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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 32  |  Issue : 2  |  Page : 183-185
 

Spirocheatal shock syndrome


1 Department of Internal Medicine, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
2 Department of Gastroenterology, FACP College of Medicine and medical sciences, Taif University, Taif, Saudi Arabia

Date of Submission06-May-2013
Date of Acceptance11-Jul-2013
Date of Web Publication2-Apr-2014

Correspondence Address:
I Masoodi
Department of Gastroenterology, FACP College of Medicine and medical sciences, Taif University, Taif
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.129822

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 ~ Abstract 

In this paper we describe a clinical scenario of high grade fever, jaundice, hypotension and multi-organ dysfunction syndrome in a 30-year-old homeless male without radiological biliary obstruction. He was brought to our hospital by the emergency medical service of Saudi Arabia (Red Crescent) from the street. After an initial resuscitation he proved to have Borrelia recurrentis. The clinical course during his hospital stay was not a smooth one, but the patient finally improved. After 20 days of hospitalisation, he was discharged in a stable condition. The present case underlines the need for high clinical vigilance, even in a non-endemic area.


Keywords: Borrelia recurrentis, Electrocardiography changes, Myocarditis, shock


How to cite this article:
Alfaifi A A, Masoodi I, Alzaidi O, Hussain S, Khurshid S, Sirwal I A. Spirocheatal shock syndrome. Indian J Med Microbiol 2014;32:183-5

How to cite this URL:
Alfaifi A A, Masoodi I, Alzaidi O, Hussain S, Khurshid S, Sirwal I A. Spirocheatal shock syndrome. Indian J Med Microbiol [serial online] 2014 [cited 2019 Sep 24];32:183-5. Available from: http://www.ijmm.org/text.asp?2014/32/2/183/129822



 ~ Introduction Top


Borrelia recurrentis, the causative agent of relapsing fever, is a helical or wavy spirocheate measuring 3-25 μm in length with a width of 0.2-0.3 μm. In North America, the infection has been shown to be transmitted by the bite of the Ornithodoros tick, and, in many other parts of the world, contact with the hemolymph of the human body louse, Pediculosis humanis, is known to transmit the infection among people with poor hygiene. This often takes place when the hemolymph from the infected louse enters the abraded skin after the louse has been killed and crushed on the skin. The disease usually presents with headache, myalgia, high grade relapsing fever and altered sensorium, etc. Conditions that favour infestation with P. humanis, such as poor hygiene, overcrowded living conditions, such as those in refugee camps, have led to large outbreaks in fact, epidemics, of relapsing fever, in the past. In the past, Borrelia recurrentis had considerable morbidity and mortality.


 ~ Case Report Top


A 30-year-old homeless male was brought to our hospital by the national emergency service from off the street. The patient was wearing very dirty clothes. He was febrile, (temperature 38°C), ill-looking, jaundiced and dehydrated. His respiratory rate was 35/min and SPO 2 of 90% on room air. He had a fast thready pulse rate of 120 beats/min and his blood pressure was 70/40 mmHg. Abdominal examination revealed hepatomegaly, 3 cm below costal margin (liver span of 16 cm). Cardiovascular, respiratory and neurological examinations were unremarkable. On evaluation, he had a haemoglobin count of 10.5 g/dl, and a leucocytic count of 5900/cumm. Platelets were reduced and a manual platelet count revealed only 34,000/cumm. Liver function tests showed direct hyper-bilirubinemia (Bil 9 mg/dl ref range 0.8-1 mg/dl). Serum transaminase (SGOT) levels were 137 IU (Ref range 0-38 IU) and SGPT levels were 541 IU (Ref 0-65 IU), and serum ALP levels were 193 (Ref 40-130 IU). The patient was non-reactive for IgM Hepatitis A, Hepatitis B core Ig M, Hepatitis B surface antigen and human immunodeficiency virus (HIV). Serum lipase and amylase levels were within normal limits. Blood urea levels were 109 mg/dl (Ref = 40 mg/dl) and serum creatinine levels were 1.9 mg/dl (Ref = 1 mg/dl). After initial resuscitation with intravenous fluids, his blood pressure improved, but he continued to be febrile. Ultrasound examination of the abdomen showed a moderately distended gallbladder, with no calculus in it. Portal vein, intra-hepatic biliary radicles and intra-hepatic veins were normal. There was hepatomegaly, but without any lesions, and in a setting of febrile jaundice, obstructive jaundice was consequently ruled out. A peripheral blood film of the patient showed loosely coiled Borrelia recurrentis [Figure 1] and treatment for Borelia recurrentis was started. The patient was given 500 mg of tablet form tetracycline orally. Three hours later his blood pressure abruptly dropped to 70/40 mm of mercury, and, in addition, he de-saturated. He was put on a ventilator, and ionotropic support was started, in addition to antibiotics (Inj. Meropenum 500 mg twice daily). Serum troponin levels were not elevated, and bedside electrocardiogram (ECG) and echocardiograms were both normal (the echocardiogram showed a normal pericardium, and all chambers were of normal size, with no lesions, mass or vegetations). However, the next day, another ECG showed diffuse ST-segment elevation [Figure 2] and serum CPK and CPKMB were 617 and 84290 IU, respectively, but troponin-I was negative. A repeat echocardiogram showed diffuse hypokinesia and a reduction in ejection fraction from an initial level of 68 to 45%. Serial serum troponin-I levels remained low. Repeat peripheral blood film showed no Borrelia recurrentis. The patient continued to receive supportive treatment. He showed progressive clinical improvement, and was discharged home in a stable condition after 20 days of hospitalisation.
Figure 1: Peripheral blood fi lm showing Borellia recurrentis

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Figure 2: ECG showing diffuse ST-T wave changes suggestive of myopericarditis due to Borelliosis

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 ~ Discussion Top


Our patient had been living alone in an unhygienic manner, and presented with jaundice, fever and hypotension at our hospital. It is possible that high grade fever, in combination with dehydration due to poor liquid intake, predisposed him to hypovolumic shock. Hypovolumic shock improved after the administration of intravenous fluids. It was difficult to suspect Borreliosis as the cause of jaundice, fever and hypotension, as Borelliosis is not endemic in Saudi Arabia. However, a report of a case in a patient returning from Saudi Arabia has been described in the literature. [1] Peripheral blood film was pivotal in clinching the diagnosis, and the patient was consequently given tetracycline, which is known to act by altering the surface of spirocheata, making them more susceptible to phagocytosis by the body's defence mechanisms. Jaundice is not a common clinical presentation in a given case of Borelliosis. In a clinical study among Ethiopian refugee camp in northern Somalia, Brown et al. observed that of 37 cases of Boreliosis, jaundice was absent contrary to the index case and majority of cases had presented with high grade fever, body aches, etc. [2] Tetracycline is the treatment of choice but one of the feared complications of this therapy is Jerix Hexmier's reaction (J-HR) as was observed in the index case. In common with our case, Webster et al. outlined a J-HR following administration of fluoroquinolones in tick-borne relapsing fever (TBRF). [3] In an experimental study, Nequssie et al.,[4] concluded that the severe pathophysiological changes characterising the J-HR of louse-borne relapsing fever were closely associated with the transient elevation of IL-6 and IL-8 concentrations. The release of cytokines after tetracycline or any other drug treatment is more common in louse-borne than in TBRF, beginning within 1-4 hours of the first dose, as in the index case. The management of J-HR is possible in an intensive care unit (ICU). An opiate partial agonist, meptazinol, has been shown to reduce the symptoms, but detailed studies on this treatment are lacking. [5] A further complication during the course of treatment in the index case was the presence of myopericarditis, as was evident by reduction in the ejection fraction from 68% to 45%, diffuse ECG changes, and the serial elevation of cardiac enzymes (CPK and CPKMB). Troponin-I levels remained normal in the index case, hence a coronary event was ruled out. Contrary to the index case, Kenith et al.,[6] reported a transient elevation of Troponin-I in a patient with TBRF associated with J-HR following treatment with flouroquinolone. The index case showed progressive improvement in his cardiac function and normalisation of the cardiac enzymes. It is pertinent to mention that of concern in a given case of Borelliosis is the ability of the parasite to persist after resolution of the fever and the danger of probable relapse, [7] which, however, in various trials has been shown to have decreased with tetracycline treatment. [8]


 ~ Conclusion Top


In conclusion, the index case reflected a triphasic pattern of shock syndrome caused by infection from this rare spirocheate. Since there has been decrease in louse-borne infections through improvements in living standards around the globe, it can thus be clinically challenging to diagnose such rare infection, especially in a non-endemic area. Failure to identify this clinical entity often leads to prolonged illness and incurs excessive and preventable medical costs. Many invasive procedures can be avoided if this rare condition is kept in mind while evaluating a patient coming from a poor socio-economic background, living in unhygienic conditions.

 
 ~ References Top

1.Keung YK, Cobos E, Kimbrough RC 3 rd , Carver RC. Borreliosis as a cause of fever in a woman who recently returned from Saudi Arabia. Clin Infect Dis 1995;21:447-8.  Back to cited text no. 1
    
2.Brown V, Larouze B, Desve 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. 2
    
3.Webster G, Schiffman JD, Dosanjh AS, Amieva MR, Gans HA, Sectish TC. Jarisch-Herxheimer reaction associated with ciprofloxacin administration fortick-borne relapsing fever. Pediatr Infect Dis J 2002;21:571-3.  Back to cited text no. 3
    
4.Negussie Y, Remick DG, DeForge LE, Kunkel SL, Eynon A, Griffin GE. Detection of plasma tumor necrosis factor, interleukins 6, and 8 during the Jarisch-Herxheimer 15 Reaction of relapsing fever. J Exp Med. 1992;175: 1207-12.  Back to cited text no. 4
    
5.Teklu B, Habte-Michael A, Warrell DA, White NJ, Wright DJ. Meptazinol diminishes the Jarisch-Herxheimer reaction of relapsing fever. Lancet 1983;1:835-9.  Back to cited text no. 5
[PUBMED]    
6.6 Hoekstra KA, Kelly MT. Elevated troponin and jarisch-herxheimer reaction in tick-borne relapsing Fever: A case report. Case Rep Infect Dis 2011;1-3.  Back to cited text no. 6
    
7.Wyplosz B, Milhaila-Amrouche L, Baixench MT, Bigel ML, Berardi-Grassias L, Fontaine C, et al. Imported tickborne relapsing fever, France. Emerg Infect Dis. 2005;11:1801-3.  Back to cited text no. 7
    
8.Guerrier G, Doherty T. Comparison of antibiotic regimens for treating louse-borne relapsing fever: A meta-analysis. Trans R Soc Trop Med Hyg. 2011;105:483-90.  Back to cited text no. 8
    


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