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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 292-293
A case report of relapsing fever

Department of Microbiology, People's College of Medical Science and Research Centre, Bhopal, India

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Relapsing fever is an acute febrile illness caused by spirochetes of the genus Borrelia. The high fevers of presenting patients spontaneously abate and then recur. Here we report a 50-year-old woman having relapsing fever associated with thrombocytopenia. Giemsa staining of peripheral blood smear revealed spiral organisms morphologically resembling Borrelia. A rare case of relapsing fever which was successfully treated with doxycycline is discussed.

Keywords: Borrelia, relapsing fever, thrombocytopenia

How to cite this article:
Aher AR, Shah H, Rastogi V, Tukaram PK, Choudhury RC. A case report of relapsing fever. Indian J Pathol Microbiol 2008;51:292-3

How to cite this URL:
Aher AR, Shah H, Rastogi V, Tukaram PK, Choudhury RC. A case report of relapsing fever. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 May 26];51:292-3. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/292/41703

   Introduction Top

Borelliosis, or relapsing fever, is caused by spirochetes Borrelia recurrentis . Relapsing fevers (RFs) are a group of acute infections characterized by recurrent cycles of pyrexia which are separated by intervals of apparent recovery. RF occurs in two epidemiologic forms - the louse-borne relapsing fever (LBRF) and the tick-borne relapsing fever (TBRF). TBRF is caused by a variety of different species of Borrelia , each of which is transmitted by and named after, the species of Ornithodoros ticks that act as vectors for the organisms. Rodents and other animals serve as natural reservoirs. Occurring in the US during the months of spring and summer, several cases of TBRF are frequently diagnosed in the western mountainous areas of USA, usually in clusters of travelers who have visited tick-infested parts of the country. [1] In contrast, LBRF is transmitted from person to person solely by human body lice which have ingested Borrelia recurrentis . Several pandemics of LBRF have occurred in Africa, the Middle East and Europe in this century. The most recent outbreaks have been in Ethiopia, Sudan and neighboring countries. [2] The disease is endemic in central and eastern parts of Africa, in the Peruvian Andes and China, where socioeconomic factors such as poverty and overcrowding encourage sustained transmission. [3] A large number of cases have been reported among refugees of wars and famines in Ethiopia and Sudan. [4] Occasionally, this form of RF has been imported into other countries of Europe and North America. [5]

There is a paucity of information about this infection in India. There are a few reports in India. [6] We report a case of one patient who presented with pyrexia. Investigations revealed unsuspected Borrelia as the cause of the fever. The illness responded promptly to doxycycline therapy. The prevalence or incidence in India is unknown. Its apparent rarity may be due to underdiagnosis and underreporting. A high index of suspicion in appropriate clinical situations will lead to its early recognition and treatment.

   Case History Top

A 53-year-old woman was admitted, with a 2-day history of fever and giddiness. On examination, she was febrile (temperature, 39.5C), her blood pressure was 110/70 mm Hg and pulse was 80/min. All other systems, including cardiorespiratory system and central nervous system, were normal. There was no hepatosplenomegaly and lympadenopathy. The patient had petechial rash and hematuria. Clinical diagnosis was recurrent fever of unknown cause. She had history of fever few weeks back, for which she took symptomatic treatment. An examination of the peripheral blood smear revealed presence of spirochetes morphologically resembling Borrelia species [Figure 1]. The platelet count showed marked thrombocytopenia. The peripheral blood smear (PBS) findings with photographs were communicated to the Department of Microbiology, AIIMS, New Delhi and they confirmed the same.

The patient was commenced on oral doxycycline, 100 mg b.i.d. She received one unit of fresh blood and also platelet concentrate. The pyrexia subsided within 2 days of therapy and the temperature remained normal thereafter. The PBF was negative after 1 week of treatment. The patient was followed up for a few weeks, after which she had no recurrence of fever.

Pathological findings

Hb - 8 gm %,; WBC - 6500 /mm 3 ; platelet count - 26,000; ESR - 48 mm.

Serum bilirubin - 0.99 mg/dL (direct - 0.35 mg/dL and indirect - 0.64 mg/dL).

SGOT(AST) - 56 /L; SGPT(ALT) - 41 /L; serum alkaline phosphate - 70 /L.

No positive findings were reported in radiological investigations. Conventional blood culture remained sterile at the end of 10 days. Serological tests for HAV, HIV, syphilis, malaria, typhoid, dengue and leptospira were negative. Urine microscopy showed plenty of RBCs (>100/HPF in centrifuged urine).

   Discussion Top

Tick-borne or louse-borne borreliosis can be an important but usually unsuspected cause of a febrile illness. It remains an important cause of morbidity and mortality, especially in young adults. In patients with high fevers, the definitive diagnosis is usually made by the demonstration of Borrelia organisms in the peripheral blood stained with Giemsa or Wright's stain. Additional clinical features of borreliosis include headaches, general body pain, liver tenderness, petechiae, nausea and vomiting, chills and rigors and epistaxis. [4]

In this case, marked thrombocytopenia was seen. The patient had petechial rash over neck and chest and hematuria. Thrombocytopenia is a prominent feature of human relapsing fever, but its etiology is unclear. It has been shown that Borrelia causes increased platelet clearance due to the binding of bacteria to platelets. [7]

The exact incidence or prevalence of RF in India is not known and cannot be estimated from this study. The apparent rarity may be a result of underreporting and underdiagnosis, as has been noted for many other febrile illnesses. Although spirochetes in humans acutely ill with RF are often easily detected by light microscopy by examination of thick drops and their smears of peripheral blood stained with Giemsa stain, it is extremely difficult to distinguish the species of Borrelia from one another. [8] The recent application of DNA hybridization probe and polymerase chain reaction in research laboratories has been shown to be able to analyze molecular and genetic determinants that may be useful in identification of these organisms. [9] Using monoclonal antibodies to detect some species has been described recently. [8] However, the complexity of these methods makes them clinically impractical.

The therapy of RF is well established. Response to penicillin, tetracycline, or erythromycin is predictably good, as observed by us in our case. It is likely that the incidence is grossly underestimated due to underdiagnosis and underreporting. The frequency of recognition of this disease will increase with a higher index of clinical suspicion. Among populations in which there are numerous common causes of febrile illnesses, the diagnosis of RF must depend mainly on a very high index of clinical suspicion on the part of the physicians. Borrelia species should be routinely looked for in patients who present with febrile illnesses of obscure causes. A prospective study of a large number of cases with febrile illness may provide better appreciation of its prevalence in the Indian population. For example, borreliosis was considered rare in West Africa until a prospective survey indicated common occurrence in Senegal. [10]

   References Top

1.Burgdorfer W. The enlarging spectrum of tick-borne spirochetes. Rev Infect Dis 1986;8:932-40.  Back to cited text no. 1  [PUBMED]  
2.Perine PL, Reynolds DF. Relapsing fever epidemic in the Sudan and Ethiopia. Lancet 1974;2:1324-5.  Back to cited text no. 2  [PUBMED]  
3.Daniel E, Beyene H, Tessema T. Relapsing fever in children: Demographic, social and clinical features. Ethiop Med J 1992;30:207-14.  Back to cited text no. 3  [PUBMED]  
4.Brown V, Laouse B, Desire G, Rousset JJ, Thibon M, Fourrier A, et al. Clinical presentation of louse-borne relapsing fever among Ethiopian refugees in Northern Somalia. Ann Trop Med Parasitol 1988;82:499-502.  Back to cited text no. 4    
5.Rummens JZ, Louwagie A, Van-Hoof A, Boelaert J, Gordts B, Van-Landuyt HW. Relapsing fever imported into Belgium: A case report. Acta Clin Belg 1987;42:210-4.  Back to cited text no. 5    
6.Kalra SL, Rao KN. Observations on the epidemiology of relapsing fever in Kashmir. Indian J Med Res 1951;39:313-21.  Back to cited text no. 6  [PUBMED]  
7.Alugupalli KR, Michelson AD, Joris I, Schwan TG, Hodivala-Dilke K, Hynes RO, et al. Spirochete-platelet attachment and thrombocytopenia in murine relapsing fever borreliosis. Blood 2003;102:2843-50.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Schwan TG, Gage KL, Karsters RH, Schrumpf ME, Hayes SF, Barbour AG. Identification of the tick-borne relapsing fever spirochete Borrelia hermsii by using a species-specific monoclonal antibody. J Clin Microbiol 1992;30:790-5.  Back to cited text no. 8    
9.Schwan IG, Simpson WJ, Shrumpf ME, Kerstens RH. Identification of Borrelia burgdorferi and Borrelia hermsii using DNA hybridization probes. J Clin Microbiol 1989;27:1734-8  Back to cited text no. 9    
10.Trape JF, Duplantier JM, Bouganali H, Godeluck B, Legros F, Cornet JP, et al. Tick-borne borreliosis in West Africa. Lancet 1991;337:473-5.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]

Correspondence Address:
Atul R Aher
Department of Microbiology, People's College of Medical Science and Research Centre, Bhanpur Bypass Road, Bhopal - 462 010, MP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.41703

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