Relapsing fever natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Most cases eventually resolve spontaneously. If left untreated, during the crisis up to 10% of patients with relapsing fever may progress to develop cerebral edema with seizures, cardiac failure, or death. Common complications of relapsing fever are iridocyclitis, meningitis, encephalitis, myocarditis, endocarditis, pneumonia, abnormal coagulation with hemorrhage and spontaneous abortion or transplacental transmission. 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.
Natural History
The symptoms of Relapsing fever usually develop within 3-7 days after exposure and start with sudden onset of high fever, chills, headache, myalgias, and weakness, followed by afebrile periods. 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. Occasionally, resolution ensues by Crisis. During the crisis, patients may develop cerebral edema with seizures, cardiac failure, or death. This stage may result in death in up to 10% of people.
- sudden onset of high fever, chills, headache, myalgias, and weakness, occur 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. Chronic relapsing fever may produce a clinical illness analogous to chronic Lyme disease.
Crisis
- Occasionally, resolution ensues by crisis which is a classic series of stages that a person will go through:
- 1. Phase one is the chill phase, with the person experiencing high fevers up to 41.5°C (106.7°F). With this high temperature, a person can develop delirium, agitation, and confusion. In addition, other signs of an increased metabolic rate are noted, such as a fast heart rate and breathing rate. This phase lasts between 10 and 30 minutes.
- 2. Phase two is the flush phase. This is where the body temperature decreases rapidly and the person has drenching sweats. During this phase, the person's blood pressure can drop dramatically[1]
- During the crisis, patients may develop cerebral edema with seizures, cardiac failure, or death. 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].
Complications
- Most cases resolve spontaneously. but after several cycles of fever, some people may develop dramatic central nervous system signs such as seizures, stupor, and coma. Also, the Borrelia organism may also invade heart and liver tissues, causing inflammation of the heart muscle (myocarditis), endocarditis, and liver (hepatitis), pneumonia are other complications such as iridocyclitis, meningitis, encephalitis, abnormal coagulation with hemorrhage and spontaneous abortion or transplacental transmission.
TBRF in pregnancy
TBRF during pregnancy can cause spontaneous abortion, [[premature birth, and neonatal death (Melkert and Stel 1991). The maternal-fetal transmission of Borrelia is believed to occur either transplacentally (Steenbarger 1982) or while traversing the birth canal. In one study, perinatal infection with TBRF was shown to lead to lower birth weights, younger gestational age, and higher perinatal mortality.
Prognosis
- Given appropriate treatment, most patients recover within a few days. The death rate for untreated LBRF ranges from 10 - 70%. In TBRF, it is 4 -10%. With early treatment, the death rate is reduced.
- Poor prognostic signs include severe jaundice, severe change in mental status, severe bleeding, and prolonged QT interval on ECG.
- Tick-borne relapsing fever is found primarily in Africa, Spain, Saudi Arabia, Asia, and certain areas in the Western U.S. and Canada. Most cases occur in the summer months and are associated in particular with sleeping in rustic cabins in mountainous areas of the Western United States. There are approximately 25 cases of TBRF in the United States each year.