Meningitis as a possible feature of the Jarisch-Herxheimer reaction in leptospirosis

The Jarisch-Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis

Within 24 hours after antibiotic treatment of the spirochetal infections syphilis, Lyme disease, leptospirosis, and relapsing fever (RF), patients experience shaking chills, a rise in temperature, and intensification of skin rashes known as the Jarisch-Herxheimer reaction (JHR) with symptoms resolving a few hours later. Case reports indicate that the JHR can also include uterine contractions in pregnancy, worsening liver and renal function, acute respiratory distress syndrome, myocardial injury, hypotension, meningitis, alterations in consciousness, seizures, and strokes. Experimental evidence indicates it is caused by nonendotoxin pyrogen and spirochetal lipoproteins. Mediation of the JHR in RF by the pro-inflammatory cytokines tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 has been proposed, consistent with measurements in patients' blood and inhibition by anti-TNF antibodies. Accelerated phagocytosis of spirochetes by polymorphonuclear (PMN) leukocytes before rise in cytokines is responsible for removal of organisms from the blood, suggesting an early inflammatory signal from PMNs. Rarely fatal, except in neonates and in pregnancy for African women whose babies showed high perinatal mortality because of low birth weight, the JHR can be regarded as an adverse effect of antibiotics, necessary for achieving a cure of spirochetal infections.

The Jarisch-Herxheimer reaction in leptospirosis: a systematic review

Background

Leptospirosis is an endemo-epidemic zoonotic disease associated with potentially fatal renal, cardiovascular or pulmonary failure. Recommended treatment includes antibiotics, which may induce a Jarisch-Herxheimer reaction (JHR). Since little information on the importance of this adverse event is available, we performed this review to quantify frequency and impact of JHR in leptospirosis management.

Methodology/Principal Findings

This review systematically summarizes the literature on the JHR in leptospirosis. To approach the broader aspects of the subject, articles considering the treatment of leptospirosis, national leptospirosis guidelines and textbook and technical reports of the World Health Organisation were reviewed. Publications describing JHR in leptospirosis are very limited and consist mainly of single case reports and small case series. A single randomized control trial specifically assessed the JHR occurrence, but it has never been systematically investigated in large trials. Not all guidelines and not all literature on leptospirosis mention this reaction which can be fatal.

Conclusions/Significance

Although generally assumed to be a rare event, the true prevalence of JHR in leptospirosis is unknown and the awareness of this event is insufficient. All leptospirosis guidelines and local leptospirosis protocols should stress on systematic monitoring for clinical status early after antibiotic administration. Large well designed studies are required to precise the incidence and the impact of JHR as well as the severity and rates between various antibiotics.