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Relapsing Fever

(Tick, Recurrent, or Famine Fever)

By Larry M. Bush, MD, Affiliate Professor of Clinical Biomedical Sciences; Affiliate Associate Professor of Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University; University of Miami-Miller School of Medicine
Maria T. Perez, MD, Associate Pathologist, Department of Pathology and Laboratory Medicine, Wellington Regional Medical Center, West Palm Beach

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Relapsing fever is a recurring febrile disease caused by several species of the spirochete Borrelia and transmitted by lice or ticks. Symptoms are recurrent febrile episodes with headache, myalgia, and vomiting lasting 3 to 5 days, separated by intervals of apparent recovery. Diagnosis is clinical, confirmed by staining of peripheral blood smears. Treatment is with a tetracycline or erythromycin.

The family Spirochaetales is distinguished by the helical shape of the bacteria. They are too thin to be visualized using routine microscopy but can be viewed using darkfield microscopy. There are 3 genera: Treponema, Leptospira, and Borrelia.

The insect vector may be soft ticks of the genus Ornithodoros or the human body louse, depending on geographic location.

Louse-borne relapsing fevers are rare in the US; they are endemic only in northeast Africa (Ethiopia, Sudan, Eritrea, Somalia) and were recently diagnosed in Europe in refugees from these African countries. Louse-borne relapsing fever tends to occur in epidemics, particularly in regions affected by war, and in refugee camps. The louse is infected by feeding on a febrile patient; humans are the only reservoir. If the louse is crushed on a new host, Borrelia are released and can enter abraded skin or bites. Intact lice do not transmit disease.

Tick-borne relapsing fevers are endemic in the Americas, Africa, Asia, and Europe. In the US, the disease is generally confined to the western states, where occurrence is highest between May and September. Ticks acquire the spirochetes from rodent reservoirs. Humans are infected when spirochetes in the tick’s saliva or excreta enter the skin rapidly as the tick bites. Infection is more likely to be acquired by people sleeping in rodent-infested cabins in the mountains.

Congenital infection with Borrelia has also been reported.

The case fatality rate is generally < 5% with treatment but may be considerably higher in very young, pregnant, old, malnourished, or debilitated people or during epidemics of louse-borne fever.

Symptoms and Signs

Because the tick feeds transiently and painlessly at night and does not remain attached for a long time, most patients do not report a history of tick bite but may report an overnight exposure to caves or rustic dwellings.

When present, louse infestation is usually obvious.

The incubation period ranges from 3 to 11 days (median, 6 days).

The clinical manifestations of tick-borne and louse-borne relapsing fever are very similar. Symptoms correspond to the level of bacteremia and, after several days, resolve when Borrelia are cleared from the blood. Bacteremia and symptoms then return after a 1-wk afebrile period. Symptoms are less severe with each subsequent return. A single relapse characterizes louse-borne relapsing fever, and up to 10 relapses may occur in tick-borne relapsing fever.

Sudden chills mark the onset, followed by high fever, tachycardia, severe headache, nausea, vomiting, muscle and joint pain, and often delirium. An eschar may be present at the site of the tick bite. An erythematous macular or purpuric rash may appear early over the trunk and extremities. Conjunctival, subcutaneous, or submucous hemorrhages may be present. Fever remains high for 3 to 5 days, then clears abruptly, indicating a turning point in the disease. The duration of illness ranges from 1 to 54 days (median, 18 days). Later in the several weeks’ course of the disease, jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease.

Other symptoms may include ophthalmitis, iridocyclitis, exacerbation of asthma, and erythema multiforme. Neurologic complications (eg, meningitis, meningoencephalitis, radiculomyelitis) may occur; they are more common in tick-borne relapsing fever. Spontaneous abortion can occur.

Patients are usually asymptomatic for several days to 1 wk between the initial episode and the first relapse. Relapses, related to the cyclic development of the parasites, occur with a sudden return of fever and often arthralgia and all the former symptoms and signs. Jaundice is more common during relapse. The illness clears as before, but 2 to 10 similar episodes may follow at intervals of 1 to 2 wk. The episodes become progressively less severe, and patients eventually recover as they develop immunity.


  • Darkfield microscopy

The diagnosis of relapsing fever is suggested by recurrent fever and confirmed by visualization of spirochetes in the blood during a febrile episode. The spirochetes may be seen on darkfield examination or Wright- or Giemsa-stained thick and thin blood smears. (Acridine orange stain for examining blood or tissue is more sensitive than Wright or Giemsa stain.) Serologic tests are unreliable. Mild polymorphonuclear leukocytosis may occur. Serologic tests for syphilis and Lyme disease may be falsely positive.

Differential diagnosis includes Lyme arthritis, malaria, dengue, yellow fever, leptospirosis, typhus, influenza, and enteric fevers.


  • Tetracycline, doxycycline, or erythromycin

In relapsing fever transmitted by ticks, tetracycline or erythromycin 500 mg po q 6 h is given for 5 to 10 days. For louse-transmitted relapsing fever, a single 500-mg oral dose of either drug is effective. Doxycycline 100 mg po q 12 h for 5 to 10 days is also effective. Children <8 yr are given erythromycin estolate 10 mg/kg po tid.

When vomiting or severe disease precludes oral administration or when the CNS is affected, parenteral ceftriaxone 2 g/day for 10 to 14 days or doxycycline 1 to 2 mg/kg IV q 12 to 24 h may be given to adults or children > 8 yr. Children < 8 yr are given penicillin G 25,000 units/kg IV q 6 h.

Therapy should be started early during fever. A Jarisch-Herxheimer reaction may occur within 2 h of starting therapy. Severity of the Jarisch-Herxheimer reaction may be lessened by giving acetaminophen 650 mg po 2 h before and 2 h after the first dose of doxycycline or erythromycin.

Dehydration and electrolyte imbalance should be corrected with parenteral fluids. Acetaminophen with oxycodone or hydrocodone may be used for severe headache. Nausea and vomiting should be treated with prochlorperazine 5 to 10 mg po or IM once/day to qid. If heart failure occurs, specific therapy is indicated.

Key Points

  • Relapsing fever is caused by several Borrelia species and is transmitted by lice or ticks.

  • Patients have sudden chills, high fever, severe headache, nausea, vomiting, muscle and joint pain, and often delirium and/or a rash on the trunk and extremities; jaundice, hepatomegaly, splenomegaly, myocarditis, and heart failure may occur, especially in louse-borne disease.

  • Untreated patients have 2 to 10 relapses at 1- to 2-wk intervals; relapses manifest with a sudden return of fever and often arthralgia and all the former symptoms and signs, although they may be less severe.

  • Diagnose using darkfield microscopy or Wright- or Giemsa-stained thick and thin blood smears; serologic tests are unreliable.

  • Treat with tetracycline, doxycycline, or erythromycin.

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