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Tick-Borne Diseases, Relapsing Fever: Follow-up

Author: Jonathan A Edlow, MD, Associate Professor of Medicine, Department of Emergency Medicine, Harvard Medical School; Vice Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center
Contributor Information and Disclosures

Updated: Dec 9, 2008

Follow-up

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.

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.

Deterrence/Prevention

  • See Tick-borne Diseases, Introduction.
  • 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.2
  • 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.

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.

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.

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.

Miscellaneous

Medicolegal Pitfalls

  • Because physicians, especially in developed countries, almost never see (or diagnose) relapsing fever, they tend not to include the diagnosis in the differential. In all patients with a febrile illness, an appropriate epidemiologic history must be taken, to include tick and other insect exposure, travel, and lifestyle. Simply asking these questions may suggest a diagnosis that might have been overlooked otherwise.
  • Taking a detailed history of the pattern of fever may suggest this diagnosis. While physicians are more likely to consider malaria in the setting of intermittent, recurring fevers, a careful examination of a blood smear will be likely to diagnose both diseases.

Special Concerns

  • The JH reaction can be severe. At a minimum, patients ought to be counseled that it might occur (so they do not mistake it for an allergic reaction). Patients who are ill should probably be observed for this reaction in a monitored setting.
 


More on Tick-Borne Diseases, Relapsing Fever

Overview: Tick-Borne Diseases, Relapsing Fever
Differential Diagnoses & Workup: Tick-Borne Diseases, Relapsing Fever
Treatment & Medication: Tick-Borne Diseases, Relapsing Fever
Follow-up: Tick-Borne Diseases, Relapsing Fever
Multimedia: Tick-Borne Diseases, Relapsing Fever
References
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References

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

  2. [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].

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

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

  10. 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].

  11. 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].

  12. 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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Further Reading

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Keywords

tick-borne diseases, tick bite, relapsing fever, Borrelia, louse-borne relapsing fever, human body louse, Pediculus humanus, P humanus, Borrelia recurrentis, B recurrentis, lice, ticks, Ornithodoros, spirochetemia, Borrelia parkeri, B parkeri, Ornithodoros parkeri, O parkeri, Borrelia hermsii, B hermsii, Ornithodoros hermsii, O hermsii, soft tick

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Contributor Information and Disclosures

Author

Jonathan A Edlow, MD, Associate Professor of Medicine, Department of Emergency Medicine, Harvard Medical School; Vice Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center
Jonathan A Edlow, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
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