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transmit the agent to the larvae the following spring after being infected by the nymphal form in early summer Adult ticks prefer the white-tailed deer as host Although only 20 25% of nymphs harbor spirochetes compared with 50 65% of adults, most infections occur in the spring and summer (when nymphs are active), and fewer cases occur in the cooler months (October to April), when adults feed This is probably due to the greater abundance of nymphs; greater human outdoor activity in spring and summer, when nymphs feed; and the fact that adult ticks are larger, easier to detect by the human host, and thus can be removed before disease is transmitted Less than 1% of larvae are infected with spirochetes, and transmission of the disease through contact with larvae is unlikely In the western United States, the I pacificus nymph prefers to feed on lizards, which are not susceptible to infection It is only the few nymph and larval ticks that feed on wood rats, which can be infected, that are capable of transmitting disease Under experimental conditions, ticks must feed for 24 36 hours or longer to transmit infections Human epidemiologic studies have indicated that the incidence of disease is significantly higher when tick attachment is for longer than 72 hours than if it is less than 72 hours, though rare cases have been documented with attachment of less than 24 hours In addition, the percentage of ticks infected varies on a regional basis In the northeastern and midwestern regions, 15 65% of I scapularis ticks are infected with the spirochete; in the western United States, only 2% of I pacificus are infected These are important epidemiologic features in assessing the likelihood that tick exposure will result in disease Exposure to I pacificus is unlikely to result in disease, since so few ticks are infected, but this is not true of exposure to I scapularis Eliciting a history of brushing a tick off the skin (ie, the tick was not feeding) or removing a tick on the same day as exposure (ie, the tick did not feed long enough) decreases the likelihood that infection will develop Ixodes ticks are smaller than the more common dog ticks (Dermacentor variabilis) Larvae are less than 1 mm in size, and the adult female is 2 3 mm in size, with a red body and black legs After a blood meal, ticks can reach two to three times their unengorged size Because the tick is so small, the bite is usually painless and goes unnoticed After feeding, the tick drops off in 2 4 days If a tick is found, it should be removed immediately The best way to accomplish this is to use a fine-tipped tweezers to pull firmly and repeatedly on the tick s mouth part not the tick s body until the tick releases its hold Saving the tick in a bottle of alcohol for future identification may be useful, especially if symptoms develop Congenital infection has been documented, but the exact frequency and manifestations have not been clearly defined Similarly, because the organism can be latent, it is not known if women infected prior to becoming pregnant can activate the disease and transmit infection to the fetus In one retrospective study, 5 of 19 pregnancies complicated by Lyme disease resulted in an adverse outcome, but all of the outcomes were different and could not be conclusively linked to infection Several serosurveys involving over 2000 pregnant women in endemic areas have not found any association between seropositivity in prospective mothers and the prevalence of congenital malformations, fetal death, and prematurity Thus, if B.



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Faucher JF et al The management of leptospirosis Expert Opin Pharmacother 2004 Apr;5(4):819 27 [PMID: 15102566] Kobayashi Y Human leptospirosis: Management and prognosis J Postgrad Med 2005 Jul Sep;51(3):201 4 [PMID: 16333193] Ricaldi JN et al Leptospirosis in the tropics and in travelers Curr Infect Dis Rep 2006 Jan;8(1):51 8 [PMID: 16448601]

LYME DISEASE (LYME BORRELIOSIS)

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omas and hyperpigmentation Patients with Cowden disease develop thyroid abnormalities (66%) such as benign adenomas and follicular adenocarcinomas, along with breast cancer (20 36% in women), and multiple hamartomas that affect the skin and multiple other organs

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Gertner ME et al Multiple endocrine neoplasia type 2 Curr Treat Options Oncol 2004 Aug;5(4):315 25 [PMID: 15233908] Lambert LA et al Surgical treatment of hyperparathyroidism in patients with multiple endocrine neoplasia type 1 Arch Surg 2005 Apr;140(4):374 82 [PMID: 15841561] Skinner MA et al Prophylactic thyroidectomy in multiple endocrine neoplasia type 2A N Engl J Med 2005 Sep 15;353(11): 1105 13 [PMID: 16162881] Waldmann J et al Adrenal involvement in multiple endocrine neoplasia type 1: results of 7 years of prospective screening Langenbecks Arch Surg 2007 Aug;392(4):437 43 [PMID: 17235589]

noma H2-blockers and metoclopramide cause hyperprolactinemia, simulating a pituitary prolactinoma Variants of MEN 1 also occur Kindreds with MEN 1 Burin variant have a high prevalence of prolactinomas, lateonset hyperparathyroidism, and carcinoid tumors, but rarely enteropancreatic tumors

2 MEN 2A (Sipple s Syndrome)

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