An 11-Year-Old Girl With Acute Respiratory Distress Syndrome and Multi-Organ Failure Caused by a Tick-Borne Illness

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Abstract Borrelia tick-borne relapsing fever (TBRF) is a rare disease with a wide clinical spectrum, ranging from mild illness to multi-organ failure and death. TBRF is characterized by recurrent spirochetemia (see Figure 1), presenting as fevers lasting approximately three days that recur every 7-10 days. Treatment of TBRF can trigger the Jarisch-Herxheimer reaction (JHR), which manifests as transient worsening of symptoms shortly after initiating antibiotic therapy. The authors report a case of an 11-year-old pediatric patient with an unusually severe presentation of TBRF and JHR following administration of antibiotics prescribed for non-specific symptoms. The patient developed multi-organ failure, including pulmonary hemorrhage, acute respiratory distress syndrome (ARDS), severe metabolic acidosis, and acute kidney injury requiring intubation, mechanical ventilation, veno-arterial extracorporeal membrane oxygenation (VA ECMO), plasmapheresis for presumed thrombocytopenia associated multiple organ failure (TAMOF), and continuous renal replacement therapy (CRRT). The patient showed rapid improvement in acidosis and thrombocytopenia, with normalization of end-organ function, allowing for decannulation from VA ECMO, extubation, and discontinuation of CRRT within five days. She was discharged home on a 14-day course of doxycycline to complete treatment. This case underscores the importance of early recognition and treatment of TBRF and JHR, as well as the extensive multidisciplinary care required to optimize outcomes for critically ill pediatric patients. Figure 1. Spirochetes and burr cells on peripheral smear

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