Relapsing fever in a traveller returning from Senegal.

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Date: Feb. 22, 2021
Publisher: CMA Impact Inc.
Document Type: Clinical report
Length: 2,280 words
Lexile Measure: 1730L

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A 24-year-old man presented to his family physician with a 1-day history of subjective fever, chills, headache, myalgia, arthralgia and mild diarrhea; he was advised to proceed to the emergency department for further assessment. On arrival at our Vancouver-area emergency department, his temperature was 38.3[degrees]C (maximal documented temperature 38.4[degrees]C), blood pressure 117/67 mm Hg, heart rate 88 beats/min and respiratory rate 16 breaths/min. He was diaphoretic but appeared otherwise well.

The patient had been travelling extensively and had returned home 9 days earlier. Eight months previously, he had embarked on a solo trip that began in Europe before he continued on to Morocco and finally spent several weeks in Senegal. He had not received any pretravel medical counselling or vaccinations and did not take malaria chemoprophylaxis. While in Senegal, he had stayed in a small village and was housed by locals. He ate local food and drank from the local water supply. Most of his time was spent participating in cycling tours of the area. He had no sexual contacts and was not in close proximity to anyone who was sick. The patient noted that there were many dogs in the village, and many were visibly infested with ticks. Midway through his stay, he experienced an "insect bite" to the leg, which became pruritic and red. He then had 4 days of subjective fever, chills and headache. He sought medical attention at a local health care facility, where a moist gauze that smelled of gasoline was applied to the area of the lesion. A thick, white "worm" 2 cm in length was extracted and the patient's systemic symptoms subsequently resolved without further treatment. A week later, he departed Senegal on a repatriation flight to Canada amid the coronavirus disease 2019 pandemic.

The patient was noted to be febrile at the time of blood collection. Complete blood count showed a normal leukocyte count (9.7 * [10.sup.9]/L), but low lymphocytes of 0.8 (normal 1.2-3.5) * [10.sup.9]/L; his thrombocyte count and hemoglobin were normal. The results of his electrolyte, liver function and transaminase tests were all within normal range. His C-reactive protein level was elevated at 116 (normal range < 3.1) mg/L. Given the patient's travel history and recurrent fever, malaria was high on our differential diagnosis, as was infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We obtained a nasopharyngeal swab for SARS-CoV-2 testing and ordered urgent malaria testing. At our regional facilities, malaria testing is performed using a rapid antigen test and preliminary screening of Giemsa-stained thin smears. If these initial tests are negative, samples are forwarded to a centralized centre for polymerase chain reaction (PCR) testing and comprehensive review of thick and thin blood smears. In the case of our patient, the rapid antigen test was negative and no malaria parasites were seen on the thin smears; however, the emergency department physician later received a call from the laboratory, identifying spirochetes (Figure 1).

Box 1: Medically important spirochetes Genus Syndrome(s) Borrelia * Lyme borreliosis * Tick-borne relapsing fever *...

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Gale Document Number: GALE|A652687849