Relapsing fever

Relapsing fever
Other names: Tick borne relapsing fever[1],Louse-borne relapsing fever[2]
Top: Borrelia hermsii-Tick-borne relapsing fever Bottom:Relapsing Fever borreliosis-cells stained red and blue are contaminating erythrocytes and leukocytes, respectively. Some of the bacteria are marked by arrows
Specialty	Infectious disease
Symptoms	Headache,muscle pain,nausea and vomiting[3]
Complications	DIC,gastrointestinal bleed,cerebral bleed,splenic rupture,hyperpyrexia,meningitis[3]
Types	Louse-borne relapsing fever, tick-borne relapsing fever[3]
Causes	Several species of bacteria in the genus Borrelia[3]
Diagnostic method	Blood test[1]
Differential diagnosis	Brucellosis Ehrlichiosis Anaplasmosis[3]
Prevention	Insect repellent, among others[3]
Treatment	Doxycycline or penicillin[3]

Relapsing fever is a vector-borne disease caused by infection with certain bacteria in the genus Borrelia,^[4] which is transmitted through the bites of lice or soft-bodied ticks (genus Ornithodoros).^[5]

The primary treatment for relapsing fever is antibiotics, which can be tetracycline, doxycycline, erythromycin, and procaine penicillin G all are commonly used^[3][6]

Signs and symptoms

Most people who are infected develop sickness between 5 and 15 days after they are bitten. The symptoms may include a sudden fever, chills, headaches, muscle or joint aches, and nausea. A rash may also occur. These symptoms usually continue for 2 to 9 days, then disappear. This cycle may continue for several weeks if the person is not treated.^[7]

Complications

The complications of Relapsing fever are as follows:^[3]

• DIC

• Gastrointestinal bleed

• Cerebral bleed

• Splenic rupture

• Hyperpyrexia

• Meningitis

• Focal neurological deficits

• Acute Respiratory Distress Syndrome

• Liver failure

Causes

Louse-borne relapsing fever -Along with Rickettsia prowazekii and Bartonella quintana, Borrelia recurrentis is one of three pathogens of which the body louse (Pediculus humanus humanus) is a vector.^[8]

Louse-borne relapsing fever occurs in epidemics amid poor living conditions, famine and war in the developing world. It is currently prevalent in Ethiopia and Sudan.Mortality rate is 1% with treatment and 30–70% without treatment. Poor prognostic signs include severe jaundice, severe change in mental status, severe bleeding and a prolonged QT interval on ECG.Lice that feed on infected humans acquire the Borrelia organisms that then multiply in the gut of the louse. When an infected louse feeds on an uninfected human, the organism gains access when the victim crushes the louse or scratches the area where the louse is feeding. B. recurrentis infects the person via mucous membranes and then invades the bloodstream. No non-human, animal reservoir exists.^{[1][9][10][11]}

Tick-borne relapsing fever-Tick-borne relapsing fever is found primarily in Africa, Spain, Saudi Arabia, Asia, and certain areas of Canada and the western United States. Other relapsing infections are acquired from other Borrelia species, which can be spread from rodents, and serve as a reservoir for the infection, by a tick vector^[13][1][14]:

• Borrelia crocidurae

• Borrelia duttoni

• Borrelia hermsii

• Borrelia hispanica

• Borrelia miyamotoi

• Borrelia parkeri

• Borrelia turicatae

• Borrelia persica

B. hermsii and B. recurrentis cause very similar diseases. However, one or two relapses are common with the disease associated with B. hermsii, which is also the most common cause of relapsing disease in the United States. ^[13][1][14]

Mechanism

As to the indicator of relapsing fever is the cyclical nature of fever episodes. This is due to Borrelia bacteria capacity to alter their surface proteins, known as variable major proteins.As the hosts immune system develops antibodies against the current VMP, the bacteria switch to expressing different VMP, effectively evading immune clearance.This continuous cycle of antigenic variation and immune response leads to recurring pattern of fever and afebrile periods.^[3][15]

Diagnosis

The diagnosis of relapsing fever can be made on blood smear as evidenced by the presence of spirochetes. Other spirochete illnesses (Lyme disease, syphilis, leptospirosis) do not show spirochetes on blood smear. Although considered the gold standard, this method lacks sensitivity and has been replaced by PCR in many settings.^[16]

Differential diagnosis

The DDx of Relapsing fever in the affected individual is as follows:^[3]

• Brucellosis
• Ehrlichiosis
• Anaplasmosis
• Plasmodium falciparum(Malaria)
• Trench fever
• Dengue fever

Treatment

Relapsing fever is easily treated with a one- to two-week-course of antibiotics, and most people improve within 24 hours. Complications and death due to relapsing fever are rare.^[1][17][3]

Tetracycline-class antibiotics are most effective. These can, however, induce a Jarisch–Herxheimer reaction in over half those treated, producing anxiety, diaphoresis, fever, tachycardia and tachypnea with an initial pressor response followed rapidly by hypotension. Some studies have shown tumor necrosis factor-alpha may be partly responsible for this reaction.^[1][17][3]

Epidemiology

In terms of epidemiology we find that Tick-Borne relapsing fever is found worldwide, except in Antarctica, Australia, and Pacific Southwest. In the United States, TBRF is generally confined to the western states, with most cases occurring between May and September^[18]

LBRF is rare in the United States but is endemic in northeast Africa -Ethiopia, Sudan, Eritrea,Somalia and has been diagnosed in Europe in refugees from these African countries.^[19]

Research

Currently, no vaccine against relapsing fever is available, but research continues. Developing a vaccine is very difficult because the spirochetes avoid the immune response of the infected person (or animal) through antigenic variation. Essentially, the pathogen stays one step ahead of antibodies by changing its surface proteins. These surface proteins, lipoproteins called variable major proteins, have only a moderate percentage of their amino acid sequences in common, which is sufficient to create a new antigenic "identity" for the organism. Antibodies in the blood that are binding to and clearing spirochetes expressing the old proteins do not recognize spirochetes expressing the new ones. Antigenic variation is common among pathogenic organisms.^[20][21]

History

Relapsing fever has been described since the days of the ancient Greeks.^[22] After an outbreak in Edinburgh in the 1840s, relapsing fever was given its name, but the etiology of the disease was not better understood for a decade.^[22] Physician David Livingstone is credited with the first account in 1857 of a malady associated with the bite of soft ticks in Angola and Mozambique.^[23] In 1873, Otto Obermeier first described the disease-causing ability and mechanisms of spirochetes, but was unable to reproduce the disease in inoculated test subjects and thereby unable to fulfill Koch's postulates.^[22] The disease was not successfully produced in an inoculated subject until 1874.^[22] In 1904 and 1905, a series of papers outlined the cause of relapsing fever and its relationship with ticks.^{[24][25][26][27]} Both Joseph Everett Dutton and John Lancelot Todd contracted relapsing fever by performing autopsies while working in the eastern region of the Congo Free State. Dutton died there on February 27, 1905. The cause of tick-borne relapsing fever across central Africa was named Spirillum duttoni.^[28] In 1984, it was renamed Borrelia duttoni.^[29] The first time relapsing fever was described in North America was in 1915 in Jefferson County, Colorado.^[30]

Sir William MacArthur suggested that relapsing fever was the cause of the yellow plague, variously called pestis flava, pestis ictericia, buidhe chonaill, or cron chonnaill, which struck early Medieval Britain and Ireland, and of epidemics which struck modern Ireland in the famine.^[31][32]

See also

• Lyme disease
• Typhus
• Continuous fever
• Intermittent fever
• Remittent fever

References

External links

• CDC: Relapsing Fever Archived 2022-07-16 at the Wayback Machine