Tick-borne relapsing fever (TBRF)

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    Last update: October 2022



    TBRFs are caused by different Borrelia species. They are endemic in temperate and warm regions of the word, especially in Africa (Tanzania, DRC, Senegal, Mauritania, Mali, the Horn of Africa) and mainly in rural areas. TBRF is a major cause of morbidity and mortality in children and pregnant women. The mortality rate for untreated TBRF ranges from 2 to 15%.

    Clinical features

    The clinical manifestations and complications of TBRF are similar to those of LBRF but central nervous system (CNS) involvement (particularly lymphocytic meningitis) is more frequent than in LBRF and the number of relapses is higher.


    The clinical diagnosis is difficult, especially during the first episode: cases occur sporadically rather than in outbreaks; the tick bite is painless and usually unnoticed by the patient; symptoms are very similar to those of malaria, typhoid fever, leptospirosis, certain arbovirosis (yellow fever, dengue) or rickettsiosis, and meningitis.


    • As for LBRF, the diagnosis is confirmed by detection of Borrelia in the patient’s blood.
    • Repeat the examination if the first smear is negative despite strong clinical suspicion.
    • In all cases, rapid test for malaria in endemic regions (and antimalarial treatment if needed, see Malaria, Chapter 6).


    • Antibiotic treatment:
      doxycycline PO for 7 to 10 days

    Children under 45 kg: 2.2 mg/kg (max. 100 mg) 2 times daily 

    Children 45 kg and over and adults: 100 mg 2 times daily 

    azithromycin PO for 7 to 10 days (if doxycycline is contra-indicated or not available)

    Children: 10 mg/kg (max. 500 mg) once daily

    Adults: 500 mg once daily


    ceftriaxone IV a Citation a. For IV administration of ceftriaxone, dilute with water for injection only. for 10 to 14 days (for pregnant women or in case of CNS involvement)

    Children: 50 to 75 mg/kg (max. 2 g) once daily

    Adults: 2 g once daily


    • Treatment of pain and fever (paracetamol PO) and prevention or treatment of dehydration in the event of associated diarrhoea.



    Antibiotic treatment can trigger a Jarisch-Herxheimer reaction with high fever, chills, fall in blood pressure and sometimes shock. It is recommended to monitor the patient for 2 hours after the first dose of antibiotic, for occurrence and management of severe Jarisch-Herxheimer reaction (symptomatic treatment of shock). Jarisch-Herxheimer reaction appears to occur more frequently in LBRF than in TBRF.


    • (a)For IV administration of ceftriaxone, dilute with water for injection only.