Volume 197 - Issue 5
The Jarisch–Herxheimer reaction in a patient with leptospirosis: a foreseeable problem in managing spirochaete infections
Authors: Ryan Markham, Andrew Slack and John Gerrard
Med J Aust 2012; 197 (5): 276-277. || doi: 10.5694/mja11.11175
Published online: 3 September 2012
Published online: 3 September 2012
To the Editor: A 60-year-old male farmer presented to the Gold Coast Hospital Emergency Department with a 2-day history of fever (38.5°C), retro-orbital pain, photophobia and confusion. In the preceding 2 weeks he had been working on a farm that had cattle and horses and which was infested with rats. The property had been flooded in the 2011 Queensland flood disaster, about a month before he worked ...
To the Editor: A 60-year-old male farmer presented to the Gold Coast Hospital Emergency Department with a 2-day history of fever (38.5°C), retro-orbital pain, photophobia and confusion. In the preceding 2 weeks he had been working on a farm that had cattle and horses and which was infested with rats. The property had been flooded in the 2011 Queensland flood disaster, about a month before he worked there.
On presentation, the patient was alert, orientated and afebrile with normal pulse and blood pressure. Findings on physical examination were unremarkable except for a mild deficit in attention.
Laboratory studies revealed thrombocytopenia, with a platelet count of 89 × 109/L (reference range [RR], 140–400 × 109/L). His haemoglobin level, white cell count and renal function were normal. Liver function tests revealed only a mildly elevated gamma-glutamyltransferase level of 64 U/L (RR, < 55 U/L).
The patient was treated with a single dose of intravenous benzylpenicillin and ceftriaxone. Two hours later, he became tachycardic, tachypnoeic and hypertensive and developed severe rigors. We concluded that the incident was a Jarisch–Herxheimer reaction. Empirical antibiotics were continued and the patient had no further events.
On subsequent analysis of the patient’s initial blood sample, Leptospira DNA was detected. Serological testing was positive for Leptospira IgM, and the microscopic agglutination test titre was 1 : 100 (RR, < 1 : 50). The patient’s time in hospital was otherwise uneventful, and he was discharged 5 days later.
Leptospirosis is a zoonotic infection caused by a spirochaete of the genus Leptospira. It begins as a non-specific febrile illness lasting up to 7 to 10 days, but in severe cases can be associated with acute renal failure, jaundice and pulmonary haemorrhage.1
The Jarisch–Herxheimer reaction is a known complication of the treatment of spirochaete infections including syphilis and relapsing fever. It is characterised by the onset of fever, rigors, myalgias and hypertension or hypotension several hours after antibiotic therapy, and resolution of these symptoms within 24 hours.2 A proposed mechanism for the reaction includes endotoxin release from spirochaete destruction and the activation of the cytokine cascade.3
Treatment for the reaction is largely supportive. Paracetamol and certain opioids can be used to reduce the symptoms and duration of the reaction but do not prevent it.3 Some studies have shown that antibodies against tumour necrosis factor-α can decrease the prevalence of the reaction compared with no therapy.4
Competing interests
No relevant disclosures.
References
- Slack A. Leptospirosis. Aust Fam Physician 2010; 39: 495-498 0_CBBIAAGA
- See S, Scott EK, Levin MW. Penicillin-induced Jarisch-Herxheimer Reaction. Ann Pharmacother 2005; 39: 2128-2130. 0_CBBFADGJ
- Pound MW, May DB. Proposed mechanisms and preventative options of the Jarisch-Herxheimer reactions. J Clin Pharm Ther 2005; 30: 291-295. 0_i1142867
- Fekade D, Knox K, Hussein K, et al. Prevention of the Jarisch-Herxheimer reaction by treatment with antibodies against tumor necrosis factor alpha. N Engl J Med 1996; 335: 311-315. 0_i1142871