TBE

Quick Overview

• What is FSME? TBE stands for early-summer meningoencephalitis. This is a virus-induced acute inflammation of the meninges (meningitis) and possibly also the brain (encephalitis) and the spinal cord (myelitis).
• symptoms: Mostly no symptoms or just flu-like symptoms. In other cases, it depends on the spread of inflammation in the central nervous system, which causes symptoms of FSME. Possible are fever, headache, stiff neck and photophobia, dizziness, nausea and vomiting, neurological deficits such as swallowing and speech disorders, paralysis, convulsions, etc.
• Diagnosis: Doctor-patient interview (anamnesis), blood tests, removal and analysis of a nerve water sample (CSF), possibly magnetic resonance imaging (magnetic resonance imaging, MRI)
• Treatment: only symptomatically possible, for example with analgesic and antispasmodic agents. For neurological symptoms such as movement disorders or paralysis possibly physiotherapy, ergotherapy or speech therapy. In severe cases treatment at the intensive care unit.
• Forecast: TBE usually heals without consequences. However, the more extensive the inflammation in the central nervous system, the more likely it is to develop severe courses and long-lasting complaints (such as paralysis). The latter can also last for life. About one in every 100 patients dies from a nervous system-borne FSME.

TBE: description

Early-summer meningoencephalitis (TBE) is an acute inflammation of the meninges and often in addition to the brain and spinal cord. It is triggered by the TBE virus. Ticks in Germany are almost always transmitted by TBE. Therefore, the disease also tick-borne encephalitis called. Rarely, transmission occurs through virus-infected raw milk from goats, sheep and, extremely rarely, cows. A TBE infection from person to person is not possible.

FSME: Rare but dangerous

Not every tick bite (colloquial: tick bite) leads to a TBE infection and not every infection to the disease: In the risk areas of Germany carry only about 0.1 to five percent of the ticks the TBE virus in itself. When such infected ticks sting people and thereby transmit the virus, only develops up to a third the sufferer actually has an early-summer meningoencephalitis. Most infected people show no symptoms.

However, one should keep in mind that the disorder can be severe and even fatal: The healing process can last for months. Sometimes persistent neurological limitations (such as concentration problems) are left behind. In about one in a hundred patients, FSME infestation of the nervous system leads to death.

FSME: frequency

In 2017, more than 450 cases of TBE were registered in Germany. The case numbers are quite different from year to year. For example, fewer than 200 cases of TBE were reported in 2012, compared with over 540 in 2006.

In the main, people are infected with recreational activities in nature with TBE, for example while camping or hiking. Most diseases are observed in spring and summer.

Children are more likely to have tick bites than adults and are therefore more vulnerable to TBE. In these cases, the infection is usually mild and heals without permanent damage.

Not to be confused with Lyme disease

TBE should not be confused with another tick-borne disease, Lyme disease. It is a disease caused by bacteria (Borrelia). It occurs nationwide and is much more common than TBE: Up to 30 percent of the ticks in Germany carry the Lyme disease virus in itself (the Durchseuchung may be small-scale but very strong). With timely diagnosis, the Lyme disease is easily curable.

TBE: symptoms

If TBE viruses have been transmitted during a tick bite, it takes some time until the first symptoms appear: the pathogen first has to spread in the body and reach the brain. On average pass between the infection (tick bite) and the onset of the disease one to two weeks, This time will be TBE incubation called. In some cases, it may take up to 28 days for the onset of tick-borne encephalitis.

Two-phase disease course

TBE is in two phases for most patients:

The first signs of FSME are flu-like symptoms such as a general malaise, fever, headache and body aches. Occasionally, abdominal pain also occurs. The complaints are often dismissed as a cold or flu. After about a week, the symptoms resolve, and the fever drops again.

In a small part of the patients it comes after a few days to one renewed fever rise, It marks the beginning of the second phase of the disease. This is expressed as follows:

• About 50 percent of patients develop one isolated meningitis (meningitis).
• In about 40 percent of patients joins the meningitis encephalitis (encephalitis). Doctors then speak of one meningoencephalitis.
• In addition, about ten percent of the patients additionally inflame the spinal cord. Then it is a question Meningoenzephalomyelitis.

• Infrequently the inflammation in a TBE is limited to the spinal cord alone (myelitis) or on nerve roots originating at the spinal cord (radiculitis).

In 70 to 95 percent of all TBE infected people show no symptoms (asymptomatic infection) or the second disease phase is missing.

The exact second-stage TBE symptoms depend on the spread of inflammation:

TBE symptoms in isolated meningitis

In pure meningitis, the symptoms of TBE are not significantly different from those of other viral meningitis. However, they are often more pronounced: the patients complain severely limited general condition such as Fever, fatigue and headache, Especially diagnostically relevant are the stiff neck and the resulting photophobia, These are typical signs of meningitis. Also, the TBE can be symptoms like Dizziness, vomiting and nausea cause.

TBE symptoms in meningoencephalitis

If, in addition to the meninges, the brain is also affected by the inflammation (meningoencephalitis), further symptoms of TBE appear: the focus is on one Disorder of movement coordination (Ataxia), Disturbances of consciousness such as Paralysis of the arms, legs and cranial nerves, The latter can cause hearing, swallowing or speech disorders, for example. In addition, the inflammation of the brain can also seizures cause.

TBE symptoms in meningoencephalomyelitis

The most severe TBE symptoms can be found in meningoencephalomyelitis, which is the simultaneous inflammation of the meninges, brain and spinal cord. The spinal cord represents the connection between the brain and the rest of the body. If an inflammation occurs here, the consequences can often be observed all over the body:

Usually occur flaccid paralyzes in the arms and legs on. It usually happens too Swallowing and speech disorders such as Paralysis of the face and neck muscles, Among the most sought-after symptoms of TBE in this disease is the respiratory paralysis, It can lead to death!

TBE symptoms in children

In children and adolescents, TBE is usually associated with nonspecific symptoms similar to those of a flu-like infection. Severe TBE symptoms are less common than in adults. The disease usually heals in the young patients without consequential damage.

Consequential damages of a TBE

In most cases, an FSME heals without consequences. However, some patients still suffer from symptoms such as headaches, tiredness, difficulty concentrating, seizures or paralysis for weeks or months. Often these complaints are only temporary. But you can also persist permanently.

Severe disease progression and permanent damage of TBE are particularly prevalent in older adults. In children, they are almost never observed.

Dual infection: FSME plus Lyme disease

Rarely, a tick bite simultaneously transmits TBE viruses and Lyme disease bacteria. Such a double infection is usually severe. Those affected can sustain lasting neurological damage.

Vaccination against TBE

There is a vaccine against the tick-borne encephalitis. It is a dead vaccine: It consists of inactivated pathogens that can no longer cause disease. Nevertheless, they stimulate the immune system to produce specific antibodies against TBE viruses. These then prevent a long-term “real” TBE infection.

To build up this vaccine protection (basic immunization) are three vaccinations necessary: ​​The second vaccine dose is given one to three months after the first. Depending on the preparation, the third dose is given after another five to twelve or nine to twelve months. Three years after the primary vaccination you should take the TBE vaccine with a single dose refresh, The additional booster vaccinations should take place every five years (in the case of people aged 50 to 60 years, even at three-year intervals).

Experts recommend the TBE vaccine on the one hand all people living in TBE risk areas (see below), as well certain professional groups (Foresters, hunters etc.). On the other hand, the vaccine is also useful for Travelers in TBE areasif there is the possibility of TBE infection (eg during planned hiking tours).

More about the effects and side effects of the vaccination against tick-borne encephalitis in the article TBE vaccine.

TBE areas

In Germany comes TBE especially in Bavaria and Baden-Württemberg before, but also in southern Hesse (Odenwald) as well as in the southeastern Thuringia, Further TBE risk areas are for example Saar-Pfalz-Kreis (in Saarland), Birkenfeld (in Rhineland-Palatinate) and Vogtlandkreis (in Saxony). Outside of these areas, there are only very isolated cases of early summer Meningoze asphaltis in Germany.

Other regions that can be infected with TBE include Austria, northern Switzerland, northern Italy, Hungary, southern Sweden and Croatia. In addition, from northeastern Europe to Japan, viruses are closely related to the TBE viruses. They trigger a similar clinical picture as the tick-borne encephalitis (RSSE = Russian-Spring-Summer-Encephalitis).

Find out more about the spread of TBE viruses in Germany and abroad in the article TBE Areas.

TBE: causes and risk factors

The cause of tick-borne encephalitis is an infection with the TBE virus. It belongs to the so-called flaviviruses such as the causative agents of dengue fever, Japanese encephalitis and yellow fever. In contrast to these tropical diseases, TBE is native to Germany.

TBE: infection routes

TBE will be mainly by tick bites transferred to humans. Ticks are parasites that feed on the blood of a host organism. They live mainly in forest and meadow areas up to an altitude of about 1,500 meters. They prefer warm and moist spots. Ticks are particularly keen to stay in tall grass and undergrowth: Adult ticks usually frolic at a height of 30 to 60 centimeters above the ground; they are rarely found at heights of up to 1.5 meters.

The ticks can “capture” the TBE agent when they are sucking blood from infected wildlife (especially small rodents such as mice). The animals carry the pathogen in themselves, without suffering from TBE. If an infected tick stabs a human at the next blood meal, it can use its saliva to introduce the TBE virus into the human bloodstream.

Very rarely does the TBE transmission take place virus contaminated raw milk of hauling and sheep (more rarely cows) and raw milk products derived therefrom. This transmission path presents a risk of infection especially in Eastern Europe, in Germany it is regarded as a rarity.

Direct transmission of FSME from person to person is not possible. That’s why Infected or infected people are not contagious!

TBE risk factors

All people who have an increased risk of FSME traveling outdoors in a TBE risk area are – for example, in the free time (for example, when hiking) or professional (hunters, foresters, forest workers, etc.). Overall, however, the likelihood of TBE infection is low because, as mentioned above, only a small proportion of the ticks in risk areas carry the TBE agent. So far, only up to 40 TBE cases per 100,000 inhabitants have occurred in the designated FSME areas in five years.

It can not be predicted how serious an infection will be in a particular case. In most cases, TBE infection causes no or only mild symptoms. Rarely, it comes to heavy progressions. The affected are almost exclusively adults. Age plays an important role here: The older a patient is, the more often TBE experiences a severe course, and the more often it leaves lasting damage.

FSME: examinations and diagnosis

First, the doctor will conduct a detailed conversation with the patient to record his medical history (anamnese): In the process, he lets himself be described in detail about the complaints that have occurred. The doctor also asks about visits to a TBE risk area and possible tick bites in the previous weeks. However, many patients have already forgotten or even not noticed the tick bite. The saliva of a tick contains, among other things, narcotic substances, so that many people do not feel the tick bite. For the doctor this means that even if the patient can not remember a tick bite, this does not rule out an FSME.

After the anamnesis interview blood tests on: In TBE, various inflammatory parameters are increased (number of leucocytes, erythrocyte sedimentation rate, CRP). In addition, it is looking for specific antibodies against TBE viruses in the blood. Normally, IgM (immunoglobulin M) is detectable in an infection about two to four weeks after the tick bite. About one to two weeks later, specific IgG antibodies (immunoglobulin G) are found in the patient’s blood.

The diagnosis of FSME is established when both specific IgM and IgG are detectable in the blood, the patient shows the corresponding disease symptoms and is not vaccinated against FSME.

In rare cases, no specific IgM are formed in a TBE infection, such as weakened or drug-suppressed immune system. The diagnosis is then based on other parameters: The significant increase in specific IgG antibodies already provides a clear indication of the infection. In addition, the doctor may request a sample of Brain / spinal fluid (CSF) (CSF). It is examined in the laboratory for specific antibodies and traces of the genome of the TBE viruses. However, the virus is detectable only in the liquor during the first phase of the disease. Later, only the response of the immune system to the pathogens – in the form of specific antibodies – can be measured.

In some cases, the doctor will additionally use detailed images of the brain Magnetic resonance imaging (magnetic resonance imaging, MRI) make. This is especially helpful in distinguishing brain inflammation from TBE viruses from encephalitis caused by herpes simplex viruses.

TBE is notifiable. Thus, if a patient is diagnosed as having acute TBEs through direct virus detection (genetic material) or indirect virus detection (specific antibodies), the physician must report this to the appropriate health authority (with the patient’s name).

Examination of dead ticks?

There are companies that examine consigned ticks for TBE viruses (or other pathogens). The idea behind it: If you discover a sucking tick on your own body, you can remove it and send it in for analysis. If disease symptoms develop, the test result should assist the physician in the diagnosis. But that’s for three reasons little sense:

1. Even if the tick is infected with TBE viruses, it does not necessarily mean that it has transmitted the pathogens to the patient.
2. The methods for detecting TBE viruses (and other pathogens) in ticks have different sensitivities. Despite a negative test result (no TBE viruses detected in the tick), the tick may still be infected and have endured the virus.
3. Even though the tick in question does not actually contain any TBE viruses – perhaps the patient was stung unnoticed by another tick, which was well infected.

TBE: treatment

There is no causal (causal) TBE treatment, so no therapy that specifically targets the TBE virus in the body. One can only support the body in its fight against the pathogen. It is about alleviating TBE symptoms and preventing long-term damage as much as possible.

So should TBE patients bed rest comply. The TBE prescribes seizures, prescribes the doctor anticonvulsant agents, To help against a severe headache Painkiller such as ibuprofen, diclofenac, acetaminophen or metamizole. These remedies work simultaneously antipyretic, However, one will general reduction of fever not recommended, The markedly elevated temperature helps the body fight the TBE pathogens.

For very persistent headaches, TBE patients sometimes get opiates. These are powerful painkillers that can be addictive. They are therefore used only when absolutely necessary and very controlled.

neurological disorders such as movement or speech disorders can be a Physiotherapy, occupational therapy or speech therapy make sense.

In severe TBE (such as with dysregulation or respiratory paralysis), patients on the intensive care unit be treated.

TBE: disease course and prognosis

In most cases, TBE is without complications and completely heals. This is especially true if the infection is a pure meningitis (meningitis) caused.

Is additionally the brain inflamed (meningoencephalitis) suffer many sufferers for weeks on symptoms such as headache, increased fatigue, decreased resilience and emotional lability. In addition, memory, concentration and coordination disorders, speech and speech disorders and paralysis may exist. Often, these symptoms heal completely, although sometimes only months or a few years later. However, meningoencephalitis causes lasting damage in one to two in ten TBE patients.

About three years after a meningitis and encephalitis due to FSME is no longer expected that existing symptoms improve much.

The worst prognosis is for TBE, which affects the brain, meninges and spinal cord equally (Meningoenzephalomyelitis): In one study, 57 patients were followed up ten years after the disease. Only at 20 percent did the early summer meningoencephalitis heal completely. About 50 percent of patients had permanent neurological deficits. About 30 percent died as a result of the disease.

Overall, that is risk of death at an early summer meningoencephalitis at about one percent.

Lifelong immunity?

Experts believe that people are immune to the pathogen after a TBE overcame, so you can not contract TBE a second time. However, one does not know whether this immune protection lasts for life. Those who continue to be exposed to TBE contagion risk should therefore have their immune protection refreshed after three to five years with a TBE vaccine.

FSME: Prevention

Effective protection against TBE is the TBE vaccination mentioned above. But you can do even more to prevent infection – by avoiding tick bites as much as possible. For this you should heed the following advice:

• Wear while staying in woods, bushes and tall grass closed shoes, long pants and long sleeves, Put the trouser legs in your socks, then a tick may have to crawl around the outside of your clothes – it will be easier to spot you there. For the same reason is bright clothes meaningful.
• Use before you enter forest and meadows Tick ​​Repellent (Repellent) on your skin. Note, however, that it has only a temporary effect and does not provide 100% protection.
• Do not touch wild animals like mice or hedgehogs. These often have ticks!
• After an outdoor stay you should wear the clothes and your whole skin search for ticks, The bloodsuckers prefer soft warm body parts. Therefore, they are often found in the popliteal fossa or groin, under the armpits, in the navel, in the elbow, in the genital area, behind the ears and on the head and hairline.

Remove ticks correctly

If you spot a sucking tick on your skin, you should remove it as soon as possible. Use one for this tweezers or a special instrument for tick removal, If you have neither one nor the other at hand, you should nevertheless remove the bloodsucker as quickly as possible, for example with the fingernails.

Grasp the tick in the head area and as close to the skin as possible and pull it careful and straight out. Avoid turning or squeezing the animal! Otherwise she can deliver her saliva with the pathogens into the wound. For the same reason, you should use sucking ticks never pour over with oil or glue!

After removing the tick you should use the small wound carefully disinfect.

In the following days and weeks, be aware of possible signs of TBE (or Lyme disease). If they show up, you should see a doctor immediately.

Additional information

guidelines:

• Guideline “Early Summer Meningoencephalitis (FSME)” of the German Society of Neurology (2016)