Relapsing fever

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Classification according to ICD-10
A68 Relapsing fever
A68.0 Relapsing fever transmitted by lice. Relapsing
fever caused by Borrelia recurrentis
A68.1 Relapsing fever transmitted by ticks. Relapsing
fever from any type of Borrelia except Borrelia recurrentis
ICD-10 online (WHO version 2019)

Under relapsing fever (Latin relapsing fever ; English relapsing fever , Spirillium fever ) refers to two of Rückfallfieber- Borrelia caused bacterial infectious diseases from the group of Spirochätosen that by repeated bouts of fever, recurrent fever, so-called, are characterized. Relapsing fever cases proven in Germany are without exception rare, imported medical travel illnesses that previously only occurred in times of war in German-speaking countries. Two of pathogens and transfer different types of relapsing fever are known: the rare, but then usually epidemic occurring Lice relapsing fever (. English louse-borne relapsing fever , LBRF , Cardinal pathogen is Borrelia recurrentis ) and the tick relapsing fever , also known as tick fever (Engl. Tick- borne relapsing fever , TBRF , mostly caused by Borrelia duttoni ).

Relapsing fever is transmitted by arthropods (lice, ticks) and thus belongs to the group of bacterial zoonoses or arthropozoonoses (diseases transmitted by arthropods). Together with Lyme borreliosis , relapsing fever diseases are assigned to human borreliosis and can be clearly distinguished from one another. Osip Osipovič Močutkovskij (1845–1903), the head of the infection department at the Odessa City Hospital, recognized lice bites as the cause of the infection with relapsing fever. The pathogens causing relapsing fever were first discovered in the blood of sick people in 1868 by Otto Obermeier (1843–1873). Obermeier publicly announced this at a meeting of the Berlin Medical Society on February 26, 1873. Relapsing fever is thus considered to be the first human infectious disease in which this was successful. The species Borrelia recurrentis therefore initially bore the name Borrelia obermeieri (previously Spirochaeta obermeieri ) after its discoverer .

Relapsing lice fever

Clothes lice ( Pediculus humanus var. Corporis ): A carrier of relapsing lice fever

Lice relapse fever is transmitted by clothes lice or, rarely, head lice ( Pediculus humanus var. Corporis or capitis ), which become infected with Borrelia recurrentis during a blood meal on a febrile patient . The pathogens multiply in the louse for about six days and accumulate in the haemocoel ( body space filled with organs and hemolymph ); The digestive tract and salivary glands of the louse are not infected, so that transmission to humans can only take place if the louse is injured or crushed and the hemolymph can escape. With an undisturbed blood meal, the Borrelia are therefore not transmitted. The louse can not transmit Borrelia recurrentis to its offspring. Further animal reservoirs for B. recurrentis are not yet known.

Lice relapse fever is endemic in South America ( Peru , Bolivia , northern Brazil ), in North and Equatorial Africa , Eritrea , Ethiopia , Somalia , Eastern Europe and occasionally in countries in the Near and Middle East, Japan and a few other Asian countries. There is an increased risk of infection, especially when traveling to endemic areas under poor hygienic conditions. In mass quarters , prisons and refugee camps , major outbreaks can occur that are similar to the occurrence of typhus , also known as "lice fever".

In Europe (the Netherlands, Switzerland, Germany) there were several diagnosed cases of imported lice relapsing fever in refugees from Eritrea and other countries in the Horn of Africa in the summer of 2015. The transmissions also occurred on the escape route in accommodation in Rome. The clinical course was predominantly difficult and also required intensive medical care due to the Herxheimer reaction that occurred. During the same period, three similar cases were identified in Germany.

Relapsing tick fever

In infected ticks, the Borrelia can be found in the salivary gland secretion, so that humans can be infected with every meal of blood. In addition, the pathogens are passed on to the offspring of the tick, which can then transmit the Borrelia as juvenile forms ( tick nymph ). Numerous animal species, mainly rodents, serve as further natural reservoirs for the pathogen. The tick relapsing fever should not be confused with the Lyme borreliosis (tick borreliosis ) that occurs in Europe .

The occurrence of relapsing tick fever is linked to the presence of the transmitting tick species of the genus Ornithodoros (family of leather ticks ). The relapsed tick fever is found, in addition to the distribution areas of relapsed lice fever, also in North and Central America and in southern Africa, but not in Australia. In Europe it is only detectable in Spain and Portugal.

Pathogens and laboratory diagnostics

Borrelia theileri in the “ thick drop ” after Giemsa staining

In Asia, Africa and America, only B. recurrentis is usually found in relapsing lice fever . The species that can be detected in relapsing tick fever are Borrelia duttoni, B. crocidurae (both mainly in Africa), B. hispanica (causative agent of the Spanish relapsing fever, formerly known as Spirochaeta hispanica), B. hermsii, B. venezuelensis, B. turicatae, B. mazzottii, B. persica and B. parkeri .

The genus Borrelia belongs to the spirochete family ; the Borrelia can easily be recognized under the microscope due to their elongated and helical shape. Relapsing fever Borrelia, in contrast to other spirochetes, can easily be stained (for example by Giemsa staining ) or by acridine orange in the fluorescence microscope. As in the diagnosis of malaria, an enriched blood smear is examined as a so-called thick drop . The blood sample should only be taken during the fever, as only then are the pathogens present in the blood. The pathogens can be seen between the erythrocytes as thin, long and twisted bacteria. The concentration of the pathogens is very high during the acute attacks of the disease; this distinguishes relapsing fever from other diseases with spirochetes (Lyme borreliosis, leptospirosis or syphilis ), in which the pathogens are not visible in the blood smear. Specialized laboratories can detect and differentiate between the different Borrelia species using molecular methods such as the polymerase chain reaction and the sequencing of certain gene segments.

The detection of specific antibodies in the blood is routinely not possible and also not useful. Antibody detection methods for Lyme borreliosis in relapsing fever are often false positive due to cross-reactions .

Relapsing fever Borrelia and their vectors
Borrelia duttoni Leather tick of the species Ornithodorus moubata Central Africa
Borrelia hispanica Leather tick of the species Ornithodorus erraticus Iberian Peninsula , North Africa
Borrelia crocidurae Leather tick of the species O. erraticus North africa
Borrelia merionesi Leather tick of the species O. erraticus Egypt , Senegal
Borrelia microti Leather tick of the species O. erraticus Turkey , Kenya
Borrelia dipodilli Leather tick of the species O. erraticus Iran
Borrelia persica Leather tick of the species Ornithodorus tholozani Asia to Egypt
Borrelia caucasica Leather tick of the species Ornithodorus verrucosus Caucasus region
Borrelia latyshevii Leather tick of the species Ornithodorus tartakovskii Iran, Central Asia
Borrelia hermsii Leather tick of the species Ornithodorus hermsii Western USA
Borrelia turicatae Leather tick of the species Ornithodorus turicata Southwest USA
Borrelia mazzoni Leather tick of the species Ornithodorus talaje South USA
Borrelia venezuelensis Leather tick of the species Ornithodorus rudis Central + South America
Borrelia coriacea Leather tick of the species Ornithodorus coriaceus Western USA
Borrelia theileri Ticks of the genus Rhipicephalus worldwide
Borrelia anserina Ticks of the genus Argas worldwide
Borrelia recurrentis Clothes louse ( Pediculus humanus humanus ) Ethiopia

Almost all relapsing fever Borrelia are ticks from the genus Ornithodorus as vectors . Each special Ornithodorus species is usually assigned only one Borrelia species. Some of these pathogens are not pathogenic to humans (cause diseases). However, they can cause disease in other mammals, for example Borrelia coriacea is responsible for miscarriages in deer and cattle and Borrelia anserina is pathogenic only to birds.

illness

Disease emergence

After the pathogen enters, also through the intact skin or mucous membrane, it spreads through the entire organism via lymph and blood vessels. The relapsing fever Borrelia only multiply within the blood vessels, but can be deposited in other organs and persist there. After the immune system first eliminates the pathogens from the bloodstream using phagocytic cells , after a few days the plasmid- mediated genetic change in the surface proteins of the Borrelia leads to renewed replication in the bloodstream; this corresponds to the second rise in fever. This interplay between elimination and adaptation of the pathogen can be repeated several times, up to four times in relapsed lice fever and up to eleven times in relapsed tick fever. The high cytokine- mediated fever occurs in each phase of reproduction . The pathogens cause damage to the vascular endothelium with an increasing tendency to bleed and necrosis in the affected organs. If the pathogen is not finally eliminated, the outcome is fatal due to sepsis and multiple organ failure .

Renewed infections after recovering from relapsing fever are possible and are then usually somewhat milder due to acquired partial immunity . Due to the regular occurrence of relapsing fever borrelia in the blood, transmission by blood transfusion, laboratory infection or congenitally (from mother to child) can occur in rare cases .

Clinical course

Typical fever course in relapsing fever

After an incubation period of 1–14 days (often around five days) the disease begins with a sudden high fever, joint, head, chest and limb pain, nausea, and sometimes shortness of breath. There may be a cough and a small speckled rash. Increased bleeding tendencies with nosebleeds and bleeding into the skin are not uncommon, as well as clouding of consciousness and yellowing of the skin ( jaundice ).

As one author of the Hippocratic writings already knew, the first fever lasts about 5–7 days, followed by a fever-free and symptom-free interval of 1–21 days (often 5–7 days). The following fever attacks usually decrease in duration and intensity. The relapsing tick fever can also affect the central nervous system in the form of meningitis ( meningitis ). In relapsing lice fever, which is often more severe, a spontaneous Jarisch-Herxheimer reaction can lead to death.

forecast

The untreated relapsing fever usually has a lethality of 20%, with relapsing fever up to 50% (with epidemics up to 70%). With simple antibiotic treatment this is 1–5%. Fetal loss is a common complication of an infection during pregnancy. Often the strong attacks of fever lead to an abortion .

therapy

Relapsing fever is treated with antibiotics with tetracyclines or erythromycin . Currently, doxycycline is the drug of choice for adults and non-pregnant women. Relapses have been described after administration of penicillin . The also effective chloramphenicol is usually out of the question because of its side effects.

A frequent mistake in the therapy of relapsing fever is too long a period between the individual antibiotics; usually an interval of six hours must not be exceeded. In the case of outpatient treatment, the patient must be informed that if necessary, he must set an alarm clock at night in order to comply with the necessary intake times for antibiotics with a short half-life . This does not apply to doxycycline, for example. A therapy duration of seven days is usually sufficient.

The Jarisch-Herxheimer reaction , which can arise when Borrelia that has been killed by antibiotics suddenly disintegrate en masse, is a dangerous complication, particularly of relapsing lice fever therapy . Bacterial toxins ( endotoxins ) are released with the risk of circulatory shock. Therefore, a therapy with the possibility of immediate intensive medical care should be carried out in the beginning.

Prevention and control

In endemic areas, the focus is on controlling the transmitted lice through disinfestation of shelters, camps and clothing. When delousing people, it should be noted that mechanical damage to the parasites (e.g. by lice combs) must be avoided. Possible contact with the parasites should be avoided when traveling: Hygienically acceptable accommodation is preferred. Closed clothing makes sense to protect against ticks in natural areas. If a possible contact with the carriers in known infection areas cannot be avoided, chemoprophylaxis with tetracyclines is possible. A vaccination is currently not available.

Reporting requirement

According to the old Federal Disease Act , suspected illness and death from relapsing fever were notifiable in Germany. At present, if the pathogen Borrelia recurrentis is detected directly or indirectly in connection with an acute illness, there is an obligation to report by name in accordance with Section 7 (1) No. 4 of the Infection Protection Act (IfSG), usually for the management of the testing laboratory (see Section 8 IfSG).

In Austria, relapsing fever is a notifiable disease in accordance with Section 1 (1) No. 2 of the 1950 Epidemic Act . Cases of illness and death must be reported. Doctors and laboratories, among others, are obliged to report this ( Section 3 Epidemics Act).

literature

  • Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid 1961, pp. 9-223, here: pp. 152-154.

Web links

Individual evidence

  1. J. Stahnke: Ludwik Teichmann (1823–1895). Anatomist in Krakow. In: Würzburg medical history reports. Volume 2, 1984, pp. 205-267; here: p. 216.
  2. Otto Obermeier: The discovery of thread-like structures in the blood of relapsing fever sufferers. (1873). Introduced and re-edited by Heinz Zeiss (= Classics of Medicine. Volume 31). Unchanged reprint [German edition] JA Barth, Leipzig 1926, p. 26ff.
  3. KR Wilting et al .: Louse-borne relapsing fever (Borrelia recurrentis) in asylum seekers from Eritrea, the Netherlands, July 2015 . Eurosurveillance (2015) 20 (30) PMID 26250069 ( pdf ).
  4. D. Goldenberger et al .: Louse-borne relapsing fever (Borrelia recurrentis) in an Eritrean refugee arriving in Switzerland, August 2015. Eurosurveillance (2015) 20 (32) ( pdf ).
  5. Epidemiological Bulletin (2015) No. 33, p. 326 ( pdf ).
  6. ^ Rüdiger Braun: Travel and Tropical Medicine. Course book for further training, practice and advice. Schattauer, Stuttgart / New York 2005, ISBN 3-7945-2286-9 , p. 85, online on Google-books .
  7. Georg Sticker : Hippokrates: The common diseases first and third book (around the year 434-430 BC). Translated, introduced and explained from the Greek. Johann Ambrosius Barth, Leipzig 1923 (= Classics of Medicine. Volume 29); Unchanged reprint: Central antiquariat of the German Democratic Republic, Leipzig 1968. P. 120 f.