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Journal of the Egyptian Society of Parasitology, Vol.42, No.3, December 2012J. Egypt. Soc. Parasitol., 42(3), 2012: 625 – 638

LOUSE AND TICK BORNE RELAPSING FEVERSBy

MAMDOUH M. EL-BAHNASAWY1, NAGRIS ALBERT LABIB2,MAGDA ABDEL-HAMEED ABDEL-FATTAH3, ABEER

MOHAMMAD ABDALLAH IBRAHIM1 AND TOSSON A. MORSY4

The Military Institute of Health and Epidemiology, Military Medical Academy1,Departments of Public Health2, Nursing Adminstration3 and Parasitology4,Faculties of Medicine2,4 and Nursing3, Cairo University2,3, and Ain Shams

University, Cairo 115664, EgyptAbstract

Relapsing fever, caused by spirochaetes belonging to the genus Borrelia, wasonce the cause of worldwide epidemic zoonotic disease. This was largely throughinfection with the louse-borne form of the disease, caused by Borrelia recurrentis[(louse-borne relapsing fever (LBRF)]. Another form of replasing fever is causedby Borrelia duttonii [(tick-borne relapsing fever (TBRF)]. The introduction and thewide use of DDT in the last century, which is forbidden now, the incidence andprevalence of both LBRF and TBRF markedly decreased.

However, with the increase of rapid transportation, crowdedness and poverty, aswell as abundance of lice and ticks, replasing fever is still endemic to some coun-tries. Besides, with the appearance of others closely related Borrelia species thatbegins to emerge, the threat or the burden of these arthropod-borne zoonotic maybe unpredicted or underestimated.Key words: Spirochaetes, Louse-borne relapsing fever, Tick-borne relapsing fever.

Review and DiscussionRelapsing fever is a zoonotic infection

transmitted by a louse or tick. It ischaracterized by repeated episodes offever. 1-Tick borne relapsing fever istransmitted mainly by ticks. In Egyptup to 32 genera and species of ticks arereported (Hoogstraal, 1958; Morsy etal, 1986; Younis et al, 1995; El-Bah-nasawy and Morsy, 2008; Abdel-Shafyet al, 2012; Morsy, 2012). 2- Louseborne relapsing fever is transmitted byhuman lice (Morsy et al, 2000; 2001).Three types of lice infesting man arecommon. Unfortunately, in Egypt, headand body lice have been encountered

among Pediatric hospitals (El-Safy etal, 1991), Household-orphanage chil-dren (El-Sherbini et al, 2008) and pre-school Schoolchildren (Morsy and El-Ghazali, 1999) and sever allergy mani-festations (Abou-Gamra et al, 1992).

Relapsing fever, caused by spiro-chetes of the Borrelia genus, is an ar-thropod-borne infection, which occursin two major forms: tick-borne relaps-ing fever (TBRF) and louse-borne re-lapsing fever (LBRF).

Tick-borne relapsing fever is a zo-onosis and is endemic in many coun-tries. The two main Borrelia spp. in-volved in North America are B. hermsii

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(in the mountainous West) and B. tur-icatae (in the southwest). Other tick-borne species cause relapsing fever onother continents. Louse-borne relapsingfever is caused by B. recurrentis (Cut-ler et al, 2009). It is principally a dis-ease seen in the developing world; it isspread from person to another by thebody louse and can occur in epidemics,including large ones involving millionsof people. As the name implies, relap-sing fever is characterized by the recur-rent episodes of fever, which accom-panies spirochetemia. The disease rela-pses are due to antigenic variation bythe spirochetes (Dworkin et al. 2008).

For several decades, the borreliosiswas synonymous with relapsing fever.

Since the discovery of the agent ofLyme disease at the beginning of the1980s, the term borreliosis now coversboth relapsing fever and Lyme borreli-osis. The relapsing fevers form a groupof similar diseases that differ from eachother mainly in the different arthropodhosts used by the spirochete as a reser-voir and vector. The relapsing fevercould be transmitted either by lice;louse-borne relapsing fever or by softticks of the genus Ornithodoros; tick-borne relapsing fever (Stanek, 1995).Clinical Manifestations:

The relapsing fever presents with thesudden onset of fever, punctuated by anintervening afebrile period, which oc-curs at least twice. The incubation pe-riod is 5-9 days. The fever attacks lastfrom several hours to 4 days, and areaccompanied by chills, headache, nau-sea and vomiting, sweating, abdominalpain, arthralgia, and cough; complica-

tions are rare. The temperature may beas high as 43ºC but above 39ºC.

Most infections occur with a mixtureof Borrelia serotypes, each of whichproduces different manifestations. Stud-ies in the experimental mice suggess-ted that the differences in disease ex-pression with B. turicatae infection aredetermined by variability in the surfaceprotein of the bacterium. With mixedinfection, one serotype may modulatethe manifestations of another one (Ca-david et al, 2007).Course of Fever:

In LBRF, the first episode of fever isunremitting for three to six days; it istypically followed by a single milderepisode. In TBRF, multiple febrile pe-riods last from one to three days each.In both forms, the interval betweenfevers ranges from 4 to 14 days.

The first fever episode ends by crisis,consisting of rigors, a further elevationin temperature, and increases in pulseand blood pressure, lasting approxi-mately 15-30 minutes. The crisis phaseis followed by the profuse diaphoresis,falling temperature, and hypotensionwhich usually persist for several hours.The mortality from the untreated relaps-ing fever is common during the crisisand the immediate aftermath (Dworkinet al, 2002).

Symptoms with the fever can be pro-tean and nonspecific as headache, my-algia, arthralgia, shaking chills, and ab-dominal complaints. Headache, neckstiffness, arthralgia, myalgia, and nau-sea may accompany the first and sub-sequent episodes. The patient with re-lapsing fever may experience dizziness

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and unsteady gait. A nonproductivecough is common during LBRF andmay in combination with high feverand myalgias suggestive influenza.Acute respiratory distress syndromemay occur during the TBRF. Localiz-ing neurologic symptoms, includinghemiplegia, facial palsy, myelitis, andradiculopathy, is more common inTBRF than LBRF. Delirium or apathyand occasionally stupor or coma canoccur in both forms.

Although the first episode of illnesstends to be the most severe, some com-plications, particularly localized neuro-logic ones, are more common duringsubsequent febrile periods.Physical Examination:

Epistaxis, petechiae, and ecchymosesare common during louse-borne relaps-ing fever but not tick-borne relapsingfever. The bleeding disorder is proba-bly the consequence of thrombocyto-penia, impaired hepatic production ofclotting factors, and/or blockage ofsmall vessels by aggregates of spiro-chetes, erythrocytes, and platelets.Splenomegaly, which the patient canexperience as abdominal or left shoul-der pain, is also common. The majorityof patients with LBRF and about 10percent of patients with TBRF haveenlarged livers (Perine et al. 1971).

Although most of the relapsing feverpatients have not had electrocardio-grams, myocarditis appears to becommon in both louse-borne and tick-borne relapsing fever. Heart involve-ment has been prominent in fatal cases.The most common evidence of myo-carditis is gallops on cardiac ausculta-

tion, and patients frequently complainof polyarthralgia, enlarged, painfuljoints are unusual (Judge et al. 1974).

Meningitis or meningoencephalitis isserious consequences of this invasionresults in residual hemiplegia or apha-sia. Unilateral or bilateral Bell's palsyor deafness from seventh or eighth cra-nial nerve involvement are the mostcommon forms of cranial neuritis inTBRF; if it occurs, cranial neuritis typ-ically presents in the second or thirdfebrile episode, not the first. Visualimpairment from unilateral or bilateraliridocyclitis or panophthalmitis may bepermanent. In LBRF, neurologic mani-festations such as altered mental stateor stiff neck are thought to be second-ary to the spirochetemia rather thandirect invasion of organisms into thecentral nervous system (Cadavid andBarbour, 1998).Diagnosis:

General laboratories findings are notspecific. A mild to moderate normo-cytic anemia is common, but frank he-molysis and hemoglobinuria do notoccur. Leukocyte counts are usually inthe normal range or only slightly ele-vated, and there can be leukopenia dur-ing the crisis. Platelet counts can fallbelow 50,000/microl. Laboratory evi-dence of hepatitis can occur with ele-vated serum concentrations of uncon-jugated bilirubin and aminotransferas-es; the prothrombin and partial throm-boplastin times may be moderately pro-longed. Hypoalbuminemia can occurbut is more often due to malnutritionthan hepatic dysfunction. The electro-cardiogram may reveal a prolonged

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QTc interval in patients with myo-carditis. Some of them showed cardio-megaly and pulmonary edema on chestradio-graph (Pankuweit et al, 2005).

Analysis of cerebrospinal fluid (CSF)is indicated in suspected case whenthere are signs of the meningitis or themeningoencephalitis. The presence of amononuclear pleocytosis and/or mildlyto moderately elevated protein levels inthe CSF provides justification for in-travenous antibiotic therapy in patientswith tick-borne relapsing fever. Glu-cose concentrations in the CSF areusually not depressed. So, CSF exami-nation excludes bacterial and othernon-viral causes of meningitis (Bot-tieau et al, 2012).Differential Diagnosis:

A number of both common and lessfrequent conditions can mimic relaps-ing fever. Besides, other illnesses mayaccompany the louse-borne form. Orni-thodoros, vectors of TBRF, are notknown to transmit other infections tohumans. Under conditions that fosterepidemics of louse-borne diseases, pa-tients can acquire epidemic typhus,typhoid, measles, tuberculosis, or ma-laria. Differen-tial diagnosis includes:malaria granulocytic or monocytic,ehrlichiosis, babesiosis, typhoid, tula-remia, brucellosis, Colorado tick fever,rickettsioses, dengue, leptospi- rosis,rat-bite fever, meningococcemia, viralhepatitis (Pachner, 1986).

The relapsing fever should be con-sidered in a patient with characteristicfever pattern especially if recurrence isaccompanied by crisis and a history ofexposure to lice or soft-bodied ticks.

Thin and thick smears of blood areusually the first tests performed forsuspected relapsing fever. Giemsa orWright stains typically reveal the spi-rochetes in a methanol-fixed thin smearif the concentration of microorganismsis greater than 10(5)/ml. As many as200 oil immersion fields should beviewed before judging the smear to benegative. The optimum time to obtainblood is between the fever's onset andits peak (Roscoe and Epperly, 2005). Athick smear is a more sensitive assaydetecting at least one log fewer organ-isms. The slide should first be treatedwith 0.5 percent acetic acid to lyse he-moglobin and then stained with Giemsaor Wright stain. The acetic acid treat-ment can be omitted if the smear isstained with acridine orange, whichbinds to nucleic acids in spirochetes,and then examined microscopicallyunder ultraviolet light. Direct or indi-rect immunofluorescence is anotherprocedure that can be used with thickor thin smears to visualize spirochetes.Fluorescein-labeled polyclonal anti-body to B. burgdorferi is commerciallyavailable but with sufficient cross-reactivity with other Borrelia spp. to beuseful for detecting relapsing fever spi-rochetes in the blood or in tissues.Slides can be fixed with methanol; ace-tic acid treatment is not necessary (Sci-otto et al. 1983). Lescot et al. (2008)reported that the vector specializationof louse-borne pathogens responsiblefor epidemics was associated with rap-id genome reduction, and that the cor-relation between gene loss and in-creased virulence of B. recurrentis wasparallels to that of Rickettsia prowaze-

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kii, with both species being genomicsubsets of less-virulent strains.

When temperature declins or i back tothe normal range in the absence of an-tipyretics, spirochetes usually cannotbe visualized in blood. Previously, la-boratory technicians carefully review-ing a routine peripheral smear for awhite cell differential count often madediagnosis (Poulsen and Iversen, 1996).

A further increase in sensitivity canbe achieved by centrifugation of hepa-rinized or citrated blood followed byexamination of the Buffy coat andoverlying plasma. The anticoagulatedblood can be centrifuged in capillarytubes, the same procedure used for amicrohematocrite. Spirochetes are usu-ally found in the same fraction as plate-lets. The examination for platelets inthe suspension serves as a quality con-trol on centrifugation step as long aspatient is not severely thrombocytope-nic; if platelets are not present, the cen-trifugation has been too rapid or long.

Another diagnostic maneuver is thewet mounts. Non-centrifuged plasma orthe concentrated Buffy coat is exam-ined by phase contrast or dark fieldmicroscopy for motile spirochetes. Wetmount is prepared by merging a drop ofcitrated or heparin zed blood with onedrop of normal saline or phosphate-buffered saline under a cover slip. Are-as at the interface between the salineand blood erythrocytes are examined at400X magnification (Cadavid, 2006).Coiling, uncoiling, and bending mov-ements of the spirochetes as they swimamong erythrocytes can be visualized.

All of the direct visualization meth-ods facilitate diagnosis. A smear or wetmount properly evaluated can be diag-nostic since Borrelia spp are an unlike-ly contaminant and an asymptomaticcarrier state is not known to occur. Inless experienced hands, stain artifactsin blood smears and incorrect interpre-tation of wet-mounts may produce falsediagnoses (Magnarelli et al, 2002).Cultures:

When relapsing fever is suspected butspirochetes are not directly visualizedby the above techniques, laboratoryconfirmation of the clinical diagnosisrequires techniques that are not availa-ble in most laboratories, namely animalinoculation and in vitro cultivation.Inoculation of blood into weanlingmice may yield a Borreliaspp from theblood or, less commonly, from CSFeven between fever episodes. Most ofthe agents of tick-borne relapsing feverwill infect and proliferate in mice.However, B. recurrentis, the agent ofLBRF, infects mice only transiently; ifat all (Barbour et al. 1996). For sus-pected TBRF, blood, plasma, Buffycoat, or CSF is injected intraperitone-ally into the suitable mouse; most in-bred or outbred strains. Infection of themouse is enhanced by the severe com-bined immunodeficiency (SCID) phe-notype, or by splenectomy. Blood ofthe inoculated mice should be exam-ined daily for presence of the spiro-chetes for seven days (Chohan, 1967).

The in-vitro cultivation is an alterna-tive to animal inoculation for organismin blood. Kelly's medium and its com-monly used derivative, Barbour-Stoe-

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nner-Kelly (BSK) medium, support thegrowth of most Borrelia spp. The sup-plementation of the medium with theRifampin, Phosphomycin, Neomycin,and/or Amphotericin B reduces growthof contaminants. Cultures are inoculat-ed with several drops of blood or plas-ma and incubated at 34- 36ºC in tight-ly-capped tubes for up to 2 weeks. Cul-ture samples are examined every day orother day by the dark-field or phase-contrast microscopy (Chohan, 1967).

PCR on specimens of blood, brain,CSF, and joint tissues of mice havebeen used to study B. hermsii and B.turicatae, two species causing TBRF.The technique is probably is as sensi-tive as culture for detecting borreliasand has the advantage over culture thatthe results can be obtained in a fewhours rather than several days. But,there was little reported experiencewith the PCR for diagnosis of humanrelapsing fever (Cadavid et al, 1993).

For most infections, serology pro-vides indirect evidence of disease whenan etiologic agent cannot be detecteddirectly. Such is not the case for relaps-ing fever because specific diagnosticBorrelia antibodies have not been de-fined. Available serologic assays basedupon whole cells of a relapsing feverBorrelia species, may not include theantigens to which the patient is re-sponding. ELISA or IFA on wholecells proved valuable in diagnosis. But,paired acute and convalescent seramust be analyzed in the same assay andmust demonstrate a fourfold or greaterchange in titer. These assays are onlyavailable at a few reference laborato-ries (Dodge, 1973).

Convalescent sera from the majorityof relapsing fever patients gave cross-reactive positive reactions in a com-mercially available ELISA assay forantibodies to B. burgdorferi. For theseELISA results to be considered sup-portive of the diagnosis of relapsingfever, however, the Western blot assayfor Lyme disease and treponeme-specific assays for syphilis should benegative. Recombinant antigens, suchas GIpQ, that are specific for relapsingfever species may provide a basis fordiscriminating between relapsing feverand Lyme disease by serologic assay(Schwan et al, 1996).Treatment:

Penicillin and Tetracycline are theantibiotics of choice for relapsing feverfor several decades, without evidencethat Borrelia spp have acquired re-sistance to them. The minimum inhibi-tory concentrations (MICs) of Penicil-lin G and Tetracycline for Borrelia spp.are generally <0.1 mcg/ml. Relapsingfever Borrelia spp. is also susceptiblein vitro to Cephalosporins, Macrolides,and Chloramphe-nicol, but there is lessclinical experience with these antibiot-ics. Borrelias are relatively resistant tothe Rifampin, Sulfonamides, Fluoro-quinolones, Metronidazole, and Ami-noglycosides (Barbour et al. 1982).

The effectiveness of the antibiotictherapy of relapsing fever can be as-sessed by observing the clearance ofspirochetes from the blood. Most pa-tients will no longer have detectablespirochetes in the blood within eighthours of the first dose of an effectiveantibiotic.

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A single dose of antibiotic is usuallysufficient for the treatment of LBRF;the recurrence rate after antibiotics isless than five percent. Tetracycline(500 mg) and Erythromycin (500 mg)are effective oral antibiotics for adultswith this disease. The doses of eitherTetracycline or Erythromycin for chil-dren are 12.5 mg/kg. Tetracycline hasbetter efficacy and is preferred overErythromycin, except for pregnant andnursing women and for children lessthan nine years old(Butler et al. 1978).When the patient cannot take Tetracy-cline by mouth, the intravenous dose is250 or 500 mg for adults' parenteraltreatment with intramuscular PenicillinG procaine is 600,000 to 800,000 unitsfor adults and 400,000 units for chil-dren (Fekade et al. 1996)

The preferred treatment for TBRF inadults is Tetracycline (500 mg or 12.5mg/kg orally every six hours) orDoxycycline (100 mg twice daily),both for 10 days. When Tetracyclinesare contraindicated, the alternative isErythromycin (500 mg or 12.5 mg/kgorally every six hours) for 10 days(Guerrier and Doherty, 2011).

If a Beta-lactam antibiotic adminis-tered intravenously rather than orally,especially if CNS involvement is con-firmed or suspected. Penicillin G (3million units every four hours) orCeftriaxone (2g once daily or 1g twicedaily) for 10-14 days for adults is theintravenously for Lyme disease. In ex-perimental model, the regimens wereeffective for relapsing fever with neu-rologic involvement (Horton andBlaser, 1985).

Jarisch-Herxheimer Reactions: JHRoccur following antibiotic treatment fora number of spirochetal and bacterialinfections; symptoms and signs includerigors, fever, and hypotension. Treat-ment of LBRF is the classic situation inwhich this reaction arises, occurring inapproximately 80% of treated patients.While both penicillin and tetracyclinecan induce JHR, penicillin therapy ap-pears to cause a more prolonged reac-tion. JHR can occur following treat-ment of TBRF, with an incidence of54% in one series. These reactions tendto occur within two hours of the antibi-otic administration; thus, observationfor several hours after treatment is rec-ommended (Negussieet al. 1992).

Proinflammatory cytokines, especial-ly tumor necrosis factor (TNF-α), inter-leukin (IL)-6 & IL-8, have been impli-cated in the pathogenesis of this pro-cess. The patients with proven LBRF,pretreatment with anti-TNF-alpha anti-bodies reduced incidence of rigorsfrom 90% in placebo recipients to 50%and the mean increase in temperaturefrom 1.5ºC to 0.8ºC.. However, admin-istration of Pentoxifylline or recombi-nant IL-10 did not affect the occur-rence or degree of JHR (Remicket al.1996).

The mortality rates for untreatedLBRF and TBRF are in the ranges of10%up to 70%and 4%up to 10%, re-spectively. With prompt treatment withappropriate antibiotics, the death ratefor LBRF is 2% to 5% and for TBRF isless than 2%. Poorer prognostic fea-tures include: Stupor or coma on ad-mission diffuse bleeding myocarditispoor hepatic function broncho-pneu-

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monia co-infection with typhus, typh-oid, or malaria. The mortality rate fromJHR in LBRF patients was about 5%.However, some patients have survivedthe crisis or JHR, only to die suddenlylater that day or next one, perhaps froman arrhythmia (Cooper et al. 2000).Relapsing fever in Pregnancy:

The relapsing fever during pregnancyfrequently leads to abortion or still-birth. There appears to be transplacen-tal transmission of the infection or anewborn may be infected at birth.Pregnant women and infants tend tohave more severe and prolonged ill-nesses with relapsing fever. Congenitalmalformations as a result of relapsingfever have not been reported (Jongen etal. 1997). Nevertheless, Mahran andGhavami (2009) reported a case ofcongenital tick-borne relapsing feverwith transplacental transmission.

A murine model of gestational re-lapsing fever infection found that infec-tion during pregnancy causes intrauter-ine growth retardation, placental dam-age and inflammation, impaired fetalcirculation, and decreased maternal he-moglobin levels (Larsson et al. 2006).Prevention and Control:

Decreasing louse and tick exposure isthe major means of preventing relaps-ing fever. There is not a vaccine foreither LBRF or TBRF. The prospectsfor a suc-cessful vaccine are poor be-cause of the various emerging speciesof Borrelia and a single strain can man-ifest a large number of serotypes iden-tities (Chen and Zückert, 2011).

LBRF can be prevented by loweringthe risk of louse infestation through

improved personal hygiene, reductionof crowding, and better access to wash-ing facilities. Clothing appears to beimportant in maintaining lice. Indige-nous peoples who commonly wore clo-thes were observed to be at the higherrisk of developing LBRF than those insame geographic area who were gener-ally naked (Desenclos et al, 2011).

In Egypt, Abou El-Ela et al. (2000)evaluated four commercially availablepediculicides against the head lice Pe-diculus h.capitis among school chil-dren. They found that Licid was themost effective and with less side ef-fects. Morsy et al. (2000) studied thein-vitro pediculicidal efficacy of fourwell known commercial insecticidesand three medicinal plant extracts.They concluded that Neem extract ofthe Indian trees and castor oil provedvery effective without any side effectparticularly the last one. El-Basheir andFouad (2002) evaluated several medic-inal plants for their pediculicidal effi-cacy and recommended Neem extract.Abdel-Ghaffar et al. (2012) recommen-ded a single Neem seed extract to treathead lice and their nits.

TBRF can be reduced by constructionof houses with concrete or sealed plankfloors and without thatched roofs ormud walls. Log cabins pose a particularrisk in North America when rodentsnest in the roofs or beneath the houseor porch. Interiors of buildings infestedwith Ornithodoros can be sprayed with2% benzene hydrochloride, 0.5% Dia-zinon, or 0.5% Malathion, but Dia-zinon, besides its severe toxicity, wasless effective in Rhipicephalus mi-croplus (Kumar et al, 2011).

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In Egypt, Morsy and Haridy (2000)successfully used ivermectin as topicalapplication in controlling the browndog tick, R. sanguineus infesting a pet-dog. Abdel-Shafy et al. (2011) evaluat-ed various levels of dietary Jatrophacurcas seed meal as acaricide againstHyalomma m. marginatum infestedrabbits.

Persons usually are bitten by softticks while sleeping in an infested dwe-lling, but the ticks may be observedduring daytime exploration of a cave orcrawling under a house. Domestic ani-mals, such as pigs, can serve as reser-voirs for infection, especially whenthey are kept adjacent to the livingquarters (Southern and Sanford, 1969).

The efficacy of post-exposure treat-ment with Doxycycline was demon-strated in a placebo-controlled trial of93 healthy subjects in Israel with sus-pected tick exposure. The patients wererandomly assigned to Doxycycline(200mg on day one followed by 100mgdaily for four days) or placebo Cases ofTBRF was defined as a patient withfever and a positive blood smear. Atthree weeks, ten cases of TBRF werediagnosed; all were in the placebogroup (attack rate 22%).These findingssupport post-exposure treatment, asefficacy appeared to be 100%. Thisregimen can also be used after acci-dental inoculation with infected bloodor culture medium in the laboratory,hospital, or clinic (Hasin et al. 2006).

Mortality rates form 30%-70% werereported in untreated patients duringepidemics of the louse-borne variety,the mortality rate falls to about 5%

with treatment. b- The mortality rate ofpatients with tick-borne relapsing feverwho are treated was less than 1% (Ra-mos et al, 2009).

Generally, Assous and Wilamowski(2009) reported TBRF in Eurasia andattributed mainly to B. persica, andother entities (B. baltazardi, B. cauca-sica B. crocidurae, B. latyschewii, andB. microtii). They added that O. tho-lozani is the most important tick vector,found in India and Kashmir, the south-ern countries of the former USSR, Iran,Iraq, Syria, Jordan, Turkey, Egypt, Is-rael, and Cyprus. The number of hu-man cases varied among countries,from eight cases per year in Israel to 72cases per year in Iran.

In Egypt, Morsy et al. (1994) report-ed different clinical features of pedicu-losis among school children. AbdelFattah et al. (1994) correlated betweenpediculosis infestation in children andthe cervical lymphadenopathy. Morsyet al. (1996) found an abnormal distri-bution of the histocompatiblity anti-gens (HLA) in lousy preschool andschool aged children. They concludedthat not all the children were suscepti-ble to the allergic and/or complicationscaused by lice infestation.

Helmy (2000) in Dahshore, GizaGovernorate studied the seasonal dy-namics of O. (O.) savignyi and Borre-lia sp. in the tick, domestic animals andman. The tick population densitieswere high from June to October withmaximum levels in August and Sep-tember. Annual spirochetes infectionrate in adults and immatures variedfrom 34.4%-36.9% without significant

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difference. Of 1396 sera from man and553 sera from animals tested, 309(22.1%) & 157 (28.4%), respectively,were reactive for antibody to Borreliasp. antigen with the highest infectionrate in camel, sheep, goat, cow andthen buffalo. Shanbaky and Helmy(2000) at Shelateen, Halayeb Provincedetected Borrelia sp. in O. savignyi,which showed specificity for its ownnatural tick host species when com-pared with B. crocidurae isolated fromO. erraticus. Reeves et al. (2006) col-lected 1,023 of 5 species lice on ratsand domestic cattle from 13 gover-norates by PCR amplification and se-quencing detected five different louse-borne bacterial agents in lice; Bartonel-la rattimassiliensis, B. phoceensis, andBartonella sp. near B. tribocorum, Co-xiella burnetii, and Rickettsia typhi.They concluded that lice of urban anddomestic animals harbor pathogenic orpotentially pathogenic bacterial agents.

In Egypt Eastern border, McNamaraand Kay (1988) presented a case of anadolescent tourist who contracted re-lapsing fever (Borrelia) in Israel, andtick-borne relapsing fever (TBRF) isendemic to Israel (Sidi et al, 2005;Halperin et al, 2006).

Safdie et al. (2010) identified TBRFagent in Israel and the Palestinian Au-thority relies on the morphology andthe association of B. persica with itsvector O. tholozani, and sequencedthree complete 16S rRNA genes, 12partial flaB genes, 18 partial glpQgenes, 16 rrs-ileT intergenic spacers(IGS) from nine ticks and ten humanblood samples originating from theWest Bank and Israel. Phylogenic se-

quence analysis defined all the Borreliaisolates from O. tholozani and fromhuman TBRF cases in Israel and theWest Bank as B. persica that clusteredbetween the African and the NewWorld TBRF species. Gene organiza-tion of the intergenic spacer betweenthe 16S rRNA and the 23S rRNA wassimilar to that of other TBRF Borreliaspecies and different from the Lymedisease Borrelia species. Balicer et al.(2010) examined the safety and effec-tiveness of post-exposure pro-phylaxispolicy in preventing TBRF found thatTick-bite screening and prophy-lactictreatment with doxycycline in endemicareas proved to be a practical, safe, andhighly effective policy.

ConclusionGenerally speaking, in the 21st centu-

ry, the vector-borne, respiratory tractand gastrointestinal infections can beaccepted as the challenging issues withthe considerable significant mortality.

This article reviewed the current stateof knowledge about the louse and tick-borne relapsing fevers with especialreference to Egypt and neighboringcountries. So, the Public Health, Veter-inary and Agricultural authorizes arerequested to keep this zoonotic arthro-pod-borne disease into consideration.

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