Relapsing fever differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The following infectious diseases should be considered in someone with recurrent episodes of a febrile illness: Colorado tick fever,Infectious mononucleosis, Ascending (intermittent) cholangitis, Yellow fever, African hemorrhagic fevers, Lymphocytic choriomengitis, Dengue fever, Leptospirosis, Infections with echovirus 9, Malaria, Chronic meningococcemia, Infections with Bartonella species, Brucellosis, Rat bite fever.

Differentiating Relapsing fever from other Diseases

The following infectious diseases should be considered in someone with recurrent episodes of a febrile illness:

• Colorado tick fever
• Infectious mononucleosis
• Ascending (intermittent) cholangitis
• Yellow fever
• African hemorrhagic fevers
• Lymphocytic choriomengitis
• Dengue fever
• Leptospirosis
• Infections with echovirus 9
• Malaria
• Chronic meningococcemia
• Infections with Bartonella species
• Brucellosis
• Rat bite fever.
• In a febrile patient in or from Africa, who has all the classic features of LBRF – jaundice, petechial rash, epistaxis, hepatosplenomegaly, thrombocytopenia, coagulopathy, and elevated serum aminotransferases – severe falciparum malaria is the most differential diagnosis.
• In the Horn of Africa, yellow fever and other viral hemorrhagic fevers such as Rift Valley Fever and viral hepatitis, rickettsial infections, especially louse-borne typhus must be considered.
• If there is evidence of acute kidney injury, leptospirosis is more likely.
• Trench fever (Bartonella Quintana), transmitted by lice, can also cause episodic recurrent fever with headache and pains in the shins, but it lacks the bleeding and jaundice that is seen in LBRF.
• In endemic areas, complicating bacterial infections, particularly typhoid, or coinfection with malaria should be considered.
• In refugees diagnosed in Europe, P. falciparum malaria, sepsis, leptospirosis, and meningitis have been cited as leading differential diagnoses of LBRF.

Disease		Organism	Vector	Symptoms
Bacterial Infection
Borreliosis (Lyme Disease)		Borrelia burgdorferi sensu lato complex and B. mayonii	I. scapularis, I. pacificus, I. ricinus, and I. persulcatus	Erythema migrans, flu-like illness(fatigue, fever), Lyme arthritis, neuroborreliosis, and carditis.
Relapsing Fever	Tick-borne relapsing fever (TBRF):	Borrelia duttoni, Borrelia hermsii, and Borrelia parkerii	Ornithodoros species	Consistently documented high fevers, flu-like illness, headaches, muscular soreness or joint pain, altered mental status, painful urination, rash, and rigors.
	Louse-borne relapsing fever (LBRF) :	Borrelia recurrentis	Pediculus humanus
Typhus (Rickettsia)
Rocky Mountain Spotted Fever		Rickettsia rickettsii	Dermacentor variabilis, Dermacentor andersoni	Fever, altered mental status, myalgia, rash, and headaches.
Helvetica Spotted Fever		Rickettsia helvetica	Ixodes ricinus	Rash: spotted, red dots. Respiratory symptoms (dyspnea, cough), muscle pain, and headaches.
Ehrlichiosis (Anaplasmosis)		Ehrlichia chaffeensis, Ehrlichia ewingii	Amblyomma americanum, Ixodes scapularis	Fever, headache, chills, malaise, muscle pain, nausea, confusion, conjunctivitis, or rash (60% in children and 30% in adults).
Tularemia		Francisella tularensis	Dermacentor andersoni, Dermacentor variabilis	Ulceroglandular, glandular, oculoglandular, oroglandular, pneumonic, typhoidal.
Viral Infection
Tick-borne meningoencephalitis		TBEV virus	Ixodes scapularis, I. ricinus, I. persulcatus	Early Phase: Non-specific symptoms including fever, malaise, anorexia, muscle pains, headaches, nausea, and vomiting. Second Phase: Meningitis symptoms, headache, stiff neck, encephalitis, drowsiness, sensory disturbances, and potential paralysis.
Colorado Tick Fever		CTF virus	Dermacentor andersoni	Common symptoms include fever, chills, headache, body aches, and lethargy. Other symptoms associated with the disease include sore throat, abdominal pain, vomiting, and a skin rash. A biphasic fever is a hallmark of Colorado Tick Fever and presents in nearly 50% of infected patients.
Crimean-Congo Hemorrhagic Fever		CCHF virus	Hyalomma marginatum, Rhipicephalus bursa	Initially infected patients will likely feel a few of the following symptoms: headache, high fever, back and joint pain, stomach pain, vomiting, flushed face, red throat petechiae of the palate, and potentially changes in mood as well as sensory perception.
Protozoan Infection
Babesiosis		Babesia microti, Babesia divergens, Babesia equi	Ixodes scapularis, I. pacificus	Non-specific flu-like symptoms.