Chills, a rise in temperature, headaches, myalgia, exacerbation of skin rashes and other symptoms can occur within 24 hours of starting antibiotic treatment for spirochaetal infections. This is known as a Jarisch-Herxheimer reaction, which is named after two dermatologists who first observed such reactions at the end of the 19th century in syphilis patients treated with mercury preparations. The reaction is attributed to the treatment-related disintegration of a large number of pathogens and the release of spirochaetal lipoproteins, leading to the activation of the immune system and an inflammatory reaction (1).
Jarisch-Herxheimer reaction during antibiotic treatment of spirochaetal infections
Incident data |
Description |
|---|---|
Year: 2015 Age group: adult Sex: female Medicinal product: Ceftriaxone Active substance: Ceftriaxone Indication: Suspected typhoid fever / later confirmed as leptospirosis ADR: Jarisch-Herxheimer reaction Outcome: recovering |
A literature report (2) describes a case of familial leptospirosis after a trip to Thailand, during which river water had been swallowed during rafting. The report concerns a 43-year-old woman who presented to her doctor with headaches, non-bloody, watery diarrhoea, a fever of 39.8 °C with chills, myalgia, arthralgia and abdominal pain. Since typhoid fever was initially suspected, empirical treatment was started with ceftriaxone. Her haemodynamic status subsequently deteriorated and was accompanied by the onset of a transient maculopapular rash and mild conjunctival hyperaemia. The new symptoms, the history and the haemodynamic instability after the initiation of the treatment with ceftriaxone pointed to a Jarisch-Herxheimer reaction. Leptospirosis was later confirmed by specific laboratory tests. The patient's condition slowly started to improve, and the antibiotic therapy with ceftriaxone was continued without any other measures. The outcome of the Jarisch-Herxheimer reaction was documented as an improvement in her condition (recovering). Leptospirosis was also diagnosed in the patient's 15-year-old son who was also on the rafting trip in Thailand, and his treatment with meropenem and doxycycline also triggered a Jarisch-Herxheimer reaction. |
Summary and recommendation
In some patients with spirochaetal infections, a Jarisch-Herxheimer reaction can occur shortly after the start of antibiotic treatment. This reaction occurs most frequently in patients with early syphilis (3). Isolated incidents of the reaction have also been reported in connection with other infections, e.g. Whipple's disease (4).
In the WHO global database of suspected adverse drug reactions, most cases of Jarisch-Herxheimer reactions were reported in connection with doxycycline, ceftriaxone and benzylpenicillin.
The reaction usually follows a self-limiting course or can be treated symptomatically. If such a reaction occurs, the antibiotic therapy should not be discontinued because it is an indication of the efficacy of the antibiotic treatment (5).
Statutory duty of healthcare professionals to report adverse drug reactions (ADRs)
In Switzerland, healthcare professionals who are authorised to dispense or administer medicinal products are obligated to report severe and/or previously unknown side effects. Reports to Swissmedic can be entered and sent in the Electronic Vigilance Reporting Portal “ElViS” (ElViS login).
References
- 1 Butler T. The Jarisch-Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis. Am J Trop Med Hyg. 2017;96(1):46-52.
- 2 Gallardo C, Williams-Smith J, Jaton K, Asner S, Cheseaux JJ, Troillet N, et al. [Leptospirosis in a family after whitewater rafting in Thailand]. Rev Med Suisse. 2015;11(470):872-6.
- 3 Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
- 4 Giger RT, T.; Gross, A.; Guevara Pineda, C.; Berg, J.; Lippuner, N. Morbus Whipple. Swiss Medical Forum. 2016;16(9):219-21.
- 5 Information for healthcare professionals (www.swissmedicinfo-pro.ch)
Reporting adverse drug reactions
Electronic reports via the ElVis portal
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