Maternal mortality in a rural Tanzanian hospital: fatal Jarisch-Herxheimer reaction in a case of relapsing fever in pregnancy

Tick borne relapsing fever - a systematic review and analysis of the literature

Tick borne relapsing fever (TBRF) is a zoonosis caused by various Borrelia species transmitted to humans by both soft-bodied and (more recently recognized) hard-bodied ticks. In recent years, molecular diagnostic techniques have allowed to extend our knowledge on the global epidemiological picture of this neglected disease. Nevertheless, due to the patchy occurrence of the disease and the lack of large clinical studies, the knowledge on several clinical aspects of the disease remains limited. In order to shed light on some of these aspects, we have systematically reviewed the literature on TBRF and summarized the existing data on epidemiology and clinical aspects of the disease. Publications were identified by using a predefined search strategy on electronic databases and a subsequent review of the reference lists of the obtained publications. All publications reporting patients with a confirmed diagnosis of TBRF published in English, French, Italian, German, and Hungarian were included. Maps showing the epidemiogeographic mosaic of the different TBRF Borrelia species were compiled and data on clinical aspects of TBRF were analysed. The epidemiogeographic mosaic of TBRF is complex and still continues to evolve. Ticks harbouring TBRF Borrelia have been reported worldwide, with the exception of Antarctica and Australia. Although only molecular diagnostic methods allow for species identification, microscopy remains the diagnostic gold standard in most clinical settings. The most suggestive symptom in TBRF is the eponymous relapsing fever (present in 100% of the cases). Thrombocytopenia is the most suggestive laboratory finding in TBRF. Neurological complications are frequent in TBRF. Treatment is with beta-lactams, tetracyclines or macrolids. The risk of Jarisch-Herxheimer reaction (JHR) appears to be lower in TBRF (19.3%) compared to louse-borne relapsing fever (LBRF) (55.8%). The overall case fatality rate of TBRF (6.5%) and LBRF (4-10.2%) appears to not differ. Unlike LBRF, where perinatal fatalities are primarily attributable to abortion, TBRF-related perinatal fatalities appear to primarily affect newborns.

Epidemiology of Tick-Borne Relapsing Fever in Endemic Area, Spain

Incidence of this disease increased over time; peak incidences were observed in 2011, 2014, and 2015.

Tick-borne relapsing fever (TBRF) is caused by spirochetes of Borrelia bacteria. We collected data on all TBRF cases in a TBRF-endemic area in southwest Spain during 1994–2016. We analyzed data from 98 patients in whom TBRF was diagnosed by light microscopy and analyzed the relationship between climatic data and TBRF incidence. Most cases occurred a rural environment during summer and autumn. We describe demographic, epidemiologic, clinical, and analytical characteristics, treatment, and occurrence of Jarisch-Herxheimer reaction. Most patients had fever and headache, and laboratory test results included elevated C-reactive protein, thrombocytopenia, and neutrophilia. No patients died, but 10.1% had Jarisch-Herxheimer reaction. B. hispanica was the infecting species in 12 cases with PCR results. Clinicians often do not suspect TBRF because clinical signs and symptoms vary; therefore, it is likely underdiagnosed, even in disease-endemic areas.

Immunological Responses to the Relapsing Fever Spirochete Borrelia turicatae in Infected Rhesus Macaques: Implications for Pathogenesis and Diagnosis

The global public health impact of relapsing fever (RF) spirochetosis is significant, since the pathogens exist on five of seven continents. The hallmark sign of infection is episodic fever and the greatest threat is to the unborn. With the goal of better understanding the specificity of B-cell responses and the role of immune responses in pathogenicity, we infected rhesus macaques with Borrelia turicatae (a new world RF spirochete species) by tick bite and monitored the immune responses generated in response to the pathogen. Specifically, we evaluated inflammatory mediator induction by the pathogen, host antibody responses to specific antigens, and peripheral lymphocyte population dynamics. Our results indicate that B. turicatae elicits from peripheral blood cells key inflammatory response mediators (interleukin-1β and tumor necrosis factor alpha), which are associated with preterm abortion. Moreover, a global decline in peripheral B-cell populations was observed in all animals at 14 days postinfection. Serological responses were also evaluated to assess the antigenicity of three surface proteins: BipA, BrpA, and Bta112. Interestingly, a distinction was observed between antibodies generated in nonhuman primates and mice. Our results provide support for the nonhuman primate model not only in studies of prenatal pathogenesis but also for diagnostic and vaccine antigen identification and testing.

Bacterial arthropod-borne diseases in West Africa

Arthropods such as ticks, lice, fleas and mites are excellent vectors for many pathogenic agents including bacteria, protozoa and viruses to animals. Moreover, many of these pathogens can also be accidentally transmitted to humans throughout the world. Bacterial vector-borne diseases seem to be numerous and very important in human pathology, however, they are often ignored and are not well known. Yet they are in a phase of geographic expansion and play an important role in the etiology of febrile episodes in regions of Africa. Since the introduction of molecular techniques, the presence of these pathogens has been confirmed in various samples from arthropods and animals, and more rarely from human samples in West Africa. In this review, the aim is to summarize the latest information about vector-borne bacteria, focusing on West Africa from 2000 until today in order to better understand the epidemiological risks associated with these arthropods. This will allow health and veterinary authorities to develop a strategy for surveillance of arthropods and bacterial disease in order to protect people and animals.

The Jarisch-Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis

Within 24 hours after antibiotic treatment of the spirochetal infections syphilis, Lyme disease, leptospirosis, and relapsing fever (RF), patients experience shaking chills, a rise in temperature, and intensification of skin rashes known as the Jarisch-Herxheimer reaction (JHR) with symptoms resolving a few hours later. Case reports indicate that the JHR can also include uterine contractions in pregnancy, worsening liver and renal function, acute respiratory distress syndrome, myocardial injury, hypotension, meningitis, alterations in consciousness, seizures, and strokes. Experimental evidence indicates it is caused by nonendotoxin pyrogen and spirochetal lipoproteins. Mediation of the JHR in RF by the pro-inflammatory cytokines tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 has been proposed, consistent with measurements in patients' blood and inhibition by anti-TNF antibodies. Accelerated phagocytosis of spirochetes by polymorphonuclear (PMN) leukocytes before rise in cytokines is responsible for removal of organisms from the blood, suggesting an early inflammatory signal from PMNs. Rarely fatal, except in neonates and in pregnancy for African women whose babies showed high perinatal mortality because of low birth weight, the JHR can be regarded as an adverse effect of antibiotics, necessary for achieving a cure of spirochetal infections.

Congenital Tick Borne Diseases: Is This An Alternative Route of Transmission of Tick-Borne Pathogens In Mammals?

Tick-borne diseases (TBDs) have become a popular topic in many medical journals. Besides the obvious participation of ticks in the transmission of pathogens that cause TBD, little is written about alternative methods of their spread. An important role is played in this process by mammals, which serve as reservoirs. Transplacental transfer also plays important role in the spread of some TBD etiological agents. Reservoir species take part in the spread of pathogens, a phenomenon that has extreme importance in synanthropic environments. Animals that accompany humans and animals migrating from wild lands to urban areas increase the probability of pathogen infections by ticks This article provides an overview of TBDs, such as tick-borne encephalitis virus (TBEV), and TBDs caused by spirochetes, α-proteobacteria, γ-proteobacteria, and Apicomplexa, with particular attention to reports about their potential to cross the maternal placenta. For each disease, the method of propagation, symptoms of acute and chronic phase, and complications of their course in adults, children, and animals are described in detail. Additional information about transplacental transfer of these pathogens, effects of congenital diseases caused by them, and the possible effects of maternal infection to the fetus are also discussed. The problem of vertical transmission of pathogens presents a new challenge for medicine. Transfer of pathogens through the placenta may lead not only to propagation of diseases in the population, but also constitute a direct threat to health and fetal development. For this reason, the problem of vertical transmission requires more attention and an estimation of the impact of placental transfer for each of listed pathogens.

Jarisch-Herxheimer reaction among HIV-positive patients with early syphilis: azithromycin versus benzathine penicillin G therapy

Introduction

The Jarisch-Herxheimer reaction, a febrile inflammatory reaction that often occurs after the first dose of chemotherapy in spirochetal diseases, may result in deleterious effects to patients with neurosyphilis and to pregnant women. A single 2-g oral dose of azithromycin is an alternative treatment to benzathine penicillin G for early syphilis in areas with low macrolide resistance. With its potential anti-inflammatory activity, the impact of azithromycin on the incidence of the Jarisch-Herxheimer reaction in HIV-positive patients with early syphilis has rarely been investigated.

Methods

In HIV-positive patients with early syphilis, the Jarisch-Herxheimer reaction was prospectively investigated using the same data collection form in 119 patients who received benzathine penicillin G between 2007 and 2009 and 198 who received azithromycin between 2012 and 2013, when shortage of benzathine penicillin G occurred in Taiwan. Between 2012 and 2013, polymerase chain reaction (PCR) assay was performed to detect Treponema pallidum DNA in clinical specimens, and PCR restriction fragment length polymorphism of the 23S ribosomal RNA was performed to detect point mutations (2058G or A2059G) that are associated with macrolide resistance.

Results

The overall incidence of the Jarisch-Herxheimer reaction was significantly lower in patients receiving azithromycin than those receiving benzathine penicillin G (14.1% vs. 56.3%, p<0.001). The risk increased with higher rapid plasma reagin (RPR) titres (adjusted odds ratio [AOR] per 1-log₂ increase, 1.21; confidence interval [CI], 1.04–1.41), but decreased with prior penicillin therapy for syphilis (AOR, 0.37; 95% CI, 0.19–0.71) and azithromycin treatment (AOR, 0.15; 95% CI, 0.08–0.29). During the study period, 310 specimens were obtained from 198 patients with syphilis for PCR assays, from whom T. pallidum was identified in 76 patients, one of whom (1.3%) was found to be infected with T. pallidum harbouring the macrolide resistance mutation (A2058G). In subgroup analyses confined to the 75 patients infected with T. pallidum lacking resistance mutation, a statistically significantly lower risk for the Jarisch-Herxheimer reaction following azithromycin treatment was noted.

Conclusions

Treatment with azithromycin was associated with a lower risk for the Jarisch-Herxheimer reaction than that with benzathine penicillin G in HIV-positive patients with early syphilis. Previous benzathine penicillin G therapy for syphilis decreased the risk, whereas higher RPR titres increased the risk, for the reaction.