Louse-borne relapsing fever (LBRF), caused by Borrelia recurrentis and transmitted by the body louse (Pediculus humanus), is a neglected infectious disease that has been responsible for huge outbreaks in the past but has virtually disappeared from Europe since the end of World War II.1,2 War, famine, overcrowding, and poor living conditions are recognized risk factors favoring the re-emergence of this disease.
From June to December 2015, around 50 cases of LBRF were described among asylum seekers from Eastern Africa arriving to Europe with reports from Germany, Italy, Belgium, Switzerland, the Netherlands, and Finland.3–19 The latest report of imported LBRF in Europe regards a patient observed in Italy in June 2016 and coming from Mali.20 In all published instances described as yet, migrants had stationed in overcrowded refugee camps in Libya before arriving to Italy after having crossed the Mediterranean Sea, with the exception of two patients who were probably infected in Turin, Italy, while sheltered in the same asylum as other individuals with the disease.5
We report herein two additional cases of LBRF in refugees from Somalia and Sudan who were admitted to our Department of Infectious Diseases in Milan, Italy, in June 2016. We describe their clinical presentation, the difficulties encountered in diagnosing the disease, and finally we review all cases of LBRF imported to Europe thus far.
Bryceson ADM, Parry EHO, Perine PL, Warrell DA, Vukotich D, Leithead CS, 1970. Louse-borne relapsing fever. A clinical and laboratory study of 62 cases in Ethiopia and a reconsideration of the literature. QJM 153: 129–170.
Wilting KR, Stienstra Y, Sinha B, Braks M, Cornish D, Grundmann H, 2015. Louse-borne relapsing fever (Borrelia recurrentis) in asylum seekers from Eritrea, the Netherlands, July 2015. Euro Surveill 20: 21196.
Ciervo A, Mancini F, di Bernardo F, Giammanco A, Vitale G, Dones P, Fasciana T, Quartaro P, Mazzola G, Rezza G, 2016. Louseborne relapsing fever in young migrants, Sicily, Italy, July–September 2015. Emerg Infect Dis 22: 152–153.
Goldenberger D, Claas GJ, Bloch-Infanger C, Breidthardt T, Suter B, Martinez M, Neumayr A, Blaich A, Egli A, Osthoff M, 2015. Louse-borne relapsing fever (Borrelia recurrentis) in an Eritrean refugee arriving in Switzerland, August 2015. Euro Surveill 20: 21204.
Costescu Strachinaru D-I, Cambier J, Kandet-Yattara H, Konopnicki D, 2016. Relapsing fever in asylum seekers from Somalia arriving in Belgium in August 2015. Acta Clin Belg 71: 353–355.
Hoch M et al. 2015. Louse-borne relapsing fever (Borrelia recurrentis) diagnosed in 15 refugees from northeast Africa: epidemiology and preventive control measures, Bavaria, Germany, July to October 2015. Euro Surveill 20: 30046.
Selmaier M et al. 2016. 25 Fälle von Läuserückfallfieber bei Flüchtlingen aus Ostafrika. (Louse-borne-relapsing fever in refugees from the Horn of Africa: a case series of 25 patients). Dtsch Med Wochenschr 141: e133–e142 (article in German).
Antinori S et al. 2016. Louse-borne relapsing fever (Borrelia recurrentis) in a Somali refugee arriving in Italy: a re-emerging infection in Europe? PLoS Negl Trop Dis 10: e0004522.
Zammarchi L et al. 2016. Louse-borne relapsing fever with meningeal involvement in an immigrant from Somalia to Italy, October 2015. Vector Borne Zoonotic Dis 16: 352–355.
Keller C, Zumblick M, Streubel K, Eickmann M, Muller D, Kerwat M, Becker S, Gress T, 2016. Hemorrhagic diathesis in Borrelia recurrentis infection imported to Germany. Emerg Infect Dis 22: 917–919.
Osthoff M, Schibli A, Fadini D, Lardelli P, Goldenberger D, 2016. Louse-borne relapsing fever- report of four cases in Switzerland, June–December 2015. BMC Infect Dis 16: 210.
Darcis G, Hayette M-P, Bontems S, Sauvage A-S, Meuris C, Van Esbroeck M, Leonard P, 2016. Louse-borne relapsing fever in a refugee from Somalia arriving in Belgium. J Travel Med 23: 1–3.
Colomba C, Scarlata F, Di Carlo P, Giammanco A, Fasciana T, Trizzino M, Cascio A, 2016. Fourth case of louse-borne relapsing fever in young migrant, Sicily, Italy, December 2015. Mini review article. Public Health 139: 22–26.
Hytonen J, Khawaja T, Gronroos JO, Jalava A, Meri S, Oksi J, 2017. Louse-borne relapsing fever in Finland in two asylum seekers from Somalia. APMIS 125: 59–62.
Jochum J, Tannich E, Tappe D, Schmiedel S, 2017. A Somali refugee with fever and abnormal blood smear. Internist 58: 287–292 (article in German).
Grecchi C, Zanotti P, Pontarelli A, Chiari E, Tomasoni LR, Gulletta M, Barbui A, Caligaris S, Matteelli A, Castelli F, 2017. Louse-borne relapsing fever in a refugee from Mali. Infection 45: 373–376.
Relman DA, 1993. Universal bacterial 16S rDNA amplification and sequencing. Persing DH, Smith TF, Tenover FC, White TJ, eds., Diagnostic Molecular Microbiology: Principles and Applications. Rochester, Minnesota: Mayo Foundation, 489–495.
Vial L, Diatta G, Tall A, Ba el H, Bouganali H, Durand P, Sokhna C, Rogier C, Renaud F, Trape JF, 2006. Incidence of tick-borne relapsing fever in west Africa: longitudinal study. Lancet 368: 37–43.
Igwe CU, Duru LA, Ukwamedua H, Ikaraoha CI, 2007. Louse-borne relapsing fever and malaria co-infection in Ethiopia. Trop Doct 37: 121–122.
Wacker C, Prkno A, Brunkhorst FM, Schlattman P, 2013. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis 13: 426–435.
Shehabi Y et al. 2014. Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis. A randomized controlled trial. Am J Respir Crit Care Med 190: 1102–1110.
Poulakou G, Bassetti M, Timsit J-F, 2016. Critically ill migrants with infection: diagnostic considerations for intensive care physicians in Europe. Intensive Care Med 42: 245–248.
Alp E, Erdem H, Rello J, 2016. Management of septic shock and severe infections in migrants and returning travellers requiring critical care. Eur J Clin Microbiol Infect Dis 35: 527–533.