TICK ENCEPHALITIS and CENTRAL EUROPEAN ENCEPHALITIS ( T.E. ) Acute, vir al

viral disease transmitted by ticks with the sub-sequent damage of

the nervous system as a meningitis, meningoencephalitis or myeloencephalitis with possible development of flaccid paralyses and pareses mainly of muscles of a shoulder girdle and neck.

Historic reference
1932 - in the Far East was registered flashout of disease among the visitants with a damage of the nervous system with a high lethality and paralyses for survived

1934 - А.G.Panov - has determined etiological independence of disease

1937- L.А. Zilber etc. - have detected of the infectious agent of the illness

29 serovars of a virus, have described variants of illness,

have developed of the methods treatment and prophylaxis

ETIOLOGY ( F. Togaviridae, K. Flavivirus)
It is small spherical virus by a size 35 - 50 nm. The a nucleo-capsid contains one-filamentous RNA (+). It is covered with the lipoid envelope.
The replication of a virus occurs in a cytoplasma of the host`s cells.
At pasteurizing is inactivated in 10 minutes. At boiling is perished in 2 minutes. Under effect disinfectants and UVL survives from 1 – to 10 minutes. In 50 % glycerinum -some months and at a lyophilization - years are saved.

Distinguish the Central European and the Far East variants of a viral tick encephalitis.

of viruses are 16 sorts ixodes ticks ( viruses in

them are saved from 2 – to 4 years, transmiting one transphase ( larva- nimph- tick) and transovarial ( via eggs).
The infection ticks can reach 20 - 40 %.
The main carriers of TE and them spreading:
Ixodes persulcatus - in Asia (from Sakhalin up to the Urals,
Mongolia, China, Korea)


Ixodes ricinus – from the Urals up to Poland, in Czechia,
Slovakia, Hungary, Bulgaria, Romania, Austria,
Germany, Sweden, Finland)


Ixodes cooкei - in USA and Canada

wild animals (hedgehogs, moles, ground-sqirrels) the home mammals and birds

– carriers of the ticks.

Auxiliary mode of transmission – nutritional- via crude

milk: goats, cows, sheep - 20 %.
Seasonal prevalence –spring-summer months -maximal activity ticks.

The men in the age of from 20 to 40 years, cattle - breeders and working people in a wood are often sicken

In endemic sources - T.E. proceeds without clinical manifestations with creation of proof immunity in 95 % of the recovered.

tick) or mucous (at nutritional mode of infection). Adapting and

creating colony

2. Active absorption of viruses by cells of the system macrophagal phagocytes, intensive replication in them and output of virus - descendants in a blood

3. Destruction of a part of viruses- descendants in a blood with development of a syndrome intoxication

bodies and systems of an organism with the subsequent fixing

mainly in cells of the nervous system, but especial in an oblong brain and anterial roots of a cervical portion of a spinal cord (less often) in a cerebel-lum and pia mater membrane) with development of inflammatory and degenerative processes in them,

5. Development further of exudative proliferative processes in membranes of a brain, in motor roots of a spinal cord, peripheral nerves and vegetative ganglions

6. Clinical the illness appears by a diffuse or focal encephalitis, meningitis, myelitis, disorder of activity CVS, respiratory systems etc.

resulting in to restoring of broken functions, but for the

majority of the patients both the muscle weakness and atrophy (less often) of the struck muscles, especially of shoulder girdle is saved. Sometimes process becomes chronic.

PATHOMORPHOLOGY:
- degeneration and bloodfull of the internal bodies
hemorrhages in pericardium, stomach, intestine, mucous
URT
- edema and bloodfull of cerebral membranes
- substance of the brain and spinal cord is edematosus with hemorrhages, flabby.

( from 1 – to 60 days ) 7 -

14 days

Prodromal stage – 3 - 7 days (for some patients)
- weakness and fast fatigue
- headache, paresthesia and radicular pains
- the disorder of sleep, psychosis ( is rare)

The feverish form TE.
- acute starts, chill
- fast increase temperature of body up to 38 - 40 d.C
- strong headache, muscle and a articular pain
- nausea, vomiting, anorexia
- sleepiness or insomnia, photophobia and paresthesia

injection of vessels of scleras and conjuctivitis
- appearance of

an erythema in a place of a sting tick
- hypotonia and relative bradycardia
- WBC – neutrophilic leukocytosis, moderate rise ESR.
At the Central European variant TE is often normocytosis or leukopenia,

Diagnosis confirms:
- epidemiologic (sting tick or the use of crude milk)
- immunologic (appearance in a blood of antibodies against viruses TE).
The feverish form TE is often ended convalescence with by creates of immunity, but can be relapses

headache, joins

a meningeal syndrome:
the repeated vomiting (does not bring facilitation to the patient)

- appearance tension of muscles of a neck, s-ms: Kernig’s,
Brudzinsky’s , Lesage’s (for children)
- hyperacusia, photophobia, paresthesia, weakening
abdominal of reflexes

In CSF - lymphocytosis 100 - 200 cells
increase contents of a protein,
the level of a glucose is not reduced.
Current favourable and in 2 - 3 weeks - complete convalescence without complications

syndromes, which
in 3 - 4 days joins a

polyencephalomyelitic syndrome:

- oppression of consciousness, hallucination, sometimes
delirium, repeating epileptiform cramps

- atrophic paralyses of a muscles neck, shoulder girdle,
proximal portion of upper extremities

the patient can not lift a head, bend or unbend to arms
- spastic paralyses of muscles of lower extremities,
- appearance of pathological reflexes - damage of
pyramidal tract

dysphagia, paresis of muscles of a soft palate, deviation of

the tongue and atrophy of its muscles, disorder ventilation of the lungs with the subsequent pneumonia
for 25 % - damage of nuclei of the 7, 9, 11, 12 pairs of the
cranial nervous.
For the majority of the survived patients through 10 -
12 days:
- are normalized temperature,
- the signs of an intoxication and meningitis disappear,
- the motor disorders are exposed to sluggish return
development,
- but for many patients is saved atrophy of muscles
causing them to disability. ( lethality 25-30 %)

an aphrenia

- myoclonic hyperkinesias with epileptiform by attacks or

epilepsy Кожевникова (simultaneous myoclonic
hyperkinesias + epileptiform attacks with losses
consciousness)

- syndrome of a chronic polyomyelitis

- syndrome of a side amyelothrophic sclerosis

course of nervous trunks
- paresthesia in distal portions of extremities

- disorder of sensitivity in distal portions of extremities
(s-ms "socks", "«gloves")

Tick encephalitis with two-wavy current:
- on an extent 3 - 7 days proceed as the feverish form with
normalization of temperature
- in 7-12 days аpyrexia again there is a fever and the illness
starts to proceed in to the meningial form.
- the convalescence is more often complete, but
sometimes passes in chronic TE.

signs on which background the early SYMMETRIC, flaccid paralyses and

pareses all muscles of a neck, upper extremities and trunk develop.
after 3 weeks from a beginning of disease develops an atrophy of muscles the patient: does not hold a head, can not move with shoulders and upper extremities.
the motor disorders of lower extremities more often miss or inappreciable
Tick encephalitis can proceed as:
Focal encephalitis
As a uprising Landry’s paralysis
As the fulminant forms with a edema brain, coma, fast resulting in death of the patient

months seasonal prevalence, sting tick, use crude of milk

2. Differential

diagnosis - with meningitises and encepha-litises of other etiology, a damage of vessels of a brain, comas of a various genesis, tumours and abscesses of a brain, polyomyelitis

3. Laboratory diagnosis:
IFt - search of a virus and its antigenes in tissues tick
virologic inspection (intracerebral infection mouse) or usage of cellular cultures from kidneys of pigs
The immunological inspection (HAt, CFt, Nt, ELISA) - since 7-th day of illness, is repeated through in 7 - 10 days and in 2-3 months (the antibodies in a blood occur late)

antiencephalitic immunoglobulin is entered IM in a dose 3 -

12 ml / day within 3 days. At the serious forms a dose double. But duration of treatment also 3 days.
PROPHYLAXIS:
Decrease of a population ticks (disinfestation, rational support of a wood facilities (cutting down underbrush)

Prophylaxis of an attack ticks on the people and animals limitation free pasture of cattle, usage antickal of costumes and repellents)

The immunization of groups of hazard by killed cultural vaccine is three time (efficiency 82 %) with a revaccination in 1 year (efficiency up to 92 % raises)

Usage of immunoglobulins in a dose of 0,05 ml/ kg at a sting infection tick (at + IFt) is one time

transmissible disease starting with of a radiatic dermal erythema, fever

with the subsequent damage nervous, CVS and locomotor apparatus
ETIOLOGY:
The infectious agents- Borrellia burgdorferi (1984), Borrellia garinii, Borrellia afzelii etc.

It has the spiraly form of a body of length 4 - 30 microns and width 0.3 - 1 microns with 4 - 11 flagella on each ends, which enlarge its mobility, Gram (-) is well coloured by aniline stains and silver.

In the external environment, at warming and at contact with disinfectants fast perishes.
It’s cultivated only on mediums with a complete set of aminoacids.

Canada, Europe, Asia, Australia)
The main host - wide circle

animals (deer, lambs, goats, sheep, cattle, cats, dogs, rodents and the birds)
Animals can infect from each other contact way (urine)

Main carrier – ixodes ticks. The infection ticks in the sources changes in limits from 8 up to 61 %, but only in 6 % infectious ticks Bor. find out in a saliva - therefore the people even in the dangerous source seldom fall ill.
A case rate only sporadic.

Fall ill only people frequently visiting sources (tourism, fishing, hunting, working in a wood)
80 % infect in June - July.
Except for transmissible mode of transmission - exists
also nutritional mode- use crude milk - 20%

skin (sting of the tick) or mucous GIT (crude milk)

also adapt from 2 about 32 days

2. Migration in a skin and creation of a ring erythema,

3. Migration in all bodies (CNS, liver, kidneys, myocardium,
joints, eyes and etc)

4. In the struck bodies can be saved 10 years and more,
supporting in them an inflammation as independently
and with involvement autoimmune responses

CLINIC (incubation interval from 2 about 30 days)
In clinic is observed 3 particular stages.

(3 - 32 days)

- fever, myalgia, arthralgia, pharyngitis, anorexia,

nausea, vomiting

appearance of a ring erythema for 60 % of the patients in a place of a sting tick which is gradually enlarged up to 16 sm on the average (from 3 up to 68 sm)

saving bright edge, and the centre turns pale and will atrophy gaining sort "of tissue paper" in typical cases

- lymphadenitis and hepatospleenomegaly

- from the side NS - only paresthesia in a zone of a damage

2 up to 21 weeks) and proceeds with:
neurologic

or cardiologic by disorders

Neurologic as:
- of a serous meningitis with a long-lived pleocytosis both standard pressure and level of a glucose in СSF

- in 30 % of cases as an encephalitis (disorder of sleep,
lowering of concentration of attention, memory defect,
hyperexcitability

radicular disorders in cervical, thoracal and lumbar portions of

a spinal cord, paresises of separate groups muscles, pareses of cerebral nervous (VII of a piar more often)

The duration of disorders is saved from 1 about 28 weeks, but after an encephalitis the headache, mental disorders, epileptiform by attacks from 1 to 8 years is saved

unpleasant sensations in the field of heart,

- brady- or

tachycardia

- less often - clinic of a myocarditis or pericarditis

- complete or incomplete blockade of the carrying out
system heart

- development of a thrombosis of its arterias

- the valval apparatus of heart not damaged!

illness) - damage of joints:
- more often one knee

joint (60 %) is damaged, less often
others (humeral, ulnar), but sometimes a little joints is
simultaneous.

Localization of an erythema and struck joint coincide only in 25 % of cases.
Duration of an arthritis from 8 days about 3 months.
More often arthritises arise in the autumn and are repeated from 1 up to 6 times with an interval from 1 about 10 weeks

Differential diagnosis:
- At a ring erythema eliminate: erypsipelas erysipelotrix,,
streptococcal cellulitis

- At an erythema and damage of joints: SLE, rheumatic
disease

encephalitis( are combined in 20 % of cases), tubercular and

cryptococcal meningoencephalites, Behcet’s illness, sarcoidosis.

- Damage PNS - Guillain-Barre’s syndrome, disseminated encephalomyolitis

LABORATORY DIAGNOSIS:
Clinico-epidemiological method- a sting tick or use of crude milk, residing indemic districts, typical erythema)

ELISA- the antibodies Ig M occur in a blood through 3 - 6 weeks, and Ig G - in some months after infection

Indirect immunofluorescence in pair serums - height of antibodies not less than 4 times

50 % of the patients, leukocytosis - 10 %,

rise AST - 20 %, rise common Ig M - 30 %
6. Seldom- find out in the dermal center, blood, CSF

TREATMENT: in any stage will carry out anti-infectious therapy
In an acute stage - doxycycline 100 mg po bid
- amoxicilin 500 mg po tid
- cefuroxime axetil 500 mg po bid
- clarithromicine 500 mg po bid
(14 - 21days)
In 2nd and 3rd of a stage - only ceftriaxonum on 1.0 g bid
IV or IM > (28 days)
Maintenance therapy
PROPHYLAXIS:
As well as at a tick encephalitis, but the methods of specific prophylaxis miss