(Relapsing Fever - Continued)

Following discovery of the borrelia organisms on her peripheral smear, the patient's body and hair were closely re-examined. She was found to have a light infestation of lice (Pediculus humanus) in her hair. Hemolymph expressed from these lice contained borrelia organisms.

To minimize the possibility of a Jarisch-Herxheimer reaction, the patient was initially treated with penicillin followed by tetracycline. She was given a 1% gamma benzene hexachloride shampoo for her louse infestation. After primaquine therapy was initiated for treatment of the malaria, she was discharged April 21 with instructions to continue primaquine therapy on an outpatient basis. Because of her positive tuberculin reaction, plans were also made for isoniazid chemoprophylaxis at a later date.

The woman had spent most of her life in Addis Ababa, Ethiopia. For 6 months before October 1973 she had lived in a rural area of that country teaching local residents to read and write. She had received an unknown medication once weekly for malaria prophylaxis during this period, except for the last 2 to 3 weeks before she returned to Addis Ababa.

Following her return to Addis Ababa, the patient had suffered frequent generalized headaches lasting approxihalf a day; otherwise she felt well. She came to the United States 18 days before she was hospitalized. Beginning 2 days after her arrival she developed fever and myalgia, followed by chills and diaphoresis. Bouts of fever and chills subsequently recurred 1 to 2 times a day. Between these episodes she felt well except for an occasional headache.

Family members, relatives, and hospital contacts of the patient were given 1% gamma benzene hexachloride shampoo. In addition, an insecticide was sprayed in the home of relatives with whom the patient was staying. None of these people reported febrile illness, and lice were not found in their hair.

Reported by BH Bolton, MD, H Anderson, BS, MT, R Krafka, BS, Miami Valley Hospital, Dayton; R Vogel, MD, Montgomery County Health Dept; TJ Halpin, MD, State Epidemiologist, Ohio State Dept of Health; and Parasitology Div, Bur of Laboratories, the Bacterial Zoonoses Br, and Epidemiologic Investigations Laboratory Br, Bacterial Diseases Div, Bur of Epidemiology, CDC.

Editorial Note: The clinical presentation of this patient was not typical for louse-borne relapsing fever, and the concurrent presence of malaria makes it difficult to ascribe Current Trends

specific manifestations to the borrelia infection. More typically, the disease is characterized by periods of fever lasting 2 to 9 days, terminating by crisis, with alternating afebrile periods of 2 to 4 days. The number of relapses is typically 1 to 3.

The form of relapsing fever usually diagnosed in the United States is the tick-borne, endemic type. Several epidemics of louse-borne relapsing fever probably occurred in this country between 1844 and 1874, although these were never laboratory confirmed (1). Isolated cases of suspect louse-borne relapsing fever reported after that time either were not laboratory confirmed or were not convincingly differentiated from tick-borne relapsing fever.

Louse-borne relapsing fever is strictly a human disease transmitted by either the head or body louse (2). The lice become infected by feeding on a patient with circulating B. recurrentis. The borreliae pass from the intestinal tract of the louse into the hemocele or celomic cavity, where they multiply. Normally a 5 to 8 day period elapses between an infective blood meal and the appearance of the organisms in the hemocele. The louse is infective from the time the borrelia are detectable in its hemocele until the end of its life span, which is 3 weeks or, occasionally, longer. It does not pass on the infection to its offspring.

The infection is not transmitted directly by the bite of the louse because the borreliae are tightly enclosed in the celomic cavity. However, lice are easily injured. The breaking off of their limbs or antennae by scratching allows celomic fluid to escape and contaminate areas of broken skin.

Formerly a quarantinable disease under the International Health Regulations, this disease has been the cause of 7 major epidemics in this century; these resulted in more than 16 million cases and 5 million deaths (3). All of these epidemics were associated with periods of war or famine. The disease is now restricted to certain remote regions of the world, including parts of Ethiopia.

References

1. Palmer JH, Crawford DJM: Relapsing fever in North America, with report of an outbreak in British Columbia, Can Med Assoc J 28:643-647, 1933

2. Felsenfeld O: Borrelia, Strains, Vectors, Human and Animal Borreliosis. St. Louis, Warren H. Green, Inc., 1971

3. Bryceson ADM, Parry EHO, Perine PL, Warrell DA, Vukotich D, Leithead CS: Louse-borne relapsing fever, a clinical and laboratory study of 62 cases in Ethiopia and a reconsideration of the literature. Q J Med 39:129-170, 1970

(ZIG - Continued)

3. School contact

exposure to an infectious classmate at an adjacent desk or in the same carpool 4. Hospital contact exposure to an infectious patient in an adjacent bed or in the same 2-4 bed room 5. Maternal varicella contact infant born to a mother who developed varicella within 4 days before delivery. In the period November 1, 1974-June 28, 1976, 490 patients were treated, including: 184 (38%) who were exposed in the household, and 149 (30%) who were exposed to playmates (Table 3): Fewer patients were treated in other exposure categories.

TABLE 3 Number of patients treated with Zoster Immune Globulin by exposure status, United States, November 1974-June 1976

The increasing demand for ZIG has led to supply shortages. The current stock will soon be exhausted. At the present time, CDC lacks the Zoster Immune Plasma to begin a new lot. All those interested in supplying convalescent plasma from patients with Herpes zoster should contact:

Center for Disease Control Bureau of Laboratories

Attn:

Dr. Robert Ellis

Biological Products Division

Atlanta, Georgia 30333

Phone: (404) 633-3311, Ext. 3356

Plasma donation should be made between 7 and 28 days following onset of the Herpes zoster rash.

Reported by Immunization Div, Bur of State Services, and Biological Products Div, Bur of Laboratories, CDC.