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.

• 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. [msdmanuals.com]

• Fever

  Due to its restricted geographical occurrence und non-specific presentation with fever and body pain resembling other serious infections such as malaria, viral hemorrhagic fever, leptospirosis or typhoid fever, the diagnosis of LBRF might be missed in [bmcinfectdis.biomedcentral.com]

  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]

  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]

  People have sudden chills followed by a high fever, severe headache, vomiting, muscle and joint pain, and sometimes a rash. Symptoms disappear, then return (relapse) several times. [msdmanuals.com]

• High Fever

  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]

  Relapsing fever is an acute febrile illness caused by spirochetes of the genus Borrelia. The high fevers of presenting patients spontaneously abate and then recur. [ncbi.nlm.nih.gov]

  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]

  Diagnosis of LBRF cases and prevention of autochthonous transmission in asylum seeker camps are important steps for the near future. [bmcinfectdis.biomedcentral.com]

• Malaise

  She presented with a 2 day history of fever, headache, general body malaise and vomiting. She was misdiagnosed as having severe malaria and was treated with quinine. The blood slide showed Borrelia duttoni. [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]

• 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]

  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]

• 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]

  Nausea and vomiting should be treated with prochlorperazine 5 to 10 mg orally or IM once a day to 4 times a day. If heart failure occurs, specific therapy is indicated. [msdmanuals.com]

  If people are dehydrated or have electrolyte imbalances because of vomiting, they are given fluids intravenously. Acetaminophen may relieve headaches, and prochlorperazine can relieve nausea and vomiting. [merckmanuals.com]

  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]

• 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]

  A Jarisch-Herxheimer reaction including aggravated hypotension, tachycardia and high-grade fever was only observed in patient 2. [bmcinfectdis.biomedcentral.com]

  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]

• Jaundice

  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]

  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]

  Later in the several weeks’ course of the disease, jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease. [msdmanuals.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]

• 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. [msdmanuals.com]

  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]

• Conjunctival Injection

  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]

• 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]

• 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]

  Infection with Borrelia recurrentis : pathogenesis of fever and petechiae. J. Infect. Dis. 140 :665–675. PubMed CrossRef Google Scholar Davis, G. E. 1956. [link.springer.com]

• 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]

• Skin Rash

  Some patients may present with skin rashes or superficial petechial lesions; haemorrhagic lesions have been reported, especially epistaxis, haematuria and haemorrhagic diarrhoea. Respiratory involvement has been described in the USA. [ecdc.europa.eu]

• Headache

  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]

  Common Conditions: Headache Fever Fatigue Headache Pain Short-term memory problems Joint or muscle aches Dizziness [nutripath.com.au]

  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]

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.

• Leukocytosis

  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 [symptoma.com]

  The complete blood count showed a white blood cell count of 12.5 × 10E9/L (mild leukocytosis with left shift), thrombocytopenia (32 000/µL), normal electrolytes, and an elevated C-reactive protein (19.8 mg/dL). Blood cultures were sterile. [bloodjournal.org]

  […] and hyponatremia Ceftriaxone for 1 day followed by doxycycline for 7 days plus HRZE b 3 F, 21 y Somalia SO, KE, UG, SU, LB, IT, CH Italy Fever, pollakisuria, swollen/painful cervical/axillary lymphadenopathy 45, 27 367, 367 Mild anemia, leukocytosis [bmcinfectdis.biomedcentral.com]

  Mild polymorphonuclear leukocytosis and thrombocythemia may occur. Serologic tests for syphilis and Lyme disease may be falsely positive. B. miyamotoi can also be diagnosed by polymerase chain reaction (PCR) tests. [msdmanuals.com]

  Mild polymorphonuclear leukocytosis and thrombocythemia may occur. Serologic tests for syphilis and Lyme disease may be falsely positive. [merckmanuals.com]

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]

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]

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]

For tick-borne relapsing fever, the prognosis is better. Death occurs in less than 10% of untreated people and in less than 2% of treated people. Antibiotics Antibiotics such as tetracycline, doxycycline, or erythromycin are usually effective. [msdmanuals.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]

[…] 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]

Borrelia recurrentis is the etiologic agent of louseborne relapsing fever and is transmitted by the body louse. The vectors of tickborne relapsing fever are the soft ticks, and a number of Borrelia species can be transmitted by these arthropods. [link.springer.com]

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]

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]

In addition, infection control and prevention measures are crucial to prevent lice transmission in asylum seeker camps in North Africa and Europe. [bmcinfectdis.biomedcentral.com]

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]

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