Louse-borne relapsing fever-A systematic review and analysis of the literature: Part 2-Mortality, Jarisch-Herxheimer reaction, impact on pregnancy

Abstract

Louse-borne relapsing fever (LBRF) is a classical epidemic disease, which in the past was associated with war, famine, poverty, forced migration, and crowding under poor hygienic conditions around the world. The disease's causative pathogen, the spirochete bacterium Borrelia recurrentis, is confined to humans and transmitted by a single vector, the human body louse Pediculus humanus corporis. Since the disease was at its peak before the days of modern medicine, many of its aspects have never been formally studied and to date remain incompletely understood. In order to shed light on some of these aspects, we have systematically reviewed the accessible literature on LBRF since the recognition of its mode of transmission in 1907, and summarized the existing data on mortality, Jarisch-Herxheimer reaction (JHR), and impact on pregnancy. Publications were identified by using a predefined search strategy of electronic databases and a subsequent review of the reference lists of the obtained publications. All publications reporting patients with a confirmed diagnosis of LBRF published in English, French, German, and Spanish since 1907 were included. Data extraction followed a predefined protocol and included a grading system to judge the certainty of the diagnosis of reported cases. The high mortality rates often found in literature are confined to extreme scenarios. The case fatality rate (CFR) of untreated cases is on average significantly lower than frequently assumed. In recent years, a rise in the overall CFRs is documented, for which reasons remain unknown. Lacking standardized criteria, a clear diagnostic threshold defining antibiotic treatment-induced JHR does not exist. This explains the wide range of occurrence rates found in literature. Pre-antibiotic era data suggest the existence of a JHR-like reaction also in cases treated with arsenicals and even in untreated cases. LBRF-related adverse outcomes are observed in 3 out of 4 pregnancies.

Fig 1. Flow diagram of search and selection of eligible publications.

Fig 2. CFR of LBRF cases from the reviewed studies according to treatment modality over time.

The dots correspond to the CFR of the respective group. The columns represent the absolute number of cases. The table gives detailed information on the data for each segment of time. Note: Since the data set is compiled from published literature reporting on cases, outbreaks and clinical studies from different regions, different populations as well as different seasons, no trend in annual incidence of LBRF can be inferred.

Fig 3. CFR in relation to treatment modality, time, and geographical region.

Fig 4. Adverse pregnancy outcomes in LBRF cases.

(A) Microscopically diagnosed cases. (B) Microscopically and clinically diagnosed cases. One study reported adverse pregnancy outcomes without specifying them (gray color) [89].