Tick-Borne

Chinh

Relapsing

can be made easily if specific

the patients
blood smear
The diagnosis
of this condition

historical
clues are
is carefully
examearly in its course

and

med.
can

save

the

work-up

clinicians

and

patients

of a fever

tioning
in
increasingly

of Pediatrics,

Three
cases of tick-borne
fever diagnosed
summer
of 1979 are reported
and
the ecoclinical
manifestations,
and treatment
of
are reviewed.
Although
challenging,
the

diagnosis
sought

the

national
popular

the

of unknown
parks
among

and
many

anxiety

and

origin.

Since

forests
has
American

cost

in log
mountains

963-966,

1980.

become
families,
in any

relapsing

tick.

bite
This

infection

country:
in 1931

many

16 cases

even

appear

pediatricians,

several

of the

66:

major

blood

to humans
soft-shelled

uncommon

in this

reportable
cases
have

in 1978

(the

it is not

textbooks,

by law
been

most

to be an exotic
since

pediatric

by the

is transmitted
Ornithodoros

is considered

including

It may

1947).

is caused

since the disease

became
in California,
only
462

reported,
to

fever

Borrelia
and
of an infected

spirochetes

forests
Pediatrics

since

disease

discussed

nor

in the

in

Report

of the Committee
on Infectious
Diseases
of the
American
Academy
of Pediatrics.2
The following
three
cases
of tick-borne
relapsing
fever
were
diagnosed
during
the summer
of 1979 at
the pediatric
clinic
of the Kaiser-Permanente
Medical Center,
Sacramento,
clinical
features
and
Because

entity.

of the

nente

for publication

Nov

28,

to (C.T.L.)
Center,

IEDIATRICS
American

in the

mountains

requests
Medical

CA. Reported
treatment
of

vacationing

Western

Received

Reprint

popular
should
tial

among
consider

diagnosis

(ISSN
Academy

2015

Dept
Morse

0031
of Pediatrics.

4005).

has

become

1979;

accepted

this

of Pediatrics,
Aye,

Sacramento,

Copyright

here are the

infectious

national

CASE
Case

3, 1980.

Kaiser-PermaCA

1980

95825.

by

Center,

American

Borrelia

families,

infections

of acute

Sacramento,

clinicians

in the

or recurrent

differen-

paroxysmal

in an endemic
history.

area

is part

fever
of a

REPORTS
I

A 15-month-old,
previously
well, white female
infant
was seen for recurrent
febrile episodes.
In late April 1979,
she developed
fever
up to 39.9 C and vomiting.
The
results
of a physical examination
were normal except for
a mildly
inflamed
pharynx.
She was given symptomatic

the

therapy

for

a presumed

viral

infection.

Over

the following
month,
the infant
was seen for four more
acute febrile episodes,
each lasting two to three days and
occurring
seven
to eight
days
apart
(Fig
1). On each
occasion,
symptoms
were nonspecific,
with fever,
mild
irritability,
decreased
appetite,
and occasional
vomiting.
She behaved
as though
she had myalgia
and photophobia.
Repeated
physical
examinations
revealed
no significant
abnormalities.
Symptomatic
therapy
was prescribed
at
each visit. Between
each febrile
episode,
she remained
asymptomatic.

The

results

of

the

following

laboratory

investigations
were normal
or within
normal
limits: multiple urine, throat,
and blood cultures;
repeated
urinalysis;
liver function
tests; stool examinations
for enteric
bacterial
pathogens
and parasites;
VDRL,
antinuclear,
and
rheumatoid
factors;
serology
for toxoplasmosis,
coccidioidomycosis,
typhoid,
and paratyphoid
A and B fevers;
skin tests for tuberculosis,
and chest x-ray films.

The

infants

family

had

always

resided

in the Sacra-

mento

area; the family

denied
traveling
outside
California; there
were no pets in the household,
and no other
family
members
were ill. However,
by the fifth febrile
episode
of this infant,
it was learned
that the family
had
spent

forests

increasingly
March

Medical

many

when
exposure
patients
medical

antipyretic

Tick-borne
by the

cabins
in the coniferous
of the United
States.

Kaiser-Permanente

of

vaca-

tick-borne
relapsing
fever should
be considered
patient
with an acute
or recurrent
fever of unknown
origin who exhibits
nonspecific
symptoms
of an undifferentiated
viral
illness,
and who gives a history
of sleeping
overnight
Western

in Children

T. Le, MD

From the Department

California

ABSTRACT.
during
the
epidemiology,
this
infection

Fever

several

weekends

at

their

grandparents

cabin

at

North
Lake Tahoe,
CA. Squirrels
were frequently
fed
with nuts at the cabin
doorstep.
Although
the family
denied
any history
or knowledge
of tick or other
animal
bites,
Borrelia
infection
was suspected.
Dark-field
examination
and Wright
stains
of blood smears
revealed
abundant
spirochetes
(Fig 2).
The infant was treated
in the hospital
with oral eryth-

PEDIATRICS

Vol.

66

No.

6 December

1 980

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on October 23, 2015

963

romycin

estolate

Two

hours

ature

rose

occurred

(60 mg/kg

after

the first

to 40.3

C, but

and

lowing

the

three

complete

She

a seven-day

blood

was

discharged

20.22

27-28

doses).

her temper-

reactions

or side

over
the

next

effects

the

fol-

day

of erythromycin.

at 4, 8, 10, and

7-8

12 hours

24-26

Socromenfo
U

divided

May

April
42

in four

defervesced

course

smears

day

of antibiotics,

no other

temperature

hours.

Repeated

per

dose

after

2-4

peared

(%)
1.

ing

fever

Fig 2.

964

1: Temperature

1: Peripheral

TICK-BORNE

physical

cytes.

57

sedimentation

relaps-

found in the blood smears.

The child was observed

curve

demonstrates

pattern.

Case

of the

cytes,

55

Case

results

12

ESR (mm/hr)

Fig

the

Erythromycin

WBC

Stab

C orally,

chills.
She apExcept
for a

11.9

37

9.8
39
19

not toxic-looking.

47

38

(%)

of 40

was

17.4
65

39

PMN

ill but

8-year-old
girl
and headache,

examination
were normal.
The child lived in Fairfield,
CA, and was on her way
home with her family from a one-week
camping
trip near
Salmon
Lake
in the Sierra
mountains,
where the family
had rented
a log cabin.
She saw many
chipmunks
but
denied
any close animal
contact
and did not recall any
tick bites. No other family members
were ill. Because
she
had been in an endemic
area,
Borrelia
infection
was
immediately
suspected.
The hemoglobin
was 13.3 gm/100
ml. The WBC count
was 8,100/cu
mm with 71% polymorphonuclear
leuko-

40

(103/cu.mm)

acutely

temperature

Hosp:toItzotson

E
a)

June

4)
0.

Case

of the erythromycin
therapy
did not reveal any
The infant
remained
asymptomatic
with no
of the infection
during
four months
of follow-

In August
1979,
a previously
healthy
was seen
for a two-day
history
of fever
diffuse
muscle
aching,
joint
pains,
and

4)

to

initiation
spirochetes.
recurrence
up.

blood

RELAPSING

smear

shows

Borrelia

spirochete

18%

The

band

cells,

platelet
rate

(Wrights

8%

level
was

stain,

lymphocytes,

was normal,
35

mm/hr.

in the

original

and

3%

mono-

and the erythrocyte

clinic

Spirochetes

after

oil immersion;

FEVER

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on October 23, 2015

were

a single

xl,000).

oral

dose

of

500

remained
vesced.

Four

a repeat
was

mg

of

stable,
hours

blood

Case

after

the

the

four

dose

no spirochetes.
250

for

ten

infection

and

signs

deferThe

mg

child

of erythro-

days.

during

She

two

did

not

months

of

decreased

appetite,

and

the febrile
child with normal
infected
pharynx.
occasions

fussiness.

except

for a mild

throat,
and urine
On each occasion,
for a presumed

had

squirrels
tick

stayed

for

in the

and

bites,

was

hour

after

rectally.

given

first
and

Chills

left.

days

gradually

in late

abound.

blood,

which

the

discovered

The

CA,

parents

recalled

members

the

1979

Forest,
were

in

where

erythromycin

no

estolate.

temperature

decreased

to 37.9

were

rose

noted,

One

to 40 C

but

the

retics.
The child was sent home
taking
a seven-day
of erythromycin
and
remained
free of febrile
Microscopic
examination
revealed
no spirochetes

course
relapses.
in blood

samples

taken

four

hours

and

seven

days

after

the

initial

of erythromycin.

and

tick-borne

rochetes

ized

the
recurrent
of

by

afebrile

quires
in the

a human
United

common

The

other

America,

wild
doros
argasid
the Western
of

rodents
(soft)
mountain

turicata,

0 parkeri,

for

Borrelia

three

louse-borne

reservoir.
It has
States
for many

in many

In North
sists

forms
of re(epidemic)

(endemic).
Both
are caused
by spigenus
Borrelia
and are characterparoxysms
of fever
separated
by

intervals.

parts

infection

re-

not been contracted

years
but remains
world.
for Borrelia

of the

States

with

unreported
trial
of

when
antibiotics

febrile

illness.

cause

of lack

cases

also

wood

tick

(Dermacen-

feed

Some

The

clinical

few

it

on

cases

could
tions

den

tively

be undiagnosed

be-

the

can

of the year,

the

days
(range,
symptoms

disease

most

reported

summer.

of tick-borne

relaps-

infectious
review
of
reported
by

period
four
were

despite
normal

including

interpreted
encountered

several

relapses

findings
in

as

to
all

was
>

approxi-

18 days).
nonspecific

As in
and

of viral
infecsummer:
sudof fever,
headache,
myalgia,
arthralgia,
and vague
abdominal
distress.
How-

involvement
hepatomegaly,
hemorrhagic)

of this
contrast

those
in the

(our

cases

condition
to

1 and

3),

can be decep-

the

frequent

organ

mentioned
in the literature:
jaundice,
splenomegaly,
rash
(morbilliform
and various
neurologic
complications

or

nm9

Southern
to 5% (20%

and Sanford
below
the

the world
literature.0
States
is probably

and

0 hermsi,

of Borrelia.2

(B

reported
a mortality
of 1 year)
from

case

reports

of 2%
cases
in

The mortality
in the United
significantly
less:
no fatalities

in 462
However,

age

cases

reported

to pregnant

in California
women,

ease may present

a potential
danger
and neonatal
death
by transplacental
Our

occur

may

incubation

easily
be
frequently

onset

may

Sanford.#{176}

reported

mately
seven
our patients,

readily

Although

manifestations

and

The

in the
is

cases

who

give
a therapeutic
acute,
undifferentiated

ing fever
are well described
in standard
disease
textbooks89
and in an extensive
1,105
cases
in the
world
literature
Southern

people

bitten.7
infection

Because

antibiotics,

during

species

as vectors

especially

they

Thus,

physicians
for an

at any time

1931.

B parkeri,

dead
nests.

but

unknown.

oral

occurred

occurred

serve

common

of relapses.

be contracted

have

con-

is

treatable

since

turicata,

in
and

of rodents,

squirrels,

is painless.6

and three
species
of Ornithoticks
found
in endemic
foci of
areas.
These
tick species,
0

the reservoir

the

relapsing
incidence

the physical
similar
louse-borne

parasites

fever recall being

of this endemic

ever,

distinct
but clinically
fever are recognized,

are

pine

Unlike

photophobia,

DISCUSSION
Two
lapsing

plains
was
to occur

They
live
primarily
rodent
burrows,

acquire
The

tem-

antipy-

species

is known

characteristically

ill.

was suspected,
and spirochetes
were
blood smears.
In the clinic, the
dose,
his
prostration

two

semiarid
of B turicata

forest
biome
of the
Western
These
ticks
can live and remain
and can also transmit
the infec-

normally

United

child

that

September

National

family

Routine

first
in

a single
case
Only 0 hermsi

transovarially.
logs,
woodpiles,

and

The
mainly

tor),
0 hermsi
ticks
are night
feeders
and take
blood meals lasting
an average
of 15 minutes,
after
which
they
detach
themselves.
Although
it may
produce
a 2- to 3-mm
pruritic
eschar,
the
bite

examination

C without

dose

coniferous
States.45
for years

humans.

were negative.
was prescribed
interval
between

during

it was

150 mg of oral

the

perature

five

no other

infection
in Wright-stained

child

attack,

Angeles

Borrelia

found

to the

to 14 days,

chipmunks

and

shift

cultures
and urinalysis
symptomatic
therapy
viral
syndrome.
The

febrile
relapses
was ten
remained
asymptomatic.
By the fourth
febrile

a log cabin

Physical

found

in the
United
infected

chipmunks

episodes
showed
a non-toxic-looking
findings
except
for fever and a mildly
The WBC counts
were normal
on two

during

are

reported

They

A 2-year-old
boy was seen in October
1979 for a temperature
of 38.6 C rectally,
the fourth
recurrence
of fever
since
the end of August
1979.
Typically,
the febrile
episodes
began
abruptly,
with
temperature
peaks as high as 40.6 C rectally
that lasted
for 48 hours.
Associated
symptoms
were mild vomiting,

respectively).

ticks

(although
in Ohio).3

tion
trees,

family

B hermsi,

of soft
regions

of erythromycin,

taking

daily

of the

Vital

gradually

initial

clinic

times

relapse

estolate.

temperature

contained

from

estolate

have any
follow-up.

the

smear

discharged

mycin

erythromycin

and

further

emphasize

this

dis-

of abortion#{176}
transmission
three

ARTICLES

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on October 23, 2015

practi-

965

cal
be

aspects
suspected

of this
and

disease.
obtained

First,
the diagnosis
can
only
if the
clinician

actively
seeks
a good
medical
history.
lana
should
be suspected
in a patient

Just
with

as maparox-

ysmal
fever
who
may
not volunteer
a history
of
travel
to endemic
parts
of the world
unless
specifically asked,
any patient
with fever
and
nonspecific,
flu-like
illness
should
be asked
whether
he or she
has slept
overnight
in a rustic
log cabin
during
the
previous
one to three
weeks
in a national
park
or
mountain
area of the Western
United
States
above
5,000-foot
tional

elevation.
cases

common
Second,
borne

Interstate

of relapsing

and

fever

have

fever

is the

the

are found
increases

diagnosis

technicians
complete
smears.3

the
ogram
deny

However,

use

of the

smears

may

this

automated

age

by

the
spi-

of the

electronic

indeed
nosis

animal

recommended
fections.#{176}

are

drugs
The

scanning

hem-

looked

may
blood

at by the

blood

smear

for

spiro-

the diagNo spe-

clinically
useful.
and chloramphenicol

for treatment

potential

are

effects

inof these

co-workers4
in Ethiopia
recently
showed
that
single
dose
of oral tetracycline
or erythromycin
effective
in the treatment
of louse-borne
relapsing
fever.
Spirochetes
disappeared
from
the patients

vation

966

(one

week)

in that

TICK-BORNE

a
is

responded

hyperpy(cases
1
may rep-

ofJarisch-Herxheimer

That

of spirochetes

by four

reaction

blood
hours

smears
after

the

dose in unknown,
empirical
seven-

course
of the

No relapse
occurred
the two- to four-month

of erythromycin.
patients
during

were
initial

bactericidal
since the oral
and the risk

of relapse
with a single
to give our patients
an

we chose
to ten-day

in any
fol-

ACKNOWLEDGMENTS
thank

Drs

1 and

R. Meagher

3, respectively.

preparation

of the

and
Della

B. Coop
Mundy,

for

referring

MLS,

assisted

manuscript.

did

RELAPSING

not

exclude

1. Tick-borne
relapsing
fever.
Calif Morbidity
Weekly
Rep,
Jan 19, 1979, p 1
2. Report
of the Committee
on Infectious
Diseases,
ed 18.
Evanston,
IL, American
Academy
of Pediatrics,
1977
3. Linnemann
CC Jr, Barber
LC, Dine MS, et al: Tick borne
relapsing
fever in the Eastern
United States. Am JDis Child
132:40, 1978
4. Felsenfeld
0: Borrelia:
Strains,
Vectors,
Human
and Animal Borreliosis.
St Louis,
Warren
Y Green,
1971, pp 30-37
5. Boyer
KM, Munford
RS, Maupin
GO, et al: Tick-borne
relapsing

6.

8.

9.

10.
1 1.
12.

after
a single
oral dose.
of the follow-up
obserstudy

degree

self-limiting.

dose suggests
that the drug is extremely
to the Borrelia
spirochetes.
However,
antibiotic
therapy
is relatively
benign

the

of Borrelia

adverse

hours
duration

cleared

7.

two drugs
in children
are well known
to pediatricians.
Penicillin
is less effective.
Linnemann
and
associates3
reported
tetracycline
failure
in a 6/2year-old
boy with B turicatae.
However,
Butler
and

blood
three
to four
However,
the short

patients

REFERENCES

computer,

by animal
inoculation
infection
in our patients.

cific serologic
tests
Third,
tetracycline

was

with

is positive
in 85% of the cases
reported
and Sanford.#{176} The Microbial
Disease
Department
of Health,
Berkeley,
CA,

confirmed
of Borrelia

three

while
doing
the
on the blood

be routinely

of the

chetemia)
by Southern
Laboratory,

a mild

which

technician.
Blood
cultures
will be negative
but animal inoculation
(by intraperitoneal
injection
of the
patients
blood
clot into mice or rats and subsequent
examinations

resent

cases

laboratory

the white
cell differential
this fortuitous
help since

no longer

Our

low-up.

blood
smear
and
smears.#{176} Often,

spirochetes
and differential
in

for obtaining
the physician

during
of cases,

accidentally

who notice
blood
count

to
site.5
tick-

of relapse.

well to oral erythromycin

estolate.
The
rexia and prostration
seen in two infants
and 3) following
antibiotic
administration

examina-

smears
70%

in the initial
with
multiple

is made

traced

vacationing
test
for

microscopic

tion
for spirochetes
in blood
febrile
episode.
In approximately
rochetes
the yield

interna-

been

exposures
in an endemic
the
simplest
diagnostic

relapsing

even

possibility

the

fever:

An

interstate

outbreak

originating

at Grand

Canyon
National
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105:469,
1977
Longanecker
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hermsi Wheeler)
in
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Am J Trop Med Hyg 31:373,
1951
Wynns HL: The epidemiology
of relapsing
fever, in Moulton
FR (ed): A Symposium
on Relapsing
Fever in the Americas.
Washington,
DC, American
Association
for the Advancement of Science,
1942, pp 100-105
Francis
BJ, Thompson
RS: Relapsing
fever, in Hoeprich
PD
(ed): Infectious
Diseases:
A Modern
Treatise
of Infectious
Processes,
ed 2. Hagerstown,
MD, Harper
& Row, 1977, pp
1067-1071
Burgdorfer
W: The
relapsing
fevers,
in Hunter
GW,
Swartzwelder
JC, Clyde DF (eds): Tropical
Medicine,
ed 5.
Philadelphia,
WB Saunders,
1976, pp 137-146
Southern
PM Jr, Sanford
JP: Relapsing
fever. A clinical and
microbiological
review. Medicine
48:129, 1969
Taber
LH, Feigin RD: Spirochetal
infections.
Pediatr
Clin
North Am 26:377,
1979
Fuchs

PC,

Oyama

AA:

Neonatal

relapsing

fever

due

to

transplacental
transmission
ofBorrelia.
JAMA
208:690, 1969
13. Malison
MD: Relapsing
fever. JAMA
241:2819,
1979
14. Butler T, Jones PK, Wallace
CK: Borrelia
recurrentis
infection: Single dose antibiotic
regimens
and management
of the
Jarisch-Herxheimer
reaction.
J Infect Dis 137:573,
1978

FEVER

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Tick-Borne Relapsing Fever in Children

Chinh T. Le
Pediatrics 1980;66;963
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1980 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on October 23, 2015

Tick-Borne Relapsing Fever in Children

Chinh T. Le
Pediatrics 1980;66;963

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/66/6/963

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1980 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on October 23, 2015