Jarisch-Herxheimer Reaction in Lyme Disease

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The Jarisch-Herxheimer reaction (or herx for short) is an inflammatory response to antibiotic treatment for certain diseases (although some non-antibiotic treatments can produce the reaction). It’s also referred to as a “healing crisis” or “die-off,” meaning a detoxification of dead or dying bacteria and other pathogenic organisms in the body.

A Herxheimer reaction feels like a worsening of illness symptoms and can include:

  • fever
  • sweating and chills
  • rapid heart rate or palpitations
  • shortness of breath
  • muscle and joint aches and pains
  • headache
  • brain fog
  • insomnia
  • swollen glands
  • ringing in the ears
  • sinusitis
  • itching
  • digestive issues
  • unstable emotions
  • general feeling of sluggishness

Blood pressure increases early in the reaction, but then usually drops quickly. Any rashes present before drug treatment can get worse. Hives are also possible. Most people usually have mild symptoms of sleepiness and fatigue. But a herx can also cause serious side effects such as seizures and anaphalactic shock.

Herxing can come on quickly or grow in intensity over the course of several days. It can last from a day to a week or two in rare cases. Over time a person’s reactions decrease as their load of infection goes down.

This effect happens with only a few diseases. The first disease associated with herx was syphilis. In fact, syphilis was the subject of the original scientific papers by Austrian dermatologist Adolf Jarisch and German dermatologist Karl Herxheimer, who each studied the effects of mercury treatment for syphilis at the turn of the 20th century. Similar reactions have been found to occur in two kinds of borreliosis (Lyme disease and relapsing fever), brucellosis, Q fever, and trypanosomiasis.

Why It Happens

A person with one of the herx-causing infections has a certain number of tiny foreign organisms in their body. The number of infectious organisms can be in the thousands or millions. Each individual organism is made up of its own cell with its own internal structure and contents. If that cell dies through an attack by the immune system or an antibiotic drug, it bursts open and releases its contents. Millions of cells bursting at the same time introduces a significant amount of cellular material in the body. These spilled contents cause the reaction, When the spilled contents are cleared from the body, the reaction stops.

Historically, the theory has been that the reaction is caused by dying organisms releasing endotoxins.  Recent experimental research suggests that the rapid and massive overstimulation of the patient’s immune system causes the symptoms. The immune system’s job is to recognize and attack foreign antigens in the body. When dead organisms spill their internal contents, a huge number of foreign antigens become present all at once. The body reacts by releasing immune system modulators (or cytokines) (e.g., Interleukin 6, Interleukin 8, and tumor necrosis factor, among others). These cytokines are what cause the fever, chills, and low blood pressure. Either way, the body gets assaulted and fights back.


It’s important if you’re starting antibiotic treatment for Lyme Disease to discuss the herx die off with your doctor. You’ll also need detox support for your liver, adrenal glands, and gut to help escort the dead bacteria out of your body. You should also discuss with your doctor any additional vitamins and supplements you may already be taking. Be aware that taking too many drugs at once, prescription and over-the-counter, can be very dangerous.

Not everyone treated for Lyme has a healing crisis. It depends on things like your load of infection, your unique body chemistry, and your reaction to the specific medications you’re taking. Most people who do herx have mild to moderate symptoms that can be uncomfortable but tolerable and lessened with:

  • rest
  • pain management (aspirin, NSAIDs, acetaminophen, Alka Seltzer Gold)
  • probiotics
  • antioxidant support
  • herbal teas
  • lots of water with lemon juice
  • enemas and colonics
  • hot Epsom salts or steam baths
  • massage therapy
  • listening to relaxing music
  • yoga or moderate walking

A word of warning: Doctors who aren’t familiar with herx-causing diseases like Lyme may mistake a strong die-off for an antibiotic allergic reaction. That’s why it’s important to talk about it with your doctor before starting antibiotic treatment. If your doctor has never heard of Herxheimer or downplays any strong, non-allergic reaction you may get from taking antibiotics, you should think about finding another doctor.

While uncomfortable symptoms usually subside in a few days to a week, you should be on the lookout for symptoms that could be life threatening, Serious herxing includes a large drop in blood pressure and difficulty swallowing or breathing. A few people have had seizures on antibiotics for Lyme. If any of these things happen, stop taking your medications immediately and call your doctor or go the the Emergency Room. Once the die-off has cleared, you’ll probably be able to go back on your medications slowly. Or change to another more compatible medication. Everyone is different. You and your doctor have to see what works best for you.

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330 Responses to “Jarisch-Herxheimer Reaction in Lyme Disease”

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  1. Serena Says:

    Good morning, I was diagnosed with Lyme on Dec 14th. I just had my first treatment on Friday the 4th through an IV. She wants to do the IV once a week. I’m also taking supplements to aid the process and build up my immune system. I went through a Herx yesterday and felt so bad. My one concern is that I’ve been experiencing air hunger for a week now and want it to go away. Anyone taking anything for it or will it go away as the bacteria dies off. Also I have a good doctor but would be interested in a Lyme Literate Doctors opinion. I live in the DC area.


    • Pam Dodd Says:

      I’m sending you DC-area Lyme info, Serena. Glad you’re being treated. Air hunger is usually a symptom of Babesia, one of the common co-infections of Lyme. the others are Ehrlichia, Bartonella, and Anaplasmosis. Have you also been tested for these?

      Thanks for asking.


  2. Christine N. Says:

    I was recently diagnosed with Lyme and told I’ve had it for 6-8 weeks. I was prescribed 3 weeks of doxy and yesterday, after a week, had a herx like reaction. Feeling much better today, but had no idea what was happening until a friend clued me in. Primary care also did not check for any accompanying infections. Seeking specialist info in MD! Thanks!


    • Pam Dodd Says:

      Maryland Lyme info coming up shortly, Christine. I’m glad you’re pursuing this further; three weeks of Doxy is rarely enough to get rid of Lyme. Thanks for asking.


    • John Benson Says:

      I have found that with the use of a holistic doctors to assist in immune support has been critical to my success during Herx reaction and day to day support to keep my Lyme at bay. Six years I have battled and continue to battle with Babisiosis and Lyme. It’s a long road but low carb and gluten free diet helps.

      DRINK plenty of water especially during Herx and long hot showers or baths.


  3. Barb Says:

    I believe I have has lyme for 5 years. Just tested positive for lyme Igg through Igenex but my regular GP does not endorse this lab. Having many neuro symptoms and under a lot of stress. Looking for LLMD in Chicago area/suburbs and willing to travel to Wisconsin as well.

    Thank you,


  4. Charlie Says:

    I am an avid outdoorsman and have traveled throughout the US and been bitten several times in various states. I was diagnosed with Lyme disease this past Tuesday and also have Babesia and Bartonella. I started Doxycycline 100mg 3xday along with Metrodiazinole 500mg 3xday along with some supplements to aid with Detoxification. I started experiencing elevated heart rate, bloating and naseua the next day and it has increased in intestity along with increaed muscle aches, headaches, fatigue and general slugggishness. I have a call in to my Dr. to confirm this a likely herx reaction. I am wondering how long this reaction typically lasts and what point I need to be concerned? The Dr. I am seeing now has been described as a Lyme expert but I am curious if you are aware of any Lyme specialists in Ohio?


    • Pam Dodd Says:

      A herx should taper off, Charlie, but there’s no typical length of time. Many people find Metrodiazinole (Flagyl) a tough drug to take; in my experience 500 mg 3X a day is a lot, especially if you’re just beginning Lyme treatment. Hopefully your doctor will tell you to back off on the Flagyl to see if your symptoms subside to within tolerable limits. It’s good to be killing the cyst versions of Lyme, which is what Flagyl does, but only at a rate that your body can handle, even with supplements to aid the detox.

      I’m sending the Ohio Lyme info I have so you can check out who the Lyme-literate doctors are in your state. Thanks for asking.


      • michelle Says:

        Hi Pam, I live in the Upstate ny area could u please send me some info on lyme literate dr”s nearby me. I’ve been dealing with lyme since 2007 now diagnosed with autoimmune (lupus)?? I had a positive punch biopsi for lupus after dealing with the lyme. Not sure how accurate those tests are. Thank u I will take any info u have.

      • Pam Dodd Says:

        NY State Lyme info is being sent shortly, Michelle. Thanks for asking.

  5. lori s Says:

    do you know of any lyme disease doctor’s in newport r.i or in that area?thank you.


  6. Cindy Says:

    Pam, in 2009 my husband came down with a very bad stomach. Then later that year he started having pain in the muscles in the plexus area. Dr thought he pulled a muscle, because he travels a lot so he put him on anti inflammatory med. pain did not get better. After a while he stopped using his arm because of the pain. Eventually he started having muscle atrophy in the deltoid muscle and started having some speech problems. Long story short, we have been to many doctors, even mayo clinic, where he had a positive Lymes test, but rerun and came back negative. Conclusion is possible ALS, but not 100%. We found a Lymes specialist in our area and he has run three different tests all have been positive in three particular bands on all three tests. Needless to say, we are being treated for Lymes by Doxycycline. He has been feeling really bad, had numbness in face, tongue and a lot of pain in the arm and muscles where all this started. Since his treatment began for Lymes, he has had pain, cramping in stiffness in the areas this all began. He grew up on a lake in Arkansas and has been bit by many ticks. After all this info….is it possible that where all his pain began is where the lymes has placed itself for years and decided to attack at his weak point and caused all these problems??? Our doctor did tell us that Lymes mimics ALS and several neuromuscular diseases.

    Thanks for your help,


    • Pam Dodd Says:

      Cindy, Lyme can cause all kinds of symptoms, both at the bite site and elsewhere. Your husband may be experiencing a herx reaction from the Doxy, which can cause more symptoms. It shouldn’t last a long time, however, as his Lyme load goes down. You didn’t mention if he’s also been tested for the common co-infections that often come with Lyme (Babesia, Bartonella, Ehrlichia, and Anaplasmosis). If he hasn’t been tested for these yet, he should be. Most can cause other symptoms and require other treatment than Doxycycline.

      If you’d like to get another doctor’s opinion, tell me where you live and I’ll send you info on how to find one. Thanks for asking.


  7. Beth Says:

    I had a tick on me…for probably at least 24 hours…bullseye red ring/itching…I live alone, it was on my back, I used a mirror to look and thought it was a mole…anyway…when I got to the emergency room they gave my Doxy and I took it for 28 days….that was 3 months ago…I know have a swollen gland under my armpit…and my knee hurts…I just don’t feel right…I’m normally very energetic and never sick…I went to my GP today and he’s going to do an ultrasound on the armpit gland…to see if it’s a cyst or a swollen gland…I’m thinking the Lyme is back…and from everything I read here, it seems so possible….I live near Houston, Texas…can you recommend a Lyme literate doctor I can go to??


    • Pam Dodd Says:

      TX Lyme info is on its way, Beth. While a month of Doxy can get rid of Lyme, it’s possible you have other infections that came with it. Most people with Lyme also have one or more of these: Babesia, Bartonella, Ehrlichia, Anaplasmosis, and Mycoplasma. Thanks for asking.


  8. Linda Says:

    Thank you so much for this article. I’m in fairly early stage of lyme, 2 – 3 months and I really want to kick butt on this thing right NOW. My GP have me Doxy 100mg x2 daily for 14 days. I asked if that would be enough and he said yes. Well it has been 10 days and I’m no better and from all the online info I’ve read I know I need a much larger dosage and much longer period. I live alone and have no family so it is really scary being this sick. I’d really like to find a doctor that specializes in this disease and isn’t afraid to be aggressive with the treatments. I live in Southwest Missouri, near Springfield. Thanks, Linda


    • Pam Dodd Says:

      Linda, MO Lyme info coming up. Thanks for asking. Make sure you find a doctor who can not only treat Lyme adequately but also knows how to diagnose it correctly since most people with Lyme have other co-infections too, like Babesia, Bartonella, Ehrlichia, and/or Anaplasmosis.


  9. Danielle Says:

    Thanks for the info on Herx. My husband has Lymes and is being treated by an ND but suffering pretty substantial Herx. We are headed back to the ND today to discuss. We never heard of Herx till he mentioned it.




  10. Stephanie Says:

    I’m relieved to find good information on this disease. I began treatment about 3 months ago, and need to find a LLMD near me. Nothern Idaho/Eastern Washinton. Please. Thank you!! Thank you for all your efforts, Stephanie


  11. Karen Says:

    I’m sorry … I forgot to mention: I’ve used all kinds of things for the rash and itch, including Aveeno’s anti-itch lotion which I discovered when I had poison ivy. I’ve used sparingly a little prescription steroid cream. One of the best things I discovered is a rosacea product — from Rosacea Care, a spray containing strontium and willowherb. It especially helped my face when the rash started there on my cheeks. It also comes in lotion or serum form, but the spray is great because it’s so lightweight.


  12. Karen Says:

    So appreciative to have found your site. I was bitten in early December 2011 and immediately developed the EM as well as a poison ivy-type rash that quickly worsened.

    Long story short: After 6 1/2 weeks of amoxicillin then doxy (with prednisone in between and after doxy for the god-awful rash and itching head to toe), another 4-6 weeks of slowly getting back to my normal energy (I’ve had CFS since early 90’s). I knew it was more than possible this round of antibios didn’t clear the infection, but I hoped getting onto meds so quickly would do so (of course, I’ve since learned that the prednisone killed my own immune system working on the bacteria, so no wonder one round didn’t do the job).

    Then for another 4-6 weeks, increasingly tired, all-over body pain and aches, knee pain, elbow pain, etc., I woke one morning to the bad hives/rash starting in same area of one arm as the original rash/hives developed. Once again, the rash quickly spread. Went back on doxy within 36 hours of seeing rash.

    After initial relief following just 3 doses, I went downhill rapidly. Continued with doxy until the widespread skin inflammation, rash, hives again appeared and started itching … which scared me as the original situation drove me nearly insane.

    Since my dr. is out of town, I decided to err on side of caution and stopped doxy (even though concerned bacteria might become resistant) … afraid to continue without knowledgable medical supervision close at hand.

    It occurred to me the first go-round that I wasn’t allergic to the antibiotic but was having toxic die-off. As I read more and more on LD, became more convinced that’s what was going on. I’ve been off doxy now for two full days, and although the rash, inflammation, hives decreasing, my skin is still very traumatized and periodically, the unbearable itching cranks up in one place or another.

    Knowing a bit about detoxing, I’ve been using quercetin, Benedryl, cat’s claw (with POA), Tri-Salts, lemon in water, some aspirin, loads of probiotics (which I take regularly but upped), modifilan, etc. A couple of hot baths and showers when my skin could tolerate.

    Both the first cycle and this recurrance, the worst areas are on my arms, especially the right arm (which was horribly affected by a poison ivy infection that went systemic about 13 years ago — my holistic MD said my dermal lymphatics were apparently damaged and that’s why this infection has so infiltrated the same areas). The tick bite was on my left midriff, which I figure is why my reaction started in upper body, not lower.

    Both cycles, my arms have just-visible and just-palpable tiny bumps under the surface of the skin. They never completely went away with first doxy treatment. Might these be the cystic form of bacteria? I kept expecting these bumps to come to surface and burst like blisters but they didn’t and haven’t. What’s your take on these bumps?

    Also, is the EXTREME itching I’ve had common? I’ve seen very little on any LD website about this … I’m talking itching so bad that I’ve said to friends the U.S. should forget any other torture methods, just set somebody down in a room full of ticks and in about a week, we would be able to learn whatever we wanted to, it’s that bad for me.

    Finally, while my holistic MD seems fairly knowledgable about Lyme (my internist refused to believe that I’d been bitten by a tick but if I had, I couldn’t have gotten Lyme because “we don’t have LD in Florida”) … this despite the photos I took of bull’s-eye rash (which had faded some by the time I got to dr., in part because I had started on amoxicillin already) … if you’ve got any doctors for Florida who really specialize in LD treatment, I’d sure like their names. My dr is too busy to really give me the time I think I need with him.

    Anyway, the day after I saw my internist, I discovered the tick crawling on my lower abdomen, apparently getting ready for lunch — I’m pretty sure my dog brought it into my bed, as I’d seen it on him a week or so prior but it was so small, I thought it was just a scab from perhaps running into a low-lying shrub’s poke. When I called my vet to report it, he told me that the past 6 months here have been the worst ever seen for ticks, and that so many of their patients have been infected, he contacted the local and state agencies about changing their vaccination recommendations … that, in fact, it is rampant in south-central Florida, in part because we never had any freezing temps this past winter.

    Oh, one last thing … I still have the tick, in a zip-loc bag, inside a pill bottle. It lived for nearly 3 weeks! Do you know if I could send it somewhere to be tested for which bacteria it carried?

    Many thanks … feel free to edit as you wish — I found it difficult to be concise. I have to say I have been stunned at how much info, how many blogs such as this, and websites for/by people effected by LD, there are … it’s far from a small or silent epidemic, but the healthcare industry continues to treat it as if it is.

    Again, thanks so much for all that you are doing,

    Karen B.
    Port St. Lucie, FL


    • Pam Dodd Says:

      Karen, rashes and itching are annoying recurrent symptoms for many people with Lyme. I’m sending you FL Lyme info so you can find someone who knows how to diagnose all that’s involved with Lyme correctly and treat it adequately. Thanks for your story and for asking.


  13. Greg Says:

    I can not find any help for the here in Delaware. I’ve been to almost every specialist you can imagine and seen some top docs at Johns Hopkins. They tell me I had Lymes in 2005 but was cured with a month of doxy. They now say I’m having vestibular migraines that are affecting my nervous system. I’ve become hypersensitive to meds and my quality of life sucks most days. I’m only 33. Any LLMD info would be great!


    • Pam Dodd Says:

      Greg, a month of Doxy rarely cures Lyme. I”m sending you MD/DE/PA Lyme info so you can find a Lyme specialist. Hang in. There is someone who will be able to help you. You should also be tested for the co-infections that often come with Lyme, Babesia, Bartonella, Ehrlichia, and Anaplasmosis. Thanks for asking.


    • nessa Says:

      hi my brother has lyme and really bad neurological symptoms. we also live in delaware and cannot get any help. they infectious disease doctor here calls us crazy. we did take him to [doctor’s name deleted] in howell nj. now he sees a lyme literate psychiatrist who is by far the BEST and very knowledgeable [doctor’s name deleted] in red bank nj. if u are experiencing neurological symptoms…see him also. do a lot of research, a few of our friends in delaware also have lyme and had to go out of state. hope it works our for you!


      • Pam Dodd Says:

        Thanks for commenting, Nessa. Sorry I had to deleted the two doctors’ names you mentioned. It’s a convention online not to name Lyme doctors to protect them from harassment by their state medical boards. The second doctors you name is well-known in the Lyme community. Good luck to your brother. I’m so glad he has you for support.

  14. Kathleen Says:

    I am 66 yo and probably contacted ticks 8-10 years ago, with no signs of bites (I’m in Minnesota). Last fall found an integrative med doc just when I needed her. Went to clinic with flaming, painful face, pain down neck and itchy arms. Nurse Practitioner asked if I had ever been tested for lyme. She knew I had been told I had chronic fatigue syndrome, which often is misdiagnosed. (also 3 spine,1 shoulder,and 1 breast surgery, radiation damage, fibro, arthritis, lots of muscle and nerve pain). Did a blood test, which was iffy accd. to former doc, and he said no tx. Yet the NP insisted. I switched to current doc and she ordered western blot test (she has treated close to 1000 people w/ lyme). Bingo! we started doxy but I failed after 2 wks. Doc then switched me to Samento and Banderol, herbal meds from Peru. She advised that these meds would kick butt more than doxy and coached me thru the tough herx times. Started having trouble w/ my eyes and doc sent me to a neuro opthamologist, who also has seen many lyme patients. I take probiotics, etc and use lots of lemon juice and fresh fruits. I feel heard and very supported and though I’m paying out of pocket and am low income, it’s worth it.

    I urge others to seek out integrative med docs, who are MDs also trained in herbals and other non-western meds.


    • Pam Dodd Says:

      Thanks for your advice, Kathleen. It’s great to hear you’re getting well with integrative medicine and just as important, that you feel heard and supported. So many people with Lyme have been told that they aren’t sick or are just anxious or stressed and to “get over it.” No one’s idea of compassion.


  15. Melissa Says:

    Hi. I think I just had a Herx reaction to antibiotics. Was being treated for strep throat (positive swab test), but the infection started in my armpit lymph node, worked it’s way up my neck, then got a sore throat. Was prescribed penicillin, felt horrible (all my joints popping especially my shoulders, had trouble swallowing, had chest pain and ended up in ER. Was sent home and was no better a few days later when I went to dr.’s office and was switched to a z-pack for 10 days. Felt horrible the first couple of days (similar to above) then started to feel better. The z pack wore off Thursday (2 days ago), I still felt great Friday (yesterday), woke up Saturday (today) and am starting to get the symptoms all over again. I had a tick bite last August and had negative Lyme disease results when I started having horrible headaches and sinus pain in October. After reading this site, I think I may have Lyme afterall. Would greatly appreciate a list of doctors in metro-west Boston. Thank you!


    • Pam Dodd Says:

      MA Lyme info is being sent shortly, Melissa. Sounds like checking out Lyme is a good idea. Thanks for asking.


  16. Pat S. Says:

    I’m beginning to believe lyme has been in me for many years. A couple of weeks ago my wife pulled a tick off my back and a rash appeared. Went to doc and was given doxy 100 mg twice a day. Took first at 7 PM. The next day my whole body hurt, even the rash, joint pain worsened knees, knuckles, neck, back, shoulders. Next I noticed a headache, my ribs hurt when I tried to bend down; these I hadn’t had before. Overall I would say my pain level rose 50%. I attribute this to herx. Good news it only lasted 12 hours at most. I have seen a multitude of MDs and basically have every disease know to man, Parkinson’s to arthritis. The more I read about lyme I cannot believe this is not a first line of exams. Also I’ve had myself tested three times in last ten years with no positives. And just one more piece good news I on my second day of antis and feel better already. Great site you have. Thanks.


    • Pam Dodd Says:

      Thanks for your kind words, Pat. Glad the Doxy is working. I agree, it’s hard to believe Lyme isn’t the first thing tested for in many cases. On the other hand, the standard CDC Lyme tests are famously unreliable, reporting a lot of false negatives. In fact, no Lyme test is 100% accurate. That’s why it’s important to see a doctor who knows how to diagnose Lyme correctly and treat it adequately if he/she thinks you have it.

      Re: your treatment, 100 mg of Doxy twice a day for 2-4 weeks is usually not enough to get rid of Lyme. You may feel better for a while, but then it will come back. Also you should be tested for the co-infections that often come with Lyme (Babesia, Bartonella, Ehrlichia, and Anaplasmosis). Most people with Lyme have at least one. These also need to be treated.

      If you tell me where you live, I’ll send you info on how to find a Lyme specialist hear you.


      • Dawn J. Says:

        I live in central MN (Alexandria)- do you know of a specialist in our area for lyme disease?

      • Pam Dodd Says:

        MN Lyme info coming up, Dawn. Thanks for asking.

      • Terese B. Says:

        I need a lyme specialist near me. I live in Boonville, California in Mendocino County. 2 & 1/2 hours north of San Francisco near the coast of Mendocino. Please advise if you know of a specialist in my area.

        Thank you in advance.


      • Pam Dodd Says:

        I’m sending CA Lyme info ASAP, Terese. Thanks for asking.

  17. Kate Says:

    Hey. I have been having some weird neurological symptoms that have been chalked up to general stress (had bell’s palsy and numbness in my whole right side, went to the ER, CT and MRI were fine, blood was fine too) but the doc on call put me on doxy just to be sure) and when I completed ten days worth of doxy my right side froze up like crazy. I never had any stage 1 Lyme symptoms–but I pulled out plenty of ticks during the time I spent stationed in Missouri a few years ago.

    A GP has now given me a 21 day round of doxy, but I’m wondering if I should speak to an LLMD. Any info on Texas?


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