Consult the medical resource doctors trust

UpToDate is one of the most respected medical information resources in the world, used by over 360,000 doctors and thousands of patients to find answers to medical questions.

  • Content written by a faculty of over 4,000 physicians from leading medical institutions
  • Unbiased: free of advertising or pharmaceutical funding
  • Evidence-based treatment recommendations
  • Continuously updated to incorporate new medical findings

Related articles included with a subscription

Preview Available
(subscription required for full access)

Clinical features and management of relapsing fever

INTRODUCTION

Relapsing fever, caused by spirochetes of the Borrelia genus, is an arthropod-borne infection, which occurs in two major forms: tick-borne (TBRF) and louse-borne (LBRF) [1,2]:

  • Tick-borne relapsing fever is a zoonosis and is endemic in many countries. The two main Borrelia spp involved in North America are B. hermsii (in the mountainous West) and B. turicatae (in the southwest). Other tick-borne species cause relapsing fever on other continents.
  • Louse-borne relapsing fever is caused by B. recurrentis. It is principally a disease seen in the developing world; it is spread from person to person by the body louse and can occur in epidemics, including large ones involving millions of people.

As the name implies, relapsing fever is characterized by recurrent episodes of fever, which accompanies spirochetemia. The disease relapses are due to antigenic variation by the spirochetes.

The clinical manifestations, diagnosis, treatment and prevention of relapsing fever borreliosis will be reviewed here. The microbiology, pathogenesis, and epidemiology are discussed separately. (See "Microbiology, pathogenesis, and epidemiology of relapsing fever".)

CLINICAL MANIFESTATIONS

Relapsing fever presents with the sudden onset of fever, punctuated by an intervening afebrile period, which occurs at least twice [3-6]. The temperature may be as high as 43ºC and is usually above 39ºC.
To continue reading this article you need to subscribe.

Read the rest of this article and others like it

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use (click here) ©2010 UpToDate, Inc.
References Top
  1. Barbour, AG, Hayes, SF. Biology of Borrelia species. Microbiol Rev 1986; 50:381.
  2. Dworkin, MS, Schwan, TG, Anderson, DE Jr, Borchardt, SM. Tick-borne relapsing fever. Infect Dis Clin North Am 2008; 22:449.
  3. Southern, P, Sanford, J. Relapsing fever: A clinical and microbiological review. Medicine (Baltimore) 1969; 48:129.
  4. Bryceson, AD, Parry, EH, Perine, PL, et al. Louse-borne relapsing fever. Q J Med 1970; 39:129.
  5. Rijkels, DF. Louse-borne relapsing fever in Ethiopia. Trop Geogr Med 1971; 23:335.
  6. Dworkin, MS, Anderson, DE Jr, Schwan, TG. Tick-borne relapsing fever in the northwestern United States and southwestern Canada. Clin Infect Dis 1998; 26:122.
  7. Cadavid, D, Thomas, DD, Crawley, R, Barbour, AG. Variability of a bacterial surface protein and disease expression in a possible mouse model of systemic Lyme borreliosis. J Exp Med 1994; 179:631.
  8. Cadavid, D, Garcia, E, Gelderblom, H. Coinfection with Borrelia turicatae serotype 2 prevents the severe vestibular dysfunction and earlier mortality caused by serotype 1. J Infect Dis 2007; 195:1686.
  9. Acute respiratory distress syndrome in persons with tickborne relapsing fever--three states, 2004-2005. MMWR Morb Mortal Wkly Rep 2007; 56:1073.
  10. Perine, PL, Parry, EH, Vukotich, D, et al. Bleeding in louse-borne relapsing fever. I. Clinical studies in 37 patients. Trans R Soc Trop Med Hyg 1971; 65:776.
  11. Dennis, D, Awoke, S, Doberstein, E, Fresh, J. Bleeding in louse-borne relapsing fever in Ethiopia. East Afr Med J 1976; 53:220.
  12. Judge, D, Samuel, I, Perine, P, Vukotic, D. Louse-borne relapsing fever in man. Arch Pathol 1974; 97:136.
  13. Wengrower, D, Knobler, H, Gillis, S, Chajek-Shaul, ST. Myocarditis in tick-borne relapsing fever. J Infect Dis 1984; 149:1033.
  14. Scott, R. Neurological complications of relapsing fever. Lancet 1944; 30:436.
  15. 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; 26:151.
  16. Pachner, AR. Spirochetal diseases of the CNS. Neurol Clin 1986; 4:207.
  17. Poulsen, LW, Iversen, G. Relapsing fever: A differential diagnosis to malaria. Scand J Infect Dis 1996; 28:419.
  18. Goodman, RL, Arndt, KA, Steigbigel, NH. Borrelia in Boston. JAMA 1969; 210:722.
  19. Sciotto, CG, Lauer, BA, White, WL, Istre, GR. Detection of Borrelia in acridine orange-stained blood smears by fluorescence microscopy. Arch Pathol Lab Med 1983; 107:384.
  20. Stoenner, HG, Dodd, T, Larsen, C. Antigenic variation of Borrelia hermsii. J Exp Med 1982; 156:1297.
  21. Magnarelli, LA, Anderson, JF, Johnson, RC. Cross-reactivity in serological tests for Lyme disease and other spirochetal infections. J Infect Dis 1987; 156:183.
  22. Barbour, AG, Maupin, GO, Teltow, GJ, et al. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: Possible agent of a Lyme disease-like disease. J Infect Dis 1996; 173:403.
  23. Chohan, IS. Tick-borne relapsing fever in Kashmir: Mice inoculation--a diagnostic method of choice. Indian J Pathol Bacteriol 1967; 10:289.
  24. Barbour, AG. Immunobiology of relapsing fever. Contrib Microbiol Immunol 1987; 8:125.
  25. Kelly, R. Cultivation of Borrelia hermsii. Science 1971; 173:443.
  26. Stoenner, HG. Biology of Borrelia hermsii in Kelly medium. Appl Microbiol 1974; 28:540.
  27. Barbour, AG. Isolation and cultivation of Lyme disease spirochetes. Yale J Biol Med 1984; 57:521.
  28. Barbour, AG. Laboratory aspects of Lyme borreliosis. Clin Microbiol Rev 1988; 1:399.
  29. Cadavid, D, Bundoc, V, Barbour, A. Experimental infection of the mouse brain by a relapsing fever Borrelia species: A molecular analysis. J Infect Dis 1993; 168:143.
  30. Restrepo, BI, Barbour, AG. Antigen diversity in the bacterium Borrelia hermsii through "somatic" mutations in rearranged vmp genes. Cell 1994; 78:867.
  31. Pennington, PM, Allred, CD, West, CS, et al. Arthritis severity and spirochete burden are determined by serotype in the Borrelia turicatae-mouse model of Lyme disease. Infect Immun 1997; 65:285.
  32. Picken, R. Polymerase chain reaction primers and probes derived from flagellin gene sequences for specific detection of the agents of Lyme disease and North American relapsing fever. J Clin Microbiol 1992; 30:99.
  33. Dodge, RW. Human serological response to louse-borne relapsing fever. Infect Immun 1973; 8:891.
  34. Schwan, TG, Schrumpf, ME, Hinnebusch, BJ, et al. GlpQ: An antigen for serological discrimination between relapsing fever and Lyme borreliosis. J Clin Microbiol 1996; 34:2483.
  35. Barbour, AG, Todd, WJ, Stoenner, HG. Action of penicillin on Borrelia hermsii. Antimicrob Agents Chemother 1982; 21:823.
  36. Butler, T, Jones, PK, Wallace, CK. Borrelia recurrentis infection: single-dose antibiotic regimens and management of the Jarisch-Herxheimer reaction. J Infect Dis 1978; 137:573.
  37. Perine, PL, Krause, DW, Awoke, S, McDade, JE. Single-dose doxycycline treatment of louse-borne relapsing fever and epidemic typhus. Lancet 1974; 2:742.
  38. Perine, PL, Teklu, B. Antibiotic treatment of louse-borne relapsing fever in Ethiopia: a report of 377 cases. Am J Trop Med Hyg 1983; 32:1096.
  39. 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; 335:311.
  40. Horton, J, Blaser, M. The spectrum of relapsing fever in the Rocky Mountains. Arch Intern Med 1985; 145:871.
  41. Cherry, JK. The prevention and treatment of tick-borne relapsing fever with special reference to aureomycin and terramycin. Trans R Soc Trop Med Hyg 1955; 49:563.
  42. Schuhardt, VT, Hemphill, EC. Brain Involvement as a Possible Cause of Relapse After Treatment in Spirochetal Relapsing Fever. Science 1946; 103:422.
  43. Negussie, Y, Remick, DG, DeForge, LE, et al. Detection of plasma tumor necrosis factor, interleukins 6, and 8 during the Jarisch-Herxheimer reaction of relapsing fever. J Exp Med 1992; 175:1207.
  44. Gebrehiwot, T, Fiseha, A. Tetracycline versus penicillin in the treatment of louse-borne relapsing fever. Ethiop Med J 1992; 30:175.
  45. Remick, DG, Negussie, Y, Fekade, D, Griffin, G. Pentoxifylline fails to prevent the Jarisch-Herxheimer reaction or associated cytokine release. J Infect Dis 1996; 174:627.
  46. Cooper, PJ, Fekade, D, Remick, DG, et al. Recombinant human interleukin-10 fails to alter proinflammatory cytokine production or physiologic changes associated with the Jarisch-Herxheimer reaction. J Infect Dis 2000; 181:203.
  47. Anderson, TR, Zimmerman, LE. Relapsing fever in Korea; a clinicopathologic study of eleven fatal cases with special attention to association with Salmonella infections. Am J Pathol 1955; 31:1083.
  48. Jongen, VH, van Roosmalen, J, Tiems, J, et al. Tick-borne relapsing fever and pregnancy outcome in rural Tanzania. Acta Obstet Gynecol Scand 1997; 76:834.
  49. Larsson, C, Andersson, M, Guo, BP, et al. Complications of pregnancy and transplacental transmission of relapsing-Fever borreliosis. J Infect Dis 2006; 194:1367.
  50. 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; 355:148.
white circle LOG IN
white circle DEMO