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Tick-Borne Relapsing Fever CLAY ROSCOE, M.D., and TED EPPERLY, M.D., Family Medicine Residency of Idaho, Boise, Idaho

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Tick-Borne Relapsing Fever CLAY ROSCOE, M.D., and TED EPPERLY, M.D., Family Medicine Residency of Idaho, Boise, Idaho Tick-Borne Relapsing Fever CLAY ROSCOE, M.D., and TED EPPERLY, M.D., Family Medicine Residency of Idaho, Boise, Idaho Tick-borne relapsing fever is characterized by recurring fevers separated by afebrile periods and is accompanied by nonspecific constitutional symptoms. It occurs after a patient has been bitten by a tick infected with a Borrelia spirochete. The diagnosis of tick-borne relapsing fever requires an accurate characterization of the fever and a thorough medical, social, and travel history of the patient. Findings on physical examination are variable; abdominal pain, vomiting, and altered sensorium are the most common symptoms. Laboratory confirmation of tick-borne relapsing fever is made by detection of spirochetes in thin or thick blood smears obtained during a febrile episode. Treatment with a tetracycline or macrolide antibiotic is effective, and antibiotic resistance is rare. Patients treated for tick-borne relapsing fever should be monitored closely for Jarisch- Herxheimer reactions. Fatalities from tick-borne relapsing fever are rare in treated patients, as are subsequent Jarisch-Herxheimer reactions. Persons in endemic regions should avoid rodent- and tick-infested areas and use insect repellents and protective clothing to prevent tick bites. (Am Fam Physician 2005;72:2039-44, 2046. Copyright © 2005 American Academy of Family Physicians.) S Patient information: ick-borne relapsing fever (TBRF) develop with TBRF, with long-term sequelae A handout on tick-borne is transmitted by Ornithodoros that may be permanent. Reviewing a broad relapsing fever, written by 1,3-6 the authors of this article, ticks infected with one of sev- differential diagnosis (Table 1 ) for fever is provided on page 2046. eral different Borrelia spirochete when TBRF is suspected will help rule out Tspecies, most commonly Borrelia hermsii other possible causes of fever that, if misdi- and Borrelia turicata. The highest concen- agnosed, could result in significant morbid- trations of TBRF in the United States are in ity or mortality (e.g., Lyme disease, malaria the western states containing the Cascade, in a returning traveler). San Bernardino, Sierra Nevada, and Rocky Mountain ranges.1-3 Illustrative Case Consideration of TBRF is critical in A 60-year-old man presented to an emer- patients presenting with recurring fevers. gency department in Boise, Idaho, with a Cardiac and neurologic complications may one-month history of intermittent fevers and headaches. The initial fever peaked at 40.6°C (105°F), was accompanied by a headache, TABLE 1 lasted for three days, and resolved spontane- Differential Diagnosis of Tick-Borne Relapsing Fever ously after an episode of shaking chills. The patient had a second fever 13 days later, peak- Occupational and ing at 39.4°C (103°F) with diffuse abdominal Foreign travel General infection recreational exposure pain and blurred vision. This fever lasted two days and resolved spontaneously. At the Amebic liver abscess Influenza Brucellosis time of the second fever, a family physician Babesiosis Meningococcemia Colorado tick fever assessed the patient. Routine blood tests were Dengue fever Salmonellosis Ehrlichiosis normal except an elevated total bilirubin Leptospirosis Shigellosis Lyme borreliosis level (6.0 mg per dL) [102.6 mmol per L]. An Louse-borne Rat-bite fever abdominal computed tomography scan was relapsing fever Rickettsiosis normal. The patient was referred to an oph- Malaria Tularemia Typhoid fever thalmologist, who diagnosed iritis. Viral hepatitis The patient developed a third fever with headache and visual symptoms 26 days after Information from references 1 and 3 through 6. the initial symptoms, prompting presenta- tion to the emergency department. Past November 15, 2005 U Volume 72, Number 10 www.aafp.org/afp American Family Physician 2039 Tick-Borne Relapsing Fever SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Diagnosis of TBRF should be made by detecting spirochetes in a C1, 13 thin and thick smear of peripheral blood prepared with Wright’s or Giemsa stain or by culture isolation. Doxycycline (Vibramycin, 100 mg orally, twice daily for seven C 4, 17, 25 to 10 days) or tetracycline (500 mg, four times daily for seven to 10 days) is recommended for treatment of TBRF. Applying an insect repellent containing DEET to the skin and C 9 clothing is recommended for prevention of TBRF. TBRF = tick-borne relapsing fever; DEET = N,N-diethyl-m-toluamide. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1949 or http://www.aafp.org/afpsort.xml. medical history and family history were unremarkable. The patient took no medi- cations. He reported traveling to Vietnam four years earlier and Honduras 18 months earlier, and he took malaria prophylaxis for both trips. The patient also had been camping in the Bear Valley region of Idaho. Review of systems was otherwise negative. On examination, the patient was febrile (39.7°C [103.4°F]), tachycardic (113 beats per minute), and hypertensive (195/107 mm Hg). Other vital signs were stable, and physi- cal examination was normal. A complete blood count was normal. Figure 1. A spirochete (arrow) in a thin smear Manual differential demonstrated 81 per- of peripheral blood with Giemsa stain. cent segmented neutrophils and a low lym- phocyte count (6 percent). Total bilirubin positive for protein (1+). Scant spirochetes was elevated (2.3 mg per dL [39.33 mmol were detected in a peripheral blood smear per L]; direct bilirubin, 0.4 mg per dL prepared with Giemsa stain (Figure 1). [6.84 mmol per L]). A reticulocyte count A presumptive diagnosis of Borrelia infec- was elevated (3.37 percent). Urinalysis was tion was made, and the patient was admit- ted and started on tetracycline (500 mg orally, four times daily). The patient’s maxi- The Authors mum temperature in the hospital was 39.3°C CLAY ROSCOE, M.D., is a resident physician at Family Medicine Residency (102.8°F), which returned to normal after of Idaho in Boise. He received his medical degree from the University of 24 hours. Visual symptoms resolved after Pennsylvania School of Medicine, Philadelphia. 24 hours, and he was discharged 36 hours TED EPPERLY, M.D., is chairman and program director of the Family Medicine after admission and continued tetracycline Residency of Idaho. He also is clinical professor at the University of Washington for 10 days. Further discussion with the School of Medicine in Seattle, where he received his medical degree. patient revealed that the area where he had Address correspondence to Clay Roscoe, M.D., Family Medicine Residency of been camping had a large squirrel popula- Idaho, 777 N. Raymond St., Boise, ID 38704 (e-mail: [email protected]). tion, though he did not recall being bitten Reprints are not available from the authors. by any insects. 2040 American Family Physician www.aafp.org/afp Volume 72, Number 10 U November 15, 2005 Tick-Borne Relapsing Fever Epidemiology rels and chipmunks. Hosts for O. turicata More than 450 cases of TBRF were reported include cattle, rodents, pigs, snakes, tor- between 1977 and 2000 in the United States.5 toises, and possibly coyotes. The majority of TBRF infections have Human infection commonly occurs in the occurred in Washington state and northern setting of a mountain cabin that has been Idaho, with clusters of infections reported in infested with rodents and O. hermsii ticks Spokane County, Wash.; Estes Park, Colo.; (Figure 2). When rodents or other natural New Mexico; Montana; and the north rim of hosts vacate a cabin, humans may become the Grand Canyon.3,7-13 the only available host. Patients usually In North America, most cases of TBRF are unaware of a tick bite or exposure.1,2,8 are associated with two species of Argasi- TBRF from B. turicata–infected ticks also dae (soft) ticks, Ornithodoros hermsii and commonly occurs after humans explore Ornithodoros turicata. Ornithodoros ticks caves or crawl under buildings, and cases are obligate blood feeders; they maintain have been described in persons who have continuous Borrelia infections in salivary handled dead rodents.1,5 Blood feeding by gland tissue, and transmit spirochetes when soft-bodied ticks takes less than one hour feeding. and usually occurs at night.1,4 O. hermsii is found in the Pacific North- west and the southwestern United States, Pathogenesis and O. turicata is found sporadically from Borrelia spirochetes do not infect blood cells Kansas to central Mexico and California. directly, but the severity of TBRF corre- Natural hosts for O. hermsii include squir- lates with the number of spirochetes in the Borrelia resides in: • Liver Borrelia spirochete • Spleen Ornithodoros tick • Bone marrow • Central nervous system ILLUSTRATION BYILLUSTRATION GRAEPEL STEPHEN Figure 2. Typical setting for transmission of tick-borne relapsing fever. November 15, 2005 U Volume 72, Number 10 www.aafp.org/afp American Family Physician 2041 Tick-Borne Relapsing Fever bloodstream. An IgM immune thalmitis may be permanent. In contrast, Mild leukocytosis, elevated response is capable of clear- altered mental status and nuchal rigidity not erythrocyte sedimentation ing one Borrelia serotype, but associated with other neurologic symptoms rate, and anemia may be because of the organism’s abil- usually are the result of spirochetemia rather present in patients with ity to undergo antigenic varia- than direct CNS infection.17 tick-borne relapsing fever. tion, several serotypes may be A gallop heard on cardiac ausculta- present in the bloodstream at tion may suggest myocardial involvement; one time. With clearance of one serotype, myocarditis is prominent in fatal cases of less common serotypes proliferate, causing TBRF.18 Splenomegaly, often presenting as the relapsing fever pattern that characterizes abdominal or left shoulder pain, is common.
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