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Volume 26, Number 10—October 2020
Dispatch

Tickborne Relapsing Fever, Jerusalem, Israel, 2004–2018

Saar Hashavya1, Itai Gross1Comments to Author , Matan Gross, Noa Hurvitz, Giora Weiser, Violeta Temper, and Orli Megged
Author affiliations: Hadassah Medical Center, Jerusalem, Israel (S. Hashavya, I. Gross, M. Gross, V. Temper); Hebrew University, Ein Kerem, Israel (N. Hurvitz); Shaare Zedek Medical Center, Jerusalem (G. Weiser, O. Megged)

Main Article

Table

Characteristics of persons with tickborne relapsing fever, Jerusalem, Israel, 2004–2018*

Variable Children and adolescents, n = 30 Adults, n = 62 Total, n = 92 p value
Age, y†
Mean (95% CI) 11.65 (10.3–13.1) 25.97 (23.5–28.5) 21.3 (21.23–21.37) <0.01
Median (range)
 12 (3–18)
 22.5 (19–70)
 19 (3–70)
Sex, no. (%)
M 21 (70.0) 54 (87.1) 75 (81.5) 0.09
F
 9 (30)
 8 (12.9)
 17 (18.5)
Hospitalization, d
Mean (95% CI) 2.57 (1.82–3.32) 2.66 (2.31–3.01) 2.63 (2.62–2.64) 0.39
Median (range)
 2
 2
 2
Mean no. ED visits (95% CI) 1.26 (1.12–1.4) 1.21 (0.99–1.43) 1.231 (1.12–1.34) 0.6
ICU admission, no. (%) 0 2 (3.2) 2 (2.2) 0.45
Treatment with doxycycline, no. (%) 25 (83.3) 61 (98.4) 86 (93.5) 0.09
Jarisch–Herxheimer reaction, no. (%)
 4 (13.3)
 15 (24.19)
 19 (20.7)
 0.35
Exposure history
Cave visits, no. (%) 24 (80.0) 52 (83.9) 76 (82.6) 0.82
Known tick bite, no. (%)
 9 (30.0)
 21 (33.8)
 30 (32.6)
 0.88
Mean incubation period, d, (95% CI)
 8.41 (6.22–10.6)
 9.4 (7.06–11.74)
 9.1 (9.05–9.15)
 0.61
Fever
Mean duration before ED visit, d (95% CI) 12.4 (8.53–16.27) 10 (7.31–12.7) 9.76 (9.69–9.85) 0.13
>1 Relapse of fever, no. (%) 12 (40.0) 7 (11.3) 19 (20.6) <0.01
No. fever episodes at diagnosis
1 6 31 <0.01
2 10 20
3 2 4
4 6 4
5 4 0
Missing information
 2
 3
Signs and symptoms, no. (%)
Gastrointestinal 16 (53.3) 22 (35.5) 38 (41.3) 0.1
Respiratory 1 (3.3) 5 (8.1) 6 (6.5) 0.39
Myalgia 8 (26.7) 22 (35.5) 30 (32.6) 0.4
Malaise 11 (36.7) 24 (38.7) 35 (38.0) 0.85
CNS symptoms 19 (63.3) 32 (51.6) 51 (55.4) 0.29
History of shivering 6 (20.0) 19 (30.6) 25 (27.2) 0.29
Organomegaly 5 (16.7) 12 (19.4) 17 (18.5) 0.76
Rash 6 (20.0) 7 (11.3) 13 (14.1) 0.26
CNS signs 4 (13.3) 2 (3.2) 6 (6.5) 0.07
Bite mark, no. (%)
 11 (36.7)
 17 (27.4)
 28 (30.4)
 0.36
Laboratory results‡
Leukocytes, mean 109/L (95% CI) 8.65 (7.71–9.59) 9.74 (7.32–12.16) 9.37 (9.35–9.39) 0.13
PMN, mean 109/L (95% CI) 5.16 (4.22–6.1) 7.12 (5.34–8.89) 6.45 (9.43–6.47) <0.01
PMN %, mean (95% CI) 0.58 (0.51–0.64) 0.72 (0.54–0.9) 0.674 (0.67–0.68) <0.01
Lymphocytes, mean, 109/L (± SD) 1.85 (1.39–2.31) 1.23 (0.92–1.54) 1.442 (1.44–1.45) <0.01
PLT, mean 109/L (95% CI) 174.2 (146–203) 136.93 (102.85–171.02) 149.64 (149.13–150.15) 0.04
PLT <150,000, no. (%) 12 (40) 35 (56.5) 47 (51.1) 0.2
Hemoglobin, mean g/dL (95% CI) 11.98 (11.3–12.7) 13.35 (10.03–16.67) 12.88 (12.87–12.89) <0.01
CRP, median mg/dL (IQR) 7.93 (6.35–9.5) 16.87 (12.67–21.07) 12.2 (5.5–17.8) <0.01
ESR, median mm/h (IQR)§ 53.92 (40.76–67.09) 53.96 (40.53–67.39) 50 (30–75) 0.99
Hyponatremia, no. (%) 9 (30.0) 17 (27.4) 26 (28.2) 0.8
Elevated creatinine level, no. (%)¶ 2 (6.7) 13 (21) 15 (16.3) 0.08
Elevated liver enzymes, no. (%)# 0 8 (12.9) 8 (8.7) 0.04

*CNS, central nervous system; CRP, C-reactive protein; ED, emergency department; ESR, erythrocyte sedimentation rate; ICU, intensive care unit; IQR, interquartile range; PLT, platelets; PMN, polymorphonuclear.
†Number of persons in each group were as follows: 2–5 y: 3; 6–9 y: 5; 10–13 y: 10; 14–17 y: 12; 14–17 y: 12; 18–22 y: 31; 23–29 y: 16; 30–45 y: 10; and 46–70 y: 5.
‡Reference ranges: Platelets (109/L), 150,000-400,000; C-reactive protein (mg/dL), <0.5; ESR (mm/h) <20.
§Children, n = 13; adults, n = 26.
¶Elevated creatinine levels in comparison to age-adjusted reference (11).
#Elevated aspartate transaminase and/or alanine aminotransferase in comparison to age-adjusted reference (11).

Main Article

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1These authors contributed equally to this article.

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