Relapsing Fever in Emergency Medicine Follow-up

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

Further Inpatient Care

  • Many patients with louse-borne relapsing fever are malnourished and will require inpatient care to correct their hypovolemia, coagulation abnormalities, and nutritional status.
  • Patients with abnormal mental status also require close observation with airway protection, as indicated.
  • Those with prolonged QTc intervals are best monitored by telemetry.
  • Be especially vigilant in monitoring for a JH reaction.
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Further Outpatient Care

  • Refer patients to follow up with their primary care physician to address complete recovery, any malnutrition issues, and any laboratory or ECG abnormalities.
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Deterrence/Prevention

  • In 2006, a study was published that studied postexposure prophylaxis with a 5-day course of doxycycline to prevent tick-borne relapsing fever. A 200-mg dose (day 1) followed by 100 mg daily for 4 more days had 100% efficacy (although the 95% confidence intervals were wide [46-100] because of small numbers of patients.[5]
  • In many situations (eg, a refugee camp) maintenance of personal hygiene is difficult or impossible.
    • Chemical delousing may be required in epidemic situations.
    • For the louse-borne variety, maintaining personal hygiene to avoid lice prevents the disease.
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Complications

  • Bleeding is a common complication with both forms of relapsing fever. Bleeding in the skin, nose, eyes, lungs, urinary tract, GI tract, and brain can occur. The latter two can be fatal.
  • JH reaction
  • ARDS
  • In pregnant women, premature labor, spontaneous abortion, and transplacental spread with neonatal death have all been reported.
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Prognosis

  • In untreated epidemics of louse-borne disease, the mortality rate is 30-70%. This is lowered to less than 1% with appropriate antibiotic therapy.
  • Poor prognostic signs include severe jaundice, severe change in mental status, severe bleeding, and prolonged QTc interval.
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Patient Education

  • Educate patients about the vectors and how they can be avoided.
  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.
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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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