Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Relapsing Fever in Emergency Medicine Medication

  • Author: Bobak Zonnoor , MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jun 08, 2016
 

Medication Summary

In the treatment of relapsing fever, antimicrobials are the drugs of choice. However, following antimicrobial treatment, patients may develop a Jarisch-Herxheimer (JH) reaction, which can be severe, especially in louse-borne relapsing fever, when patients' host defenses may be otherwise compromised. This reaction has been reported to occur in 50% of patients with tick-borne relapsing fever.

The JH reaction produces apprehension, diaphoresis, fever, tachycardia, and tachypnea with an initial pressor response followed rapidly by hypotension. The JH reaction can be fatal. Recent studies have shown that tumor necrosis factor-α (TNF-α) may be partly responsible for the reaction.[20] Preadministration of glucocorticoids does little to limit the JH reaction, but antibodies to TNF-α do help.

Note that the regimens listed below are for tick-borne relapsing fever. Adults with louse-borne relapsing fever can be treated with a single 500-mg dose of oral or intravenous tetracycline, chloramphenicol, or erythromycin or 100 mg of doxycycline. Penicillin also can be used for louse-borne disease.

Antipyretics are indicated to reduce fever.

Next

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.[21]

Tetracycline (Sumycin)

 

Useful for louse- and tick-borne cases. DOC for the latter. Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria.

Doxycycline (Doryx, Bio-Tab)

 

Has advantage of covering other tick-borne diseases and ease of bid dosing.

Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.

Erythromycin (Erythrocin, Ery-Tab)

 

DOC for patients who are allergic to or cannot tolerate tetracyclines. Is also safe in pregnant patients, although estolate salt should be avoided.

In children, age, weight, and severity of infection determine proper dosage. When twice-a-day dosing is desired, half-total daily dose may be taken q12h. For more severe infections, dosage may be doubled.

Chloramphenicol (Chloromycetin)

 

Is also useful for patients allergic to tetracycline. If a question of Rocky Mountain spotted fever exists, this is a useful drug.

Binds to 50S bacterial ribosomal subunits and interferes with or inhibits protein synthesis. Is effective against gram-negative and gram-positive bacteria.

Previous
Next

Antipyretics

Class Summary

In treating relapsing fever, bed rest and mild analgesic-antipyretic therapy are often helpful in relieving the associated lethargy, malaise, and fever associated with the disease.

Aspirin (Bayer Aspirin, Bufferin, Ascriptin)

 

Lowers elevated body temperature through vasodilation of peripheral vessels, thus enhancing dissipation of excess heat. Also acts on hypothalamus heat-regulating center to reduce fever.

Ibuprofen (Motrin, Nuprin)

 

One of the few NSAIDs indicated for reduction of fever.

Acetaminophen (Tylenol, Anacin Free Aspirin, Feverall)

 

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Inhibits action of endogenous pyrogens on heat-regulating centers.

Previous
 
 
Contributor Information and Disclosures
Author

Bobak Zonnoor , MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital

Bobak Zonnoor , MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Jon Mark Hirshon, MD, MPH, PhD 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

R Gentry Wilkerson, MD, FACEP, FAAEM Assistant Professor, Coordinator for Research, Department of Emergency Medicine, University of Maryland School of Medicine

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Acknowledgements

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. CDC. Tick-borne Relapsing Fever (TBRF). CDC. Available at https://www.cdc.gov/relapsing-fever/. October 15, 2015; Accessed: June 2, 2016.

  2. 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. 2011 Jun 30. [Medline].

  3. 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. 2011 Aug 26. [Medline].

  4. 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. 2011 Sep. 49(9):3245-9. [Medline]. [Full Text].

  5. Croche Santander B, Sánchez Carrión A, Campos E, Toro C, Marcos L, Vargas JC, et al. [Tick-borne relapsing fever in a rural area of southern Spain.]. An Pediatr (Barc). 2013 Dec 12. [Medline].

  6. Moran-Gilad J, Levine H, Schwartz E, Bartal C, Huerta-Hartal M, Schwaber MJ, et al. Postexposure prophylaxis of tick-borne relapsing Fever: lessons learned from recent outbreaks in Israel. Vector Borne Zoonotic Dis. 2013 Nov. 13(11):791-7. [Medline].

  7. Cutler SJ, Abdissa A, Trape JF. New concepts for the old challenge of African relapsing fever borreliosis. Clin Microbiol Infect. 2009 May. 15 (5):400-6. [Medline].

  8. Hayes EB, Dennis DT . p.991-995. Relapsing fever. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison's Principles of Internal Medicine. 16th edition. 2004. 991-5.

  9. Rahlenbeck SI, Gebre-Yohannes A. Louse-borne relapsing fever and its treatment. Trop Geogr Med. 1995. 47 (2):49-52. [Medline].

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

  11. Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med. 2008 Jul. 75 (7):521-30. [Medline].

  12. Hovius JW, de Wever B, Sohne M, Brouwer MC, Coumou J, Wagemakers A, et al. A case of meningoencephalitis by the relapsing fever spirochaete Borrelia miyamotoi in Europe. Lancet. 2013 Aug 17. 382 (9892):658. [Medline].

  13. Parola P, Raoult D. Ticks and tickborne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis. 2001 Mar 15. 32 (6):897-928. [Medline].

  14. Perine PL, Parry EH, Vukotich D, Warrell DA, Bryceson AD. Bleeding in louse-borne relapsing fever. I. Clinical studies in 37 patients. Trans R Soc Trop Med Hyg. 1971. 65 (6):776-81. [Medline].

  15. Sah RP, Wilson ME, Seningen J, Bhagra A. Relapsing fevers and lymphadenopathy in a young woman. BMJ Case Rep. 2013 Jul 13. 2013:[Medline].

  16. 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 Oct. 46 (4):898-905. [Medline].

  17. Chohan IS. Tick-borne relapsing fever in Kashmir: mice inoculation--a diagnostic method of choice. Indian J Pathol Bacteriol. 1967 Jul. 10 (3):289-94. [Medline].

  18. Barbour AG. Clinical features and management of relapsing fever. UpToDate. Accessed: November 25, 2008.

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

  20. 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. 1996 Aug 1. 335(5):311-5. [Medline].

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

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

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

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

  25. 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 Jan. 26(1):151-64. [Medline].

  26. 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):1073-6. [Medline].

  27. 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 Jan. 26(1):122-31. [Medline].

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

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

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

  31. 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. 2002 Jan. 66(1):71-5. [Medline].

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

 
Previous
Next
 
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.
Cases of Tick-borne Relapsing Fever - United States, 1990-2011. Courtesy of the Centers for Disease Control and Prevention (CDC).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.