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. [21] 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.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. [22]
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.
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.
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Relapsing fever can be tick- or louse-borne. Soft-bodied ticks of the genus Ornithodoros transmit tick-borne cases. Above 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.
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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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Cases of Tick-borne Relapsing Fever - United States, 1990-2011. Courtesy of the Centers for Disease Control and Prevention (CDC).
