Borrelia species (Relapsing fever)
Definitions & Key takeaways
Borrelia species are gram-negative spirochetes that cause relapsing fever. The characteristic feature of relapsing fever is the cyclical pattern of fever and afebrile periods. Transmission of Borrelia to humans generally occurs through the bite of an infected vector, commonly a tick or a louse. Lyme disease is the most common presentation of Borreliosis. Symptoms can include fever, headache, myalgia, and arthralgia. Borrelia burgdorferi is the primary causative agent of Lyme disease. Untreated Lyme disease can lead to neurologic sequelae, including meningitis and encephalitis.
Borrelia is a genus of spirochetes, which are long, thin, spiral shaped bacteria, that spin or twist to move around. The genus has two major groups.
The first one is associated with Lyme disease and the most common species is Borrelia burgdorferi. The second group is associated with relapsing fever and the most common species are Borrelia hermsii, Borrelia turicatae, Borrelia parkeri and Borrelia recurrentis.
Of the second group, the first three species cause tick-borne relapsing fever, while Borrelia recurrentis causes louse-borne relapsing fever.
By the way, you may know this already, but “louse” is actually singular for “lice” - so body lice are the vector that transmits Borrelia recurrentis.
Now, all Borrelia species have an outer membrane that contains a substance similar to lipopolysaccharides, an inner membrane, and a layer of peptidoglycan in a periplasmic space, which is the space between the inner and the outer membrane.
Since the peptidoglycan layer is thin, it doesn’t retain the purple dye used during Gram staining, so they’re classified as Gram-negative.
However, they can’t be easily visualized with Gram staining. Instead, they’re best seen with the Wright or Giemsa stain, which make the bacteria appear purple, and with dark-field microscopy, which make the bacteria appear white against a dark background.
Now, Borrelia species are motile, which means they can move around using long, thin filaments called endoflagella, which are located in their periplasmic space.
The filaments rotate in this space, between the outer membrane and the peptidoglycan layer, propelling the bacterium forward in a corkscrew-like motion.Finally, the bacteria can be cultivated on Barbour-Stoenner-Kelly medium or by intraperitoneal inoculation of immature laboratory mice, but these tests are not widely available.
Now, Borrelia can enter the body one of two ways, depending on the type of relapsing fever. So, in tick-borne relapsing fever, or TBRF, the bacteria enters the bloodstream through the bite of an infected tick.
With louse-borne relapsing fever, or LBRF, the bacteria is transmitted by lice. When lice feed on infected humans, they acquire Borrelia which then multiply in the lice gut and hemolymph - which is like their blood.
And then, infected lice can feed on an uninfected human, and the bacteria enters the bloodstream when the person crushes the louse or scratches the area where the louse is feeding.Once in the bloodstream, Borrelia species can escape the immune system through antigenic variation.
Ok, so the outer membrane of Borrelia has surface proteins called variable small proteins, or Vsp, and variable large proteins, or Vlp.
These surface proteins are constantly changing, and this allows Borrelia to trick the immune system over and over again.
So, by the time the immune system has developed antibodies against Vsp or Vlp, they’ve already changed, allowing Borrelia to escape immune recognition.
Once it’s safe from immune destruction, Borrelia replicates in the blood through binary fission. This means the bacteria splits in two identical copies - and if it sounds similar to mitosis...well, it is!
But the term binary fission is used to describe division of prokaryotic cells, which don’t have a nucleus, and therefore some steps in replication are different from mitosis.
When they replicated enough, they spread from the bloodstream to various organs such as liver, heart, lungs, bone marrow or central nervous system.
So left untreated, the disease could progress to serious complications like hepatitis, myocarditis, acute respiratory distress syndrome, thrombocytopenia, meningitis or cranial nerve palsy.
Ok, now TBRF is transmitted by ticks like Ornithodoros parkeri and Ornithodoros turicata, which are usually found endemically in the mountainous areas of North America, plateau regions of Mexico, Central and South America, Mediterranean, central Asia and Africa.
LBRF, on the other hand, is transmitted via body lice. LBRF is primarily seen in low resource countries, regions affected by war, refugee camps and in people who have poor hygiene and are exposed to lice.
A febrile episode ends with a sequence of symptoms known as a crisis. Each crisis has two phases - a chill phase in which people develop very high fever and may become delirious, agitated, tachycardic and tachypneic and usually lasts 10 to 30 minutes, and a flush phase characterized by sweats, a rapid decrease in body temperature and hypotension.
In TBRF, the febrile episode lasts usually 1 to 3 days, with an average of 7 days between the initial episode and first relapse.
In LBRF, the first febrile episode usually lasts longer, 3 to 6 days, with an average of 9 days between the first episode and the first relapse.
Between the episodes, people have no symptoms, and relapses typically become shorter and progressively milder as afebrile periods lengthen.
Symptoms of complications depend on the affected organ. With hepatitis, there can be fatigue, nausea, vomiting, hepatomegaly and abdominal pain.
Symptoms of myocarditis include chest pain, palpitations or dullness of heart sounds. With acute respiratory distress syndrome, there’s shortness of breath or fast breathing.
Thrombocytopenia may cause nosebleeds, as well as easy bruising. Symptoms of meningitis include fever, headache, neck stiffness and altered mental status.
Finally, with cranial nerve palsy there may be facial palsy, or loss of movement in the face muscles. Diagnosis is done by identifying Borrelia on a peripheral blood smear using Giemsa or Wright stain or dark-field microscopy.
Other tests include culture and PCR, which detects the bacterial DNA, but these tests are not widely available. Serological tests like enzyme immunoassay and Western immunoblot can detect antibodies against Borrelia, but these tests can also give false-negative results because of antigenic variation, as well as false-positive results, because of cross-reactions with other spirochetes like Borrelia burgdorferi, Treponema pallidum, which causes syphilis and Leptospira, which causes leptospirosis.
Treatment is done with antibiotics such as penicillin G or doxycycline. Under antibiotic treatment, monitoring is essential, as individuals can develop Jarisch-Herxheimer reaction.
That’s when a lot of spirochetes break open and release a lot of antigens all at once due to the antibiotic treatment, and that can result in fever, sweating and muscle pains.
##SummaryAlright, as a quick recap. Borrelia species are spirochetes which cause a vector-borne disease called relapsing fever.
They are motile and can be visualized with Wright or Giemsa stain and with dark-field microscopy. They have variable small proteins and variable large proteins which can undergo a process called antigenic variation to escape the immune system.
Relapsing fever can be tick-borne and louse-borne and they are both characterized by recurrent episodes of fever and constitutional symptoms and with intermittent periods of general well-being between the febrile episodes.
Diagnosis is made by identifying Borrelia in peripheral blood smears and treatment is done with antibiotics such
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