disease agent, so that might be the good news, but the bad news is that they are appear to be the causative agent of what is called the red meat allergy, an allergic reaction to a sugar that is in the saliva of these ticks and the spit of these ticks, and it sensitizes humans when they then eat red meat. They develop an allergic response. I've actually been reading about that sort of red beef allergy. It's spreading terrifyingly fast. I think most people still don't realize how big a deal it really is right now. Yes, in 2024 there were estimates of the number of tick bites Americans experience, and the number was estimated to be about 31 million, and that's of course a ginormous number. And we see about 475,000 Lyme disease cases, and we see less the other diseases. But the AlphaGaal syndrome is really on the rise. What is so difficult about this disease, this allergic disease, is that the exposure to the tick bite itself is what sensitizes you, and so in contrast to infections, right, where you can develop vaccines and so on, you can't really vaccinate yourself against an allergic response. So really, the only way we can protect ourselves is not getting bitten. Of course, every time you get bitten, you have a higher likelihood that something will happen in response to it. When you develop allergic responses like to pollen, which a lot of us have, it's not so clear whether it's constant exposure over a certain amount of time, whether just this one incident that triggered it. Usually, what causes an allergic response is a tiny amount of the antigen that that induces the allergic response to be administered in a way that our immune system thinks it needs to respond to, and then we are sort of primed, and so next time we see it, we make this huge response, which of course is not very helpful. When a patient presents with, say, a fever during the summer months, when should EM physicians begin considering a tick-borne illness? Really, always, I would say, for for Lyme disease, about 70% of patients or so will present with a. Skin rush. So, looking for a skin rash is always a good idea. The classical skin rush is called the bullseye rash. It looks like sort of a target, but it does. It is really important to know that it doesn't always present as this bullseye rash. When it does, it's great because it really sort of gives you a really good idea what this patient may have. But if you have, in particular, if your skin is more pigmented, you have darker skin, you see very little of a rash, or it doesn't present in this form. And there are at least 30% of cases, patients that never develop this raft. So even if you don't have the skin rash, it shouldn't exclude you from thinking about Lyme disease or other tick-borne diseases, what elements of the patient history would you say are the most valuable? Yeah, it's really recent exposure to the outside, so in an area that we know is endemic for Lyme disease or other tick-borne infections. So it can take up to two weeks before symptoms become obvious. So patient history is always difficult to assess. But asking about whether there have been in areas that are either forested or high grass areas is definitely a really good idea. Often because the ticks are so small, often it's not seen. The particular ticks develop in various stages, and the nymph stage, which is the stage before they become adults, is actually the ticks are so small that we often overlook them. And it's interesting that we have more reported cases of tick-borne infections in the in the late spring and early summer months, because that's when the nymphs are most active. In the fall, when the adult ticks are active, we have less reports of incidences because I I think people find them more, and so they pick them up and before they can cause disease. So, are there any physical exam findings that physicians should actively look for. Yeah, other than a good screen for for any kind of skin rashes, it's really very difficult because the symptoms are so nonspecific. We call them flu-like symptoms. You know what that means. So low-grade fever and the patient feels sort of run down, and they may also experience muscle aches, non-specific. So, you know, unless a patient reports with a really big knee and no no previous history of having arthritis or something, unfortunately, there are very few specific signets that can identify you as having a patient with Lyme disease or other tick-borne infections. Are there any sort of like laboratory abnormalities that should raise concern for tick-borne illness? The sort of if you do a CBC or something, look at the blood count. Often you will find lymphocytosis and maybe reduced neutrophil counts, again very non-specific, showing you that there might be something wrong with the patient. Unfortunately, even when you order very specific tests, say you suspect Lyme disease, you can't really wait for the results to come back. We also know that so the Lyme disease test currently relies on antibody development. We know that seroconversion is very slow in in patients, and in fact, people, GPs that sort of work and practice in Connecticut and other areas, they will often not even send out for tests because it so often comes back negative, even if the patient presents with the skin rash and all of these signs for it, if you suspect Lyme disease, treatment is probably indicated. Well, I'm glad you said that because that actually leads us into our next question. So, which patients would you recommend receiving empiric antibiotics? So, doxycycline is the treatment of choice for Lyme disease treatment of choice for anaplasmosis. Unfortunately, it doesn't work for Babesia. So Babesiosis is a parasite, not a bacteria. But I think if in doubt, you want to start treating. And and I say this, I'm not an MD. I want to make sure this is very clear. But we know from scientific studies that the earlier you treat, the higher the likelihood of the patient not having ongoing long-term symptoms. We all know the bad things about antibiotics and the side effects and taking it for a long time, but in this case, you are basically racing against the time to to not miss the window of opportunity where a course of antibiotics can make the patient better without any follow up. Going from a case of suspected tick-borne disease, what do you do when there's a tick that is physically attached to the patient? What's the best way to remove that tick? So it's important. Important to know that the tick is really bury itself into the skin. So this is not like a mosquito, which sort of puts its little bottles in there. It really is very deeply buried into the skin. So you want to take forceps or something else, and then it's important. And don't put oil on it or any of these things, but just grab it and and go as deep as you possibly can, sort of next to the next to the tick into the skin, really deep in, and then pull it out as straight as you possibly can, to try and avoid leaving pieces of the tick behind, the mouthpieces which are sort of deep in there, and then I would highly recommend that you keep that tick, and the best way is to put it in a little ziplock bag and put it in the freezer. The sort of the best way to kill a tick is freezing it, and if you if you have that available, because knowing what kind of tick it is can help us with a differential diagnosis, because different ticks carry different diseases. What sort of misconceptions do you often encounter about Lyme disease? I think a lot of people are really scared when they get the diagnosis that they have Lyme disease. I think many people now know individuals who have been suffering for a long time from very non-specific symptoms, Ongoing headaches, sort of brain fog, maybe sort of nerve pain, and it is important to know that 90% or so of patients that are treated with a course of antibiotics are going to be better and going to be fully cured from the infection. But we know that delay in treatment will actually give you a higher likelihood that the outcome is not as good, but it's not a Lyme disease diagnosis. Is not doesn't mean that for the rest of your life you now have you're going to have problems. So I think that's really important. So reassuring treat straight away, and in all likelihood, you're going to be fine. You know, it's very important because people get very scared when they when they hear that. With with regards to the red meat allergy, I think just thinking about this as a possible cause of an allergic response or of very strong gastrointestinal symptoms is is is difficult, right? It's still quite rare. Just considering that, and the differential diagnosis is is really important. And then it's called the red meat allergy because it is this is a sugar that is we don't make it, but many other animals do, including all the ones we like to eat that have that red meat. And there, it's important to know that it's not just the meat itself that can also be, you know, your your rice pudding that is on the shelf stable with adding some collagen, you know, adding some gelatin that is a product of pigs or of catalans. So even that can cause the allergy. Absolutely, it's one of those diseases that's currently exploding right now, and I think public awareness is increasing about the whole red meat allergy situation. But it's definitely something that we need to really start keeping on our differential diagnosis, which is a shame. It's all the things that are delicious to eat. Yeah, absolutely, and I think it's a little ironic that people have been not so worried about ticks for a very long time, but now that your barbecue is dented, you don't want to. You start paying attention. So I guess just to wrap up, if you could give emergency medicine physicians some never miss lessons regarding tick-borne disease, what would they be? Well, keep it in mind. In mind, at all times of year, we clearly see a peak of tick-borne illnesses in the late spring, early summer, and a second peak in the in the early fall. This is when the ticks are most active: the nymph ticks in the spring and early summer, and the adult ticks in the fall. However, when you look at the numbers of patients that are being diagnosed with, for example, Lyme disease, and I take that as an example because it's the most prevalent, we see diagnosis all through all 12 months of the year, and so a case that comes in in January can still be Lyme disease. Not that the patient likely is acutely infected, but perhaps that the infection was noted before. So, if your practice or your patient has been in areas that are endemic for tick-borne diseases, thinking about Lyme and other tick-borne illnesses is really important. Maybe one thing I'd like to add about

babesia: 15:44

it is still also a rare disease, but it is increasing. Also, it is a disease where the little parasite hides in red blood cells or lives in red blood cells, so it it really threatens our blood supply, and they are. Now increasing testing done to to avoid storing blood that is contaminated with babesia, but also something just to to keep in mind that it's very important to ensure that blood that is given has been checked. Well, thank you so much for taking the time to come on the podcast. We really appreciate it. Thanks for asking. Great.