Relapsing fever natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Natural History
- sudden onset of high fever, chills, headache, myalgias, and weakness occurs within 3-7 days (up to 18 days) after exposure. Less common symptoms include anorexia, nausea, vomiting, abdominal pain, arthralgias, neck or back pain, confusion, lethargy, cough, rash, sore throat, and swollen lymph nodes. In LBRF, the fever usually lasts 3-6 days and is usually followed by a single, milder episode. In TRBF, multiple episodes of fever occur and each may last up to 3 days.If left untreated, rapid defervescence usually occurs in 2-6 days (range 1-13 days), often with dramatic improvement in symptoms.
- Occasionally, resolution by crisis ensues with profuse diaphoresis, hypothermia, and hypotension. During the crisis, patients may develop cerebral edema with seizures, cardiac failure, or death.
- In both forms, the fever episode may end in "crisis." This consists of shaking chills, followed by intense sweating, falling body temperature, and low blood pressure. This stage may result in death in up to 10% of people.
- After several cycles of fever, some people may develop dramatic central nervous system signs such as seizures, stupor, and coma. The Borrelia organism may also invade heart and liver tissues, causing inflammation of the heart muscle (myocarditis) and liver (hepatitis). Widespread bleeding and pneumonia are other complications.
- The clinical manifestations of tick-borne and louse-borne relapsing fever are similar but can be quite variable, depending on the infecting strain of Borrelia and the host's immunity. Patients typically present 3-7 days (up to 18 days) after exposure with sudden onset of high fever, chills, headache, myalgias, and weakness.
- The afebrile interval usually lasts 1 week (up to 60 days) before relapse with symptoms similar to the first episode. Patients with louse-borne relapsing fever will typically have 1-2 relapses
(range 0-6) with each subsequent relapse usually less severe than the previous one. Patients with tick-borne relapsing fever usually have 3-5 relapses (range 0-22). Most cases eventually resolve spontaneously. Serious complications are more common with louse-borne than tick-borne disease and include iridocyclitis, meningitis, encephalitis, myocarditis, endocarditis, pneumonia, abnormal coagulation with hemorrhage and spontaneous abortion or transplacental transmission [13]. Chronic relapsing fever may produce a clinical illness analogous to chronic Lyme disease.
Complications
- Coma
- Facial droop
- Liver dysfunction
- Meningitis
- Myocarditis -- may lead to arrhythmias
- Pneumonia
- Seizures
- Shock related to taking antibiotics (Jarisch - Herxheimer's reaction, in which the rapid death of very large numbers of Borrelia organisms induces shock)
- Weakness
- Widespread bleeding
Prognosis
The death rate for untreated LBRF ranges from 10 - 70%. In TBRF, it is 4 -10%. With early treatment, the death rate is reduced. Those who have developed coma, myocarditis, liver problems, or pneumonia are more likely to die.