Deterrence/Prevention

Louse-borne relapsing fever (LBRF) can be prevented by eliminating circumstances that promote louse infection (eg, crowding, homelessness) and good personal hygiene (eg, changing clothes at frequent intervals, bathing, boiling and washing clothes and bedding).

Delousing with 1% lindane, DDT powder, or Lysol is useful in shelters and in patients and household contacts.

Avoiding rodents can prevent tickborne relapsing fever (TBRF). This includes use of appropriate clothing and tick repellents when entering tick-infested areas.

Postexposure prophylaxis is recommended in individuals who have been exposed to ticks in a high-risk environment. An initial dose of doxycycline 200 mg the first day followed by 100 mg daily for 4 days was found to be 100% efficacious in a double-blind, placebo-controlled trial of 93 subjects.^[65]If doxycycline is unavailable, tetracycline 500 mg 4 times daily for 4 days may be administered.

No vaccine is currently available for relapsing fever.

Vaccines are in development.^[66]

Complications

During episodes of spirochetemia, the organisms may invade the brain, eye, inner ear, heart, or liver.^[5]CNS involvement is more common in TBRF than in LBRF^[5]; however, eschars, ARDS, cranial nerve palsies, focal neurologic deficits, uveitis, iritis or iridocyclitis, splenic rupture, and myocarditis may be seen in both TBRF and LBRF.^{[2, 67]}Myelitis, radiculopathy, hemiplegia, stupor, and even coma have also been reported.^{[68, 69]}

ARDS has been reported in both TBRF and LBRF and may have previously been underrecognized in TBRF.^[19]From 1995-2004, two cases of ARDS were reported in patients with TBRF in Nevada and California.^[2]In the state of Washington, 3 cases of ARDS were found in patients with TBRF from 1996-2005.^[2]

Relapsing fever may be more dangerous in patients with impaired B-cell function or asplenia. T-cell deficiency/impairment does not seem to play a role in acute relapsing fever.^[59]

Treatment of relapsing fever usually results in a Jarisch-Herxheimer reaction, especially following penicillin therapy. The reaction is characterized by fever, chills, rigors, diaphoresis, tachycardia, and hypotension. Cytokines, especially tumor-necrosis factor (TNF)–alpha, IL-6, and IL-8, have all been implicated.^[30]The reaction usually occurs within 2-4 hours of administration of the antibiotic. Patients should be observed closely for this reaction, as it can mimic a febrile crisis and may be dangerous.

Relapsing fever in pregnant women increases the risk of spontaneous abortions and severe maternal infection, as well as the risk of ARDS and the Jarisch-Herxheimer reaction.^[70]Only twelve cases of TBRF during pregnancy have been reported in North America.^[71]Transplacental transmission of the bacteria is also a risk.^[30]

Prognosis

Several clinical features portend a poorer prognosis. These include stupor or coma, bleeding, myocarditis,^[72]hepatic dysfunction, pneumonia, and coinfection with typhus, typhoid, or malaria.^[30]

For more information, see Mortality/Morbidity.

Patient Education

Patients should be educated on avoidance and/or elimination of arthropod vectors.

For excellent patient education resources, see eMedicineHealth's patient education article Ticks.

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Media Gallery

Peripheral blood smear in relapsing fever. (Image originally printed in Blevins SM, Greenfield RA, Bronze MS. Blood smear analysis in babesiosis, ehrlichiosis, relapsing fever, malaria, and Chagas disease. Cleve Clin J Med. Jul 2008;75(7):521-30. Reprinted with permission from the Cleveland Clinic.)

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Author

Geneva E Guarin, MD, MBA Resident Physician, Department of Internal Medicine, Einstein Medical Center Philadelphia

Disclosure: Nothing to disclose.

Coauthor(s)

Antonette B Climaco, MD Attending Physician, Division of Infectious Diseases, Department of Medicine, Einstein Healthcare Network

Antonette B Climaco, MD is a member of the following medical societies: American Academy of HIV Medicine, HIV Medicine Association, Infectious Diseases Society of America, Philippine Medical Association

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.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Pierre A Dorsainvil, MD Medical Director, HIV Specialist, Palm Beach County Main Detention Center; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Lake Ida Medical Center

Disclosure: Nothing to disclose.

John M Leedom, MD Professor Emeritus of Medicine, Keck School of Medicine of the University of Southern California

John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Kauser Akhter, MD Assistant Professor, Department of Internal Medicine, Florida State University College of Medicine; Associate Program Director, Infectious Diseases Fellowship Program, Orlando Health

Disclosure: Nothing to disclose.

Elina Bobkova, MD Fellow in Infectious Disease, Orlando Regional Medical Center

Elina Bobkova, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.