Relapsing Fever in Emergency Medicine Clinical Presentation

  • Author: Nathaniel B Stephens; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 21, 2011
 

History

Relapsing fever develops abruptly 3-18 days (average, 7-8 d) after exposure to the spirochete.

As with all the tick-borne diseases, the season of onset and epidemiologic history suggesting possible tick exposure are important clues. Ornithodoros ticks often frequent caves and decaying woodpiles. Many patients report a history of having spent time in rustic cabins in which the ticks gain access by hitching a ride on a rodent.

  • Onset of symptoms generally is abrupt.
  • Pulse is rapid in proportion to the fever, a point of differential value with typhoid fever with which louse-borne relapsing fever can be confused.
  • Headache is a very common symptom, occurring in nearly 95% of cases.
  • Myalgias and chills also occur in approximately 90% of cases.
  • Arthralgias
  • Weakness
  • Anorexia
  • Weight loss
  • Cough
  • Over the last several years, adult respiratory distress syndrome (ARDS) has been reported in several North American patients.
  • Systemic symptoms
    • Patients commonly complain of nausea, vomiting, and upper abdominal pain due to liver and spleen involvement.
    • Hepatic and splenic involvement is more common in louse-borne relapsing fever.
    • A dry cough frequently is observed, a feature that is in common with typhoid fever.
  • Relapses
    • The primary febrile episode typically ends after 3-6 days by crisis that can culminate in fatal shock. About 7-10 days later, the first relapse occurs abruptly. Subsequent relapses tend to be less severe.
    • The primary febrile episode usually lasts an average of 3 days.[4]
    • Louse-borne relapsing fever normally produces fewer relapses.
    • In tick-borne disease, relapses average 3, and there can be more than 10.
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Physical

Physical findings are not diagnostic.

  • Fever (most common finding)
  • Tachypnea
  • Tachycardia
  • Hypotension
  • Abdominal tenderness with hepatosplenomegaly
  • Petechial or maculopapular rash
  • Rales
  • Rhonchi
  • Nuchal rigidity
  • Lymphadenopathy
  • Jaundice
  • Iritis and iridocyclitis
  • Neurologic findings are more common in louse-borne disease and include coma, cranial neuropathy (especially Bell palsy), hemiplegia, meningitis, and seizures.
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Causes

Relapsing fever is caused by infection with the causative Borrelia species.

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Contributor Information and Disclosures
Author

Nathaniel B Stephens  DO, Resident Physician, Department of Emergency Medicine, University of South Florida, Tampa General Hospital

Nathaniel B Stephens is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, Emergency Medicine Residents Association, Florida Osteopathic Medical Association, and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

R Gentry Wilkerson, MD  Assistant Professor, Director of Research, Emergency Medicine Residency Program, University of South Florida College of Medicine, Tampa General Hospital

R Gentry Wilkerson, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon Mark Hirshon, MD, MPH  Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jonathan A Edlow, MD, to the development and writing of this article.

References

  1. Palma M, Lopes de Carvalho I, Figueiredo M, Amaro F, Boinas F, Cutler SJ, et al. Borrelia hispanica in Ornithodoros erraticus, Portugal. Clin Microbiol Infect. Jun 30 2011;[Medline].

  2. Yabsley MJ, Parsons NJ, Horne EC, Shock BC, Purdee M. Novel relapsing fever Borrelia detected in African penguins (Spheniscus demersus) admitted to two rehabilitation centers in South Africa. Parasitol Res. Aug 26 2011;[Medline].

  3. Reller ME, Clemens EG, Schachterle SE, Mtove GA, Sullivan DJ, Dumler JS. Multiplex 5' nuclease-quantitative PCR for diagnosis of relapsing fever in a large Tanzanian cohort. J Clin Microbiol. Sep 2011;49(9):3245-9. [Medline]. [Full Text].

  4. Southern PM, Sandford JP. Relapsing fever: a clinical and microbiological review. Med. 1969;48:129-43.

  5. [Best Evidence] Hasin T, Davidovitch N, Cohen R, et al. Postexposure treatment with doxycycline for the prevention of tick-borne relapsing fever. N Engl J Med. Jul 13 2006;355(2):148-55. [Medline].

  6. Fekade D, Knox K, Hussein K, et al. Prevention of Jarisch-Herxheimer reactions by treatment with antibodies against tumor necrosis factor alpha. N Engl J Med. Aug 1 1996;335(5):311-5. [Medline].

  7. Guerrier G, Doherty T. Comparison of antibiotic regimens for treating louse-borne relapsing fever: a meta-analysis. Trans R Soc Trop Med Hyg. Sep 2011;105(9):483-90. [Medline].

  8. Anda P, Sanchez-Yebra W, del Mar Vitutia M, et al. A new Borrelia species isolated from patients with relapsing fever in Spain. Lancet. Jul 20 1996;348(9021):162-5. [Medline].

  9. 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. Jan 1998;26(1):151-64. [Medline].

  10. 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. Oct 19 2007;56(41):1073-6. [Medline].

  11. Dworkin MS, Anderson DE Jr, Schwan TG, et al. Tick-borne relapsing fever in the northwestern United States and southwestern Canada. Clin Infect Dis. Jan 1998;26(1):122-31. [Medline].

  12. Dworkin MS, Schwan TG, Anderson DE Jr, Borchardt SM. Tick-borne relapsing fever. Infect Dis Clin North Am. Sep 2008;22(3):449-68, viii. [Medline].

  13. Horton JM, Blaser MJ. The spectrum of relapsing fever in the Rocky Mountains. Arch Intern Med. May 1985;145(5):871-5. [Medline].

  14. Nordstrand A, Barbour AG, Bergstrom S. Borrelia pathogenesis research in the post-genomic and post-vaccine era. Curr Opin Microbiol. Feb 2000;3(1):86-92. [Medline].

  15. Paul WS, Maupin G, Scott-Wright AO, et al. Outbreak of tick-borne relapsing fever at the north rim of the Grand Canyon: evidence for effectiveness of preventive measures. Am J Trop Med Hyg. Jan 2002;66(1):71-5. [Medline].

  16. Raoult D, Roux V. The body louse as a vector of reemerging human diseases. Clin Infect Dis. Oct 1999;29(4):888-911. [Medline].

 
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Relapsing fever can be tick- or louse-borne. Soft-bodied ticks of the genus Ornithodoros transmit tick-borne cases. Below is an image of such a tick. Unlike the hard-bodied ticks, the Ornithodoros feed briefly and can transmit disease within minutes. Photo courtesy of Julie Rawlings, MPH, Texas Department of Health.
Photomicrograph of a patient who presented to the ED with cyclical fevers and chills, which she developed while traveling in one of the recently formed Soviet Republics in 1990. A blood smear for malaria was obtained, and this is what the laboratory technician observed.
 
 
 
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