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Relapsing Fever

Fevers Relapsing

Relapsing fever is a condition characterized by episodes of fever, headache, myalgias, arthralgias, and nausea followed by a few days of improvement after which there is a recurrence of symptoms. It is caused by some species of Borrelia spirochetes and can be of two types: the tick-borne relapsing fever and the louse-borne relapsing fever. Diagnosis depends on clinical features and identification of the causative organism.


Presentation

Relapsing fever (RF) is a condition caused by a spirochete and is characterized by typical features of episodic and recurrent high fever, headache, myalgias, and arthralgias. The symptoms last for approximately 3 days, then abate for a week but then recur for another 3 days. This process could continue unless treated. There are two types of RF: tick-borne RF (TBRF) and louse-borne RF (LBRF). TBRF occurs after individuals have lived or slept in rodent-infested mountain cabins while LBRF is transmitted by the body louse and happens in refugee camps or developing regions of the world.

Clinical presentation of TBRF is sudden onset of high fever lasting up to a week and ending with rigors, hypertension, and tachycardia [1]. The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea. Neurologic symptoms are more common in TBRF after the second episode of fever and include facial palsy, meningismus, myelitis, and radiculopathy followed in certain cases by deficits like hemiplegia and aphasia [1] [2]. Ophthalmic involvement is associated with a possibility of permanent visual impairment secondary to unilateral or bilateral iridocyclitis or panophthalmitis. Hepatosplenomegaly and myocarditis may be present in fatal cases. Infection of pregnant women has a higher incidence of miscarriages and stillbirths. Gravid women and children have a more serious form of the disease [3] [4]. During TBRF crises, adult respiratory distress syndrome is also known to develop [5].

The incidence of jaundice, petechiae, hemoptysis, epistaxis and CNS involvement is higher in LBRF [6]. Patients of LBRF have been reported to have mainly one relapse while those with TBRF have averagely 3 relapses [7]. Delirium and coma can arise in both TBRF and LBRF.

Fever
  • Tick-borne relapsing fever; Louse-borne relapsing fever Horton JM. Relapsing fever caused by borrelia species. In: Bennett JE, Dolin R, Blaser MJ, eds.[nlm.nih.gov]
  • External links [ edit ] CDC: Relapsing Fever Scientist and astronomer Larry Webster infected with relapsing fever[en.wikipedia.org]
  • The diagnosis of tick-borne relapsing fever requires an accurate characterization of the fever and a thorough medical, social, and travel history of the patient.[ncbi.nlm.nih.gov]
  • Relapsing fever is a condition characterized by episodes of fever, headache, myalgias, arthralgias, and nausea followed by a few days of improvement after which there is a recurrence of symptoms.[symptoma.com]
  • Differential diagnosis: malaria, typhoid fever, viral haemorrhagic fever, leptospirosis, typhus, tick-borne relapsing fever, non-typhoidal salmonellosis, meningococcal septicaemia and meningitis.[ecdc.europa.eu]
Chills
  • This consists of shaking chills, followed by intense sweating, falling body temperature, and low blood pressure. This stage may result in death.[nlm.nih.gov]
  • We discuss the case of a 44-year-old male residing in the San Juan Mountains of Western Colorado who presented with fever, myalgia, vomiting, and "violent chills" to an emergency department.[ncbi.nlm.nih.gov]
  • Recurring high fever episodes may be accompanied by symptoms of: rash chills dysuria myalgia diarrhea bleeding arthralgia dizziness headache dry cough weakness photophobia unsteady gait abdominal pain nausea & vomiting neck pain, stiffness mental status[healthblurbs.com]
High Fever
  • The high fevers of presenting patients spontaneously abate and then recur. Here we report a 50-year-old woman having relapsing fever associated with thrombocytopenia.[ncbi.nlm.nih.gov]
  • Relapsing fever (RF) is a condition caused by a spirochete and is characterized by typical features of episodic and recurrent high fever, headache, myalgias, and arthralgias.[symptoma.com]
  • Definitions of relapsing fever 1 n marked by recurring high fever and transmitted by the bite of infected lice or ticks; characterized by episodes of high fever and chills and headache and muscle pain and nausea that recur every week or ten days for several[vocabulary.com]
  • Definition of relapsing fever : a variable acute epidemic disease that is marked by recurring high fever usually lasting three to seven days and is caused by a spirochete (genus Borrelia ) transmitted by the bites of lice and ticks First Known Use of[merriam-webster.com]
Camping
  • Before the camp, a professional pest control company had rodent proofed the cabin, but no acaricides had been applied. Cabin inspection after the camp found rodents and Ornithodoros ticks, the vector of TBRF.[ncbi.nlm.nih.gov]
Malaise
  • Clinical illness is characterized by relapsing fever, myalgias, and malaise. On May 10, 2011, CDC and the Colorado Department of Public Health and Environment were notified of two patients with TBRF: a young woman and her newborn child.[ncbi.nlm.nih.gov]
  • A 13-year-old girl presented with recurrent fevers, with temperatures up to 104 F (40 C), over a 3-week period, with associated headache, chills, and malaise.[nejm.org]
Splenomegaly
  • Splenomegaly was the second most common finding reported. Diagnosis of relapsing fever was made in 20 cases by identifying spirochetes on peripheral blood smears.[ncbi.nlm.nih.gov]
  • Malaria and babesiosis cause hemolytic anemia and may be associated with hepatomegaly and splenomegaly. Recurring fever is typical of malaria and Borrelia infection.[mdedge.com]
  • Later in the several weeks’ course of the disease, jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease.[merckmanuals.com]
  • Patients may present with hepatomegaly and splenomegaly, with risk of splenic rupture.[ecdc.europa.eu]
  • Other manifestations include splenomegaly, hepatomegaly, jaundice, rash, respiratory symptoms, and central nervous system involvement. A primary febrile episode ends within 3 to 6 days and can culminate in fatal shock.[atsu.edu]
Cough
  • The fever attacks last from several hours to 4 days, and are accompanied by chills, headache, nausea and vomiting, sweating, abdominal pain, arthralgia, and cough; complications are rare.[ncbi.nlm.nih.gov]
  • Fever, dizziness, head and muscle ache, coughing, and vomiting. Episodes (a total of 2-5) of fever lasting several days followed by several days without fever. Severe disease includes liver and spleen enlargement and breathing difficulties.[extension.entm.purdue.edu]
  • Recurring high fever episodes may be accompanied by symptoms of: rash chills dysuria myalgia diarrhea bleeding arthralgia dizziness headache dry cough weakness photophobia unsteady gait abdominal pain nausea & vomiting neck pain, stiffness mental status[healthblurbs.com]
  • Systemic complications can include nausea, vomiting, upper abdominal pain due to liver and spleen involvement, and a dry cough.[atsu.edu]
Nausea
  • The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea.[symptoma.com]
  • Tickborne relapsing fever (TBRF) is a bacterial infection characterized by recurring episodes of fever, headache, muscle and joint aches, and nausea.[ncbi.nlm.nih.gov]
  • Relapsing Fever is a tick spread illness that is characterized by relapsing or recurring episodes of fever, accompanied by headache, muscle and joint aches, and nausea.[health.utah.gov]
Vomiting
  • Symptoms of relapsing fever include: Bleeding Coma Headache Joint aches, muscle aches Nausea and vomiting Sagging on one side of the face (facial droop) Stiff neck Sudden high fever, shaking chills, seizure Vomiting Weakness, unsteady while walking Relapsing[nlm.nih.gov]
  • Findings on physical examination are variable; abdominal pain, vomiting, and altered sensorium are the most common symptoms.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Findings on physical examination are variable; abdominal pain, vomiting, and altered sensorium are the most common symptoms.[ncbi.nlm.nih.gov]
  • Abdominal pain. General feeling of illness (malaise). Rash (up to 50% of cases). Prescription medicine is used to treat relapsing fever. Current as of: July 30, 2018 Author: Healthwise Staff Medical Review: William H.[myhealth.alberta.ca]
  • Recurring high fever episodes may be accompanied by symptoms of: rash chills dysuria myalgia diarrhea bleeding arthralgia dizziness headache dry cough weakness photophobia unsteady gait abdominal pain nausea & vomiting neck pain, stiffness mental status[healthblurbs.com]
  • Nausea, vomiting, abdominal pain, and rash may also occur. TBRF is characterized by recurring ("relapsing") episodes of symptoms that usually last about three days, disappear for seven days, then return.[nps.gov]
Jaundice
  • Jaundice was seen in four of the five cases, three of them died. Only twenty cases of neonatal relapsing fever were previously reported. Findings are discussed in comparison with those of former reports on relapsing fever in the literature.[ncbi.nlm.nih.gov]
  • Her condition deteriorated a few hours after admission when jaundice, hepatosplenomegaly, and hemorrhage appeared. Borrelia organisms were found on peripheral blood smear. The patient died 16 hours after admission.[jamanetwork.com]
  • The incidence of jaundice, petechiae, hemoptysis, epistaxis and CNS involvement is higher in LBRF. Patients of LBRF have been reported to have mainly one relapse while those with TBRF have averagely 3 relapses.[symptoma.com]
  • Later in the several weeks’ course of the disease, jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease.[merckmanuals.com]
  • About one-fourth of patients with babesiosis are coinfected with the Lyme disease bacterium ( Borrelia burgdorferi ) and often have more severe illness. 3 Hepatomegaly, splenomegaly, jaundice, and dark urine are common findings in patients with symptoms[mdedge.com]
Hepatomegaly
  • Malaria and babesiosis cause hemolytic anemia and may be associated with hepatomegaly and splenomegaly. Recurring fever is typical of malaria and Borrelia infection.[mdedge.com]
  • Later in the several weeks’ course of the disease, jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease.[merckmanuals.com]
  • Patients may present with hepatomegaly and splenomegaly, with risk of splenic rupture.[ecdc.europa.eu]
  • Other manifestations include splenomegaly, hepatomegaly, jaundice, rash, respiratory symptoms, and central nervous system involvement. A primary febrile episode ends within 3 to 6 days and can culminate in fatal shock.[atsu.edu]
Hepatosplenomegaly
  • Her condition deteriorated a few hours after admission when jaundice, hepatosplenomegaly, and hemorrhage appeared. Borrelia organisms were found on peripheral blood smear. The patient died 16 hours after admission.[jamanetwork.com]
  • Hepatosplenomegaly and myocarditis may be present in fatal cases. Infection of pregnant women has a higher incidence of miscarriages and stillbirths. Gravid women and children have a more serious form of the disease.[symptoma.com]
  • It should be performed in patients with persistent or recurring fever or in those who have traveled to the developing world or who have a history of tick exposure, especially if accompanied by hemolytic anemia, thrombocytopenia, or hepatosplenomegaly.[mdedge.com]
  • There was no hepatosplenomegaly and lympadenopathy. The patient had petechial rash and hematuria. Clinical diagnosis was recurrent fever of unknown cause. She had history of fever few weeks back, for which she took symptomatic treatment.[ijpmonline.org]
Tachycardia
  • Clinical presentation of TBRF is sudden onset of high fever lasting up to a week and ending with rigors, hypertension, and tachycardia. The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea.[symptoma.com]
  • Cardio-respiratory symptoms such as tachycardia, mild tachypnea and non-productive cough can occur. Patients may present with hepatomegaly and splenomegaly, with risk of splenic rupture.[ecdc.europa.eu]
  • This reaction produces apprehension, diaphoresis, fever, tachycardia, and tachypnea, with an initial pressor response followed rapidly by hypotension. Erythromycin or chloramphenicol can be used in the treatment of pregnant women and children.[atsu.edu]
  • These can, however, induce a Jarisch–Herxheimer reaction in over half those treated, producing anxiety, diaphoresis, fever, tachycardia and tachypnea with an initial pressor response followed rapidly by hypotension.[en.wikipedia.org]
Visual Impairment
  • Ophthalmic involvement is associated with a possibility of permanent visual impairment secondary to unilateral or bilateral iridocyclitis or panophthalmitis. Hepatosplenomegaly and myocarditis may be present in fatal cases.[symptoma.com]
Petechiae
  • Papules (small lumps), petechiae (small red or purple spots due to bleeding into the skin), purpura (bleeding into the skin, includes petechiae and bruises), and facial flushing have been described. Petechiae may also occur on mucous membranes.[dermnetnz.org]
  • The incidence of jaundice, petechiae, hemoptysis, epistaxis and CNS involvement is higher in LBRF. Patients of LBRF have been reported to have mainly one relapse while those with TBRF have averagely 3 relapses.[symptoma.com]
  • Clinical manifestations are severe for most tick-borne relapsing fever; headache, neck stiffness, arthralgia, myalgia, ecchymosis, epistaxis, and petechiae.[igenex.com]
  • Mycocutaneous symptoms include conjunctival injection, scattered petechiae and erythematous rash. Cardio-respiratory symptoms such as tachycardia, mild tachypnea and non-productive cough can occur.[ecdc.europa.eu]
Purpura
  • Papules (small lumps), petechiae (small red or purple spots due to bleeding into the skin), purpura (bleeding into the skin, includes petechiae and bruises), and facial flushing have been described. Petechiae may also occur on mucous membranes.[dermnetnz.org]
Myalgia
  • The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea.[symptoma.com]
  • He complained of myalgia and secondarily presented fever. Blood smears revealed spirochetes later identified as Borrelia recurrentis. LBRF should be considered in countries hosting refugees, particularly those who transit through endemic regions.[ncbi.nlm.nih.gov]
Arthralgia
  • The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea.[symptoma.com]
  • LBRF by Borrelia recurrentis should be considered among the clinical hypotheses in migrants presenting with fever, headache, chills, sweating, arthralgia, myalgia, dizziness, nausea and vomiting.[ncbi.nlm.nih.gov]
  • Definitions for relapsing fever Medical Definition of relapsing fever : a variable acute infectious disease that is marked by sudden recurring episodes of high fever which usually last from three to seven days, are typically accompanied by myalgia, arthralgia[merriam-webster.com]
Leg Pain
  • A previously healthy 20-year-old woman presented to our hospital on October 8, 2010, because of recurrent fever and lower leg pain.[ncbi.nlm.nih.gov]
Lower Leg Pain
  • A previously healthy 20-year-old woman presented to our hospital on October 8, 2010, because of recurrent fever and lower leg pain.[ncbi.nlm.nih.gov]
Headache
  • Tickborne relapsing fever (TBRF) is a bacterial infection characterized by recurring episodes of fever, headache, muscle and joint aches, and nausea.[ncbi.nlm.nih.gov]
  • The first episode is often accompanied by headaches, myalgias, arthralgias, neck stiffness, and nausea.[symptoma.com]
  • A 13-year-old girl presented with recurrent fevers, with temperatures up to 104 F (40 C), over a 3-week period, with associated headache, chills, and malaise.[nejm.org]
Confusion
  • Given the high incidence of malaria in Mali, and the potential to confuse the clinical diagnosis of these two diseases, we initiated studies to determine if there were endemic foci of relapsing fever spirochetes that could pose a risk for human infection[ncbi.nlm.nih.gov]
  • To minimize confusion among scientists and other health care professionals, we proposed that the species that are part of the Lyme disease Borrelia should be transferred to a new genus, Borreliella.[atlasofscience.org]
  • This reaction is often observed a few hours after the first antibiotic treatment and follows two successive phases: the chill phase (rigours, high fever, anxiety or confusion, increasing metabolic rate) and the flush phase (decrease in temperature, drenching[ecdc.europa.eu]
  • The patient may become dizzy and confused. The eyes may be bloodshot and very sensitive to light. A cough may develop. The heart rate is greatly increased, and the liver and spleen may be swollen.[medical-dictionary.thefreedictionary.com]
Aphasia
  • Neurologic symptoms are more common in TBRF after the second episode of fever and include facial palsy, meningismus, myelitis, and radiculopathy followed in certain cases by deficits like hemiplegia and aphasia.[symptoma.com]

Workup

The diagnosis of RF depends on identifying the typical characteristics of the fever along with a thorough medical, social, and travel history as findings of physical examination are not predictable. Spirochetes can be detected on thin and thick peripheral blood smears using Wright’s or Giemsa stain or by isolating them in Kelly culture medium in the period between onset of fever and its peak [8] [9] [10]. Peripheral blood smears have a sensitivity of 70% and are more sensitive in detecting TBRF than LBRF [11].

Direct and indirect immunofluorescence can be used to visualize spirochetes with a fluorescence microscope while polymerase chain reaction testing can identify most Borrelia species [12] [13]. Other laboratory findings include elevated erythrocyte sedimentation rate, anemia, proteinuria,leukocytosis, thrombocytopenia, increased serum unconjugated bilirubin levels, elevated hepatic transaminase levels, prolonged partial thromboplastin and prothrombin times and microhematuria. In TBRF myocarditis, an electrocardiogram may show a prolonged corrected Q-T interval [14] [15] [16]. Analysis of cerebrospinal fluid (CSF) in patients with neurological symptoms is likely to reveal mononuclear pleocytosis, an elevated protein level, and normal glucose levels [3] [7].

Features of pulmonary edema can be noticed on a plain chest X-ray when present. Other imaging studies are indicated only in cases where intracranial or other complications are suspected.

Histological studies help to detect spirochetes using silver stains like Warthin-Starry or modified Dieterle.

Cytopenia
  • Pediatric patients with prolonged fever, cytopenias, and negative aforementioned serologies are often hospitalized for further work-up.[ncbi.nlm.nih.gov]

Treatment

  • The patient continued treatment with procaine penicillin fortified for relapsing fever. Several hours later the woman died, probably due to JHR.[ncbi.nlm.nih.gov]
  • A potential severe or fatal Jarisch–Herxheimer reaction can be induced by antibiotic treatment of louse-borne relapsing fever, requiring the close monitoring of patients under antibiotic treatment.[ecdc.europa.eu]

Prognosis

  • Prognosis In epidemics of LBRF, death rates among untreated victims have run as high as 30%. With treatment, and careful monitoring for the development of the Jarish-Herxheimer reaction, prognosis is good for both LBRF and TBRF.[medical-dictionary.thefreedictionary.com]
  • Outlook (Prognosis) People with this condition who have developed a coma, heart inflammation, liver problems, or pneumonia are more likely to die. With early treatment, the death rate is reduced.[leehealth.org]
  • Prognosis The mortality rates of untreated louse-borne relapsing fever and tick-borne relapsing fever are range from 10%-70% and 4%-10%, respectively.[emedicine.medscape.com]
  • For tick-borne relapsing fever, the prognosis is better. The mortality rate is 10% for untreated patients and is 2% for treated patients.[merckmanuals.com]

Etiology

  • […] disease is remarkable because the human host is unaware of the tick bite, usually becomes very ill, may experience an exacerbation of symptoms rather than improvement shortly after beginning appropriate treatment, and, despite often high numbers of the etiologic[ncbi.nlm.nih.gov]
  • Etiology The disease may be epidemic and transmitted by lice or endemic and transmitted by soft-bodied ticks (Ornithodoros and Argas).[orpha.net]
  • The first case linked with spirochetal etiology and body louse transmission occurred in late 19th –early 20th century. Soft tick-borne relapsing fever was first discovered to cause disease in humans in the early 20th century.[igenex.com]
  • Etiology Endemic relapsing fever is caused by at least 15 different Borrelia species. Soft ticks of the genus Ornithodorus spread the tick-borne variety.[atsu.edu]

Epidemiology

  • This report summarizes the epidemiology of 504 TBRF cases reported from 12 western states during 1990-2011. Cases occurred most commonly among males and among persons aged 10‒14 and 40‒44 years.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology After exposure to an infected louse or tick, spirochetes enter the dermis and gain access to the bloodstream where they infect the endothelium.[patient.info]
  • Pathophysiology Relapsing fever is transmitted to humans by 2 vectors, ticks and lice. The human body louse, Pediculus humanus, is the specific vector ( Pediculus pubis is not a vector).[emedicine.medscape.com]

Prevention

  • Tick-bite screening and prophylactic treatment with doxycycline in endemic areas is a practical, safe, and highly effective policy for preventing TBRF.[ncbi.nlm.nih.gov]
  • This is the subject of the final section of this study session. 36.4 Prevention of louse-borne relapsing fever and typhus Let us now focus on the common prevention aspects of relapsing fever and typhus.[open.edu]

References

Article

  1. Dworkin MS, Schwan TG, Anderson DE Jr. Tick-borne relapsing fever in North America. Med Clin North Am. 2002;86:417-433.
  2. Cadavid D, Barbour AG. Neuroborreliosis during relapsing fever: review of the clinical manifestations, pathology, and treatment of infections in humans and experimental animals. Clin Infect Dis. 1998;26:151-164.
  3. Dworkin MS, Shoemaker PC, Fritz CL, Dowell ME, Anderson DE Jr. The epidemiology of tick-borne relapsing fever in the United States. Am J Trop Med Hyg. 2002;66:753-758.
  4. Jongen VH, van Roosmalen J, Tiems J, Van Holten J, Wetsteyn JC. Tick-borne relapsing fever and pregnancy outcome in rural Tanzania. Acta Obstet Gynecol Scand. 1997;76:834-838.
  5. Centers for Disease Control and Prevention (CDC). Acute respiratory distress syndrome in persons with tickborne relapsing fever--three states, 2004-2005. MMWR Morb Mortal Wkly Rep. 2007 Oct 19; 56(41):1073-1076.
  6. Goubau PF. Relapsing fevers. A review. Ann Soc Belg Med Trop. 1984; 64(4):335-364.
  7. Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med. 2008;75(7):521-530.
  8. Kelly R. Cultivation of Borrelia hermsi. Science. 1971; 173(995):443-444.
  9. Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am. 2008; 22(3):449-468.
  10. Trevejo RT, Schriefer ME, Gage KL, et al. An interstate outbreak of tick-borne relapsing fever among vacationers at a Rocky Mountain cabin. Am J Trop Med Hyg. 1998;58:743-747.
  11. Parola P, Raoult D. Ticks and tickborne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis. 2001; 32(6):897-928.
  12. Fukunaga M, Okada K, Nakao M, Konishi T, Sato Y. Phylogenetic analysis of Borrelia species based on flagellin gene sequences and its application for molecular typing of Lyme disease borreliae. Int J Syst Bacteriol. 1996;46(4):898-905.
  13. Uhlmann EJ, Seed PC, Schwan TG, Storch GA. Tick-borne relapsing fever polymerase chain reaction of tick-borne relapsing fever caused by Borrelia hermsii. Pediatr Infect Dis J. 2007;6(3):267-269.
  14. Dworkin MS, Anderson DE Jr, Schwan TG, et al. Tick-borne relapsing fever in the northwestern United States and southwestern Canada. Clin Infect Dis. 1998;26:122-131.
  15. Horton JM, Blaser MJ. The spectrum of relapsing fever in the Rocky Mountains. Arch Intern Med. 1985;145:871-875.
  16. Cadavid D, Bundoc V, Barbour AG. Experimental infection of the mouse brain by a relapsing fever Borrelia species: a molecular analysis. J Infect Dis. 1993;168:143-151.

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Last updated: 2019-06-28 12:14