What is Jarisch-Herxheimer Reaction?
The Jarisch Herxheimer reaction (JHR) was first mentioned in medical records in the late 1800s by Adolf Jarisch, an Austrian skin doctor, when he observed a worsening of skin sores on a patient with syphilis after they started treatment using a mercury-based medicine. Later in the early 1900s, Karl Herxheimer, a German skin doctor, reported a similar experience.
JHR is a temporary condition that can occur in people infected by a type of bacteria called spirochetes, who are taking antibiotic medication. This reaction usually occurs within 24 hours of starting antibiotic therapy for infections caused by these bacteria, including syphilis, leptospirosis (a bacterial disease that can affect humans and animals), Lyme disease, and relapsing fever. Symptoms often include fever, chills, shivering, feeling nauseous and potentially vomiting, headache, fast heart rate, low blood pressure, fast breathing, redness of the skin, muscle pain, and worsening of skin sores.
It’s important to be aware that JHR is a short-term condition that goes away on its own, and it’s crucial to recognize it and not confuse it with allergic reactions or sepsis (a dangerous complication of an infection), as these can potentially be life-threatening.
What Causes Jarisch-Herxheimer Reaction?
Syphilis is the main disease related to a condition called the Jarisch-Herxheimer reaction (JHR). The Jarisch-Herxheimer reaction, first described in cases of syphilis, is an adverse response to treatment observed in patients with various other infections caused by bacteria, fungi or tiny organisms called protozoa. Some other infections known to cause JHR are Lyme disease, a recurring fever caused by lice, leptospirosis, and another recurring fever caused by ticks.
The antibiotics most commonly linked to causing JHR are penicillins, tetracyclines, and erythromycin. However, newer infection-fighting drugs like cephalosporins, levofloxacin, ciprofloxacin, clarithromycin, meropenem, and azithromycin can also trigger the Jarisch-Herxheimer reaction.
Risk Factors and Frequency for Jarisch-Herxheimer Reaction
The occurrence of the Jarisch Herxheimer reaction (JHR), which can vary based on age, sex, and other factors, hasn’t been thoroughly researched. Still, we do have some information about how often it happens in the general population in relation to different diseases. The reaction can occur quite frequently in certain stages of syphilis but is less common in other conditions like Lyme disease and leptospirosis.
- In syphilis, JHR occurs in 55% of cases where the person tests negative for the disease (seronegative), 95% of cases where the person tests positive (seropositive), and 95% of secondary syphilis cases.
- JHR is typically not seen in latent (hidden) syphilis. It is also quite rare in the late stages of the disease, except in patients with general paresis of the insane (a severe neurological disorder), where it can occur in 75% of cases.
- In Lyme disease, the occurrence of JHR ranges from 7% to 30%, which is much less frequent than in syphilis.
- In patients with leptospirosis who are treated with an antibiotic, JHR occurs around 9% of the time.
- In tick-borne relapsing fever cases, JHR occurs 39% of the time. In contrast, for individuals with louse-borne relapsing fever, JHR can occur anywhere from 37% to 100% of the time based on different antibiotics used.
Signs and Symptoms of Jarisch-Herxheimer Reaction
The Jarisch Herxheimer Reaction (JHR) is a response that can happen when treating certain bacterial infections with antibiotics. It can often be missed because its symptoms such as fever, chills, body aches, and skin rashes are similar to those of the underlying infection. There’s also a chance it may be mistaken for an allergic reaction to antibiotics. Medical caregivers need to be ready for the possibility of JHR when treating certain diseases caused by spiral-shaped bacteria. This could mean paying close attention to vital signs and providing supportive care. The typical situation is a patient feeling worse (having more fever, shivers, and rashes) a few hours after taking antibiotics for such bacterial diseases.
JHR is usually marked by three short-term events:
- Changing body temperature
- Increase in symptoms
- Changes in bodily functions
The changing body temperature often shows up as cycles of high fever (38-41 degrees Celsius), along with flu-like feelings such as feeling unwell, headaches, and chills, and sore throat, followed by sweating and end of fever.
During the increase in symptoms stage, symptoms can get worse. This could look different depending on the stage of syphilis, a common disease caused by these spiral-shaped bacteria. There could be swelling and sores around the initial sore in early syphilis. In the second stage, the rash may become more noticeable. In late syphilis, there may be worsening of problems linked to the various affected body systems. Patients with certain brain-related conditions may have their psychological symptoms, seizures, or specific neurological symptoms become worse. Those with nerve damage in the spine may experience increased pain, constipation, and trouble urinating. Late syphilis and involvement of organs can lead to serious, possibly life-threatening complications during JHR.
Physical changes in JHR often start as narrowing of blood vessels, increase in blood pressure, and fast breathing. Later, there may be low blood pressure due to widening of blood vessels and reduced resistance in the blood vessels on the body’s periphery.
JHR usually happens a few hours after the first dose of antibiotics and tends to get better within 24 hours, even without specific treatment. How severe JHR is can depend on the amount of bacteria in the body. The definition of JHR could be expanded from its typical symptoms (fever, chills, and worsening rash) to include a number of serious problems such as breathing issues, brain inflammation, kidney and liver problems, heart damage, early contractions in pregnant women, and declining brain function.
Testing for Jarisch-Herxheimer Reaction
The Jarisch-Herxheimer Reaction (JHR) is a temporary and reversible condition that a doctor can diagnose based on your medical history and physical examination. However, some patients may show signs of low lymphocyte counts, increased white blood cells, and a higher than normal Erythrocyte Sedimentation Rate (ESR), which measures inflammation in the body, in lab tests. Typically, no specific tests are needed for this condition. But if a patient experiences an unusual response to antibiotics and has risk factors, a test for syphilis may be required.
Treatment Options for Jarisch-Herxheimer Reaction
If you experience a mild reaction to some treatment, it typically clears up on its own within a day. During this time, doctors will keep a close eye on you and help manage any symptoms you may have. Research suggests that medications that target a protein in your body called TNF-alpha, or in some cases steroids, can help prevent these reactions. One study found that patients who got a TNF-alpha blocker before treatment had less of a temperature spike, steadier blood pressure, and a slower heart rate. This medication also reduced the levels of certain proteins involved in inflammation in the body. While over-the-counter pain relievers like acetaminophen can help ease symptoms or shorten the length of the reaction, they can’t prevent the reaction from happening in the first place. Your healthcare team should let you know about the possibility of this kind of reaction.
You will be monitored closely for any changes in your vital signs, as this may indicate the need for intravenous fluids and other kinds of support. If you have severe reactions related to a bacterial infection called leptospirosis, part of your treatment may include intravenous fluids, steroids, medications to help support your blood pressure, and occasionally temporary dialysis.
If you’re a pregnant woman being treated for a bacterial infection called syphilis, there’s a relatively high chance that you may have this sort of reaction – about 40%. If you’re in this situation, your doctor may need to monitor your baby’s heartbeat more often because this kind of reaction can cause changes in the baby’s heart rate. Other strategies can be used to reduce your chance of having a reaction and improve your overall outcome. For example, your healthcare provider might choose a specific type of antibiotic, like azithromycin, especially if you’re a person with HIV being treated for early-stage syphilis.
What else can Jarisch-Herxheimer Reaction be?
If a person has had a prior spirochetal infection and been treated with antibiotics, and they start experiencing symptoms like fever and rash, nausea and vomiting, chilly feelings, headache, increased heart rate, and sometimes low blood pressure, the following health conditions could be considered because they share similar symptoms:
- Allergic reaction to antibiotics,
- Deteriorating infection or sepsis,
- An illness caused by a virus,
- Previous drug reactions, particularly to penicillin.
It’s important to understand that people who are allergic to penicillin often have widespread hives and increased numbers of a type of white blood cell called eosinophils, or they may have specific antibodies to penicillin in their blood. Occasionally, someone might find out that they have underlying syphilis when they start showing temporary Jarisch-Herxheimer reaction (JHR) symptoms while being treated with antibiotics for another infection, like gonorrhea.
What to expect with Jarisch-Herxheimer Reaction
Normally, recovery happens quickly and the treatment plan can be continued. Sometimes, a reaction known as Jarisch Herxheimer can occur, which can be life-threatening. This reaction can cause a severe drop in blood pressure, leading to sudden damage and failure of vital body organs.
Possible Complications When Diagnosed with Jarisch-Herxheimer Reaction
In the early stages of Syphilis, the symptoms are usually mild and not too bothersome. However, in the late stages, the symptoms can become serious and require hospital-based care. In cases of Neurosyphilis, it can cause epilepsy or specific neurological deficits. In a serious condition called General Paresis of the Insane, the patient may suffer from temporary psychosis.
Additionally, cardiovascular syphilis can lead to heart failure or even the rupture of an aortic aneurysm, leading to sudden death. There have been cases where acute pulmonary hypertension occurred after a Jarisch-Herxheimer Reaction (JHR). If Syphilis affects the larynx, a surgical procedure to aid breathing, like a tracheotomy, might be necessary due to local swelling. For late-stage pregnancies, it is advisable to monitor the health of the baby.
Common Side Effects:
- Mild symptoms in early stages
- Requires hospital care in late stages
- Can cause epilepsy or neurological deficits
- May result in temporary psychosis
- May cause heart failure or rupture of aortic aneurysm
- Can result in acute pulmonary hypertension following a JHR
- Potential for local swelling requiring tracheotomy in laryngeal involvement
- Advised to monitor baby’s health in late-stage pregnancies
Preventing Jarisch-Herxheimer Reaction
Patients should be appropriately informed about something called the Jarisch Herxheimer reaction (JHR). This is a situation that can happen when you’re being treated for diseases like syphilis or Lyme disease. Most of the time, JHR is short-lived and harmless. However, if symptoms like fever and skin rashes occur, patients should seek medical attention quickly. This is because emergency treatments, including assistance with hydration and heart function, may be needed.
It’s also vital to discuss any known drug allergies with your doctor. People who are at higher risk, such as those with a brain infection due to syphilis (neurosyphilis) and pregnant women, should get treated in a hospital setting. This ensures quick management of any potential unwanted effects of the treatment.
