Archive for the ‘Borrelia Miyamotoi (Relapsing Fever Group)’ Category

What Are Lyme Disease Co-Infections?


lyme disease co-infections

When Lyme disease was first discovered in 1975, it was the only known tick-borne illness recognized by clinicians. The disease, which is caused by an infection with the bacterium Borrelia burgdorferi, is transmitted through the bite of a black-legged (I. scapularis) tick.

Today, ticks harbor multiple infectious pathogens that can be transmitted to humans through a tick bite or tainted blood transfusion. The Centers for Disease Control and Prevention (CDC) now reports that “a single tick can transmit multiple pathogens, including bacteria, viruses, and parasites.” [1] This can result in patients developing what is referred to as Lyme disease “co-infections.”

In fact, between 2004 and 2016, the CDC identified 7 new tick-borne microbes capable of infecting humans. [1]

While most Lyme disease co-infections are acquired through the bite of an infected tick, several can be transmitted through contaminated blood transfusions. One investigation concluded, “Aside from a Babesia infection, Anaplasma is the most frequent transfusion-transmitted [tick-borne agent] with rapidly increasing clinical cases.” [2]

Ticks harbor multiple pathogens

According to a study in Suffolk County, Long Island, more than half (67%) of the ticks collected were harboring at least one pathogen. The causative agent of Lyme disease, Borrelia burgdorferi was the most prevalent (57% in adults; 27% in nymphs), followed by Babesia microti (14% in adults; 15% in nymphs).

Another study indicates that “co-infection occurs in up to 28% of black-legged ticks” in Lyme endemic areas of the United States.

Furthermore, researchers found that among infected ticks collected, 45% were co-infected and carried up to 5 different pathogens. The most prevalent co-infections included Bartonella henselae (17.6%) and Rickettsia of the spotted fever group (16.8%).

Lyme disease with co-infections

Researchers from Columbia University, Tufts Medical Center, and Yale School of Medicine examined the extent of co-infections in patients diagnosed with Lyme disease. Their findings are alarming.

  • 40% of Lyme disease patients had concurrent Babesia
  • 1 in 3 patients with Babesia had concurrent Anaplasmosis
  • Two-thirds of patients with Babesiosis experienced concurrent Lyme disease and one-third experienced concurrent Anaplasmosis

Recognizing and treating co-infections

As tick populations explode and expand into new geographic regions and cases of Lyme disease continue to soar, there is growing and warranted concern surrounding the medical communities’ ability to recognize, diagnose, and treat Lyme disease co-infections.

Sanchez-Vicente points out that nearly 1 in 4 black-legged ticks tested in their study had multiple infections. This finding “justifies the modification of the clinical approach to tick-borne diseases to cover all infection possibilities.”

Unfortunately, testing for co-infections rarely occurs. One study found that out of nearly 3 million specimens, only 17% were tested for non-Lyme tick-borne diseases.

Yet, an accurate diagnosis is critical, given that patients may require different treatment depending upon the type of co-infection. For instance, antibiotics prescribed for Lyme disease may be ineffective in treating parasitic or viral tick-borne diseases such as Babesia.

Most common co-infections

Lyme disease is the most common tick-borne illness in the United States. But it’s no longer the only threat. Lyme disease co-infections are becoming the norm, not the exception. The most frequently diagnosed tick-borne co-infections include Babesia, Anaplasmosis, Ehrlichia, Bartonella, Southern Tick-Associated Rash Illness (STARI), and Borrelia miyamotoi.


Babesia is a parasite that infects red blood cells. This parasitic infection is usually transmitted by a tick bite but can be acquired through a contaminated blood transfusion. There have also been reports of congenital transmission of Babesiosis, although rare.

Saetre describes two cases of infants with congenital babesiosis born to mothers with prepartum Lyme disease and subclinical Babesia microti infection. [3] Additionally, congenital transmission has been described in 7 previous cases, in which the infants presented with fever, anemia, and thrombocytopenia. [3]

Read more: Transfusion-transmitted Babesiosis popping up in more states in USA

Most cases of Babesia involve the strains: Babesia microti and Babesia duncani.

Symptoms typically include irregular fevers, chills, sweats, lethargy, headaches, nausea, body aches, fatigue, and in some cases, shortness of breath. But manifestations can vary.

A case series published in the Nurse Practitioner Journal demonstrates the difficulty in diagnosing the disease, as it can cause a wide range of clinical presentations.

Babesia and Lyme disease

Babesia is often present with Lyme disease and can increase the severity of Lyme disease. One study found patients co-infected with Lyme disease and Babesia experienced fatigue, headache, sweats, chills, anorexia, emotional lability, nausea, conjunctivitis, and splenomegaly more frequently than those with Lyme disease alone.

Listen to PODCAST: Delayed onset of Babesia in a Lyme disease patient

Babesia can also increase the duration of illness with Lyme disease. One study found that 50% of co-infected patients were symptomatic for 3 months or longer, compared to only 4% of patients who had Lyme disease alone.

Testing and treatment

Babesia can also be difficult to diagnose with current testing. The parasite was detected microscopically in as few as one-third of patients with Babesia. Specific amplifiable DNA and IgM antibody were more likely to be positive.

The reliability of tests for Babesia in actual practice remains to be determined.

Babesia is treated with a combination of anti-malaria medications and antibiotics such as Atovaquone with azithromycin.


Ehrlichia is a tick-borne bacteria that infects white blood cells, but it has been found in spleen, lymph node, and kidney tissue samples. An infection with Ehrlichia can lead to Ehrlichiosis.

The infection is caused by Ehrlichia chaffeensis and Ehrlichia chagrins. The bacteria is transmitted by the Lone Star tick (Amblyomma americanum) and the black-legged tick (Ixodes scapularis).

Ehrlichia is typically transmitted by a tick bite. Only rarely, has the infection been associated with blood transfusion or organ transplant cases. According to the CDC, there have been two confirmed instances of infection occurring after kidney transplants from a common donor.

Symptoms and Treatment

Symptoms may include fatigue, fevers, headaches, and muscle aches. It can be treated with antibiotics doxycycline, minocycline, and Rifampin.

If left untreated, the disease can become severe and require hospitalization.


Anaplasmosis was previously known as Human Granulocytic Ehrlichiosis or HGE. The disease can be difficult to distinguish from Ehrlichiosis, Lyme disease, and other tick-borne illnesses.

This emerging infectious disease remains under-recognized in many areas of the United States. [4] It is caused by the bacteria Anaplasma phagocytophilum.

Anaplasmosis is spread by tick bites from the black-legged tick and western black-legged tick. Although it is reportedly rare, anaplasmosis has been transmitted through contaminated blood transfusions.

In fact, Mohan and Leiby contend that aside from a Babesia infection, “Anaplasma is the most frequent transfusion-transmitted [tick-borne agent] with rapidly increasing clinical cases.” [2]

In general, most infections with anaplasmosis are mild, “however, up to 36% of patients require hospitalization, with 3% of those having life-threatening complications.” [5]

Symptoms may include headaches, fevers, chills, malaise, and muscle aches. There have been a few reported cases describing pulmonary complications, as well. In fact, one study recommends that “anaplasmosis be included in the differential diagnosis for atypical respiratory presentations.” [5]

And although uncommon, there have been patients with anaplasmosis who did not exhibit any symptoms (asymptomatic). “It is, therefore, crucial for clinicians to be aware of potential asymptomatic anaplasmosis following a tick bite,” writes Yoo and colleagues. [6]

Anaplasmosis can be treated with antibiotics such as doxycycline, minocycline, and Rifampin.


Various Bartonella species have been found in black-legged ticks in northern New Jersey and in western black-legged ticks in California.

Bartonella can be contracted through a cat scratch or bite, causing “cat scratch fever.” But it can also be transmitted by a tick bite. In fact, “ticks and small rodents are known hosts of Bartonella and play a significant role in the preservation and circulation of Bartonella in nature.” [7]

Psychiatric presentations and other symptoms

Some patients exhibit a streak-mark rash that resembles stretch marks. Symptoms may include fever, headaches, fatigue, and swollen glands.

Several studies indicate an association between Bartonella and psychiatric symptoms. Investigators describe case studies of patients with new-onset psychiatric symptoms such as sudden agitation, panic attacks, and treatment-resistant depression possibly due to Bartonella.

Another case study highlights a young boy with a Bartonella infection who developed neuropsychiatric symptoms and was later diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS), a type of basal ganglia encephalitis. [8]

Bartonella can be treated with antibiotics such as doxycycline, minocycline, azithromycin, trimethoprim-sulfamethoxazole, clarithromycin, and Rifampin.


STARI is an emerging tick-borne illness related to Lyme disease and was identified in the southeastern and south-central United States.

STARI is believed to be transmitted by the Lone Star tick; however, it is not officially confirmed as of yet.

The hallmark sign of STARI is an EM-like rash similar to that seen in Lyme disease. Symptoms may include fevers, headaches, stiff neck, joint pain, and fatigue.

The long term consequences and treatment of the illness have not been established.

It is not known whether antibiotic treatment is necessary or beneficial. Nevertheless, because STARI resembles early Lyme disease, physicians will often treat patients with oral antibiotics.


B. miyamotoi is increasingly being recognized as the agent of a nonspecific febrile illness often misdiagnosed as acute Lyme disease without rash, or as ehrlichiosis.” [9]

Borrelia miyamotoi (BMD) is a spiral-shaped bacteria that causes tick-borne relapsing fevers. However, investigators point out, Borrelia miyamotoi “should not be assumed to be biologically similar to the true relapsing fever spirochetes maintained by argasid (“soft”) ticks, nor to cause typical relapsing fever.” [9]

It appears to be a common infection in areas endemic for Lyme disease. [9]

Symptoms and prevalence

A 2011 study found the disease to generally present with more systemic signs and symptoms, particularly headache and fever, compared to Lyme disease. [10]

“Virtually all patients presented with fever … fatigue, and headache …. The next most common signs and symptoms were myalgia, chills, nausea and arthralgia, characterizing 30%–60% of the patients.” [10]

Other investigators report that “patients infected with B. miyamotoi in the United States typically do not have a rash.” But they may present with “a fever in conjunction with headache (96%), myalgia (84%), arthralgia (76%), and malaise/fatigue (82%).”

READ MORE: Tiny larval ticks can transmit Borrelia miyamotoi

The prevalence of the disease is unknown but investigators report that  “studies in New England suggest that Borrelia miyamotoi infection may be as common as anaplasmosis and babesiosis.

They also point out:

  • “Human cases are likely to be found wherever Lyme disease is endemic.”
  • “B. miyamotoi may cause serious complications, including meningoencephalitis in immunocompromised hosts.”
  • “Several studies suggest that B. miyamotoi may be transmitted through blood transfusion, consistent with the high levels of spirochetemia that occur with Borrelia species that cause relapsing fever.”

Borrelia miyamotoi is particularly concerning given that the bacterium can be transmitted to a person within the first 24 hours of tick attachment. And “the probability of transmission increases with every day an infected tick is allowed to remain attached.”

Diagnostic testing is limited. Although the CDC recommends using PCR and antibody-based tests to confirm a diagnose of B. miyamotoi, a recent study finds blood smears have poor sensitivity for confirming the disease. [9] And there is no FDA approved diagnostic test for the disease.

Treatment thus far is similar to that of Lyme disease. Studies show that doxycycline and amoxicillin have effectively treated B. miyamotoi infection in patients.

Remember, tick-borne co-infections are the norm, not the exception.

Editor’s Note: Practitioners should consider co-infections in the diagnosis when a patient’s symptoms are severe, persistent, and resistant to antibiotic therapy. Physicians have found that co-infections typically exacerbate Lyme disease symptoms.

  1. CDC Vital Signs, Weekly / May 4, 2018 / 67(17);496–501.
  2. Mohan KVK, Leiby DA. Emerging tick-borne diseases and blood safety: summary of a public workshop. Transfusion. 2020 Jul;60(7):1624-1632. doi: 10.1111/trf.15752. Epub 2020 Mar 24. PMID: 32208532.
  3. Kirsten Saetre, Neetu Godhwani, Mazen Maria, Darshan Patel, Guiqing Wang, Karl I Li, Gary P Wormser, Sheila M Nolan, Congenital Babesiosis After Maternal Infection With Borrelia burgdorferi and Babesia microti, Journal of the Pediatric Infectious Diseases Society, Volume 7, Issue 1, March 2018, Pages e1–e5,
  4. Rocco JM, Mallarino-Haeger C, McCurry D, Shah N. Severe anaplasmosis represents a treatable cause of secondary hemophagocytic lymphohistiocytosis: Two cases and review of literature. Ticks Tick Borne Dis. 2020 Sep;11(5):101468. doi: 10.1016/j.ttbdis.2020.101468. Epub 2020 May 23. PMID: 32723647.
  5. Jose E Rivera, Katelyn Young, Tae Sung Kwon, Paula A McKenzie, Michelle A Grant, Darrell A McBride, Anaplasmosis Presenting With Respiratory Symptoms and Pneumonitis, Open Forum Infectious Diseases, Volume 7, Issue 8, August 2020, ofaa265,
  6. Yoo J, Chung JH, Kim CM, Yun NR, Kim DM. Asymptomatic-anaplasmosis confirmation using genetic and serological tests and possible coinfection with spotted fever group Rickettsia: a case report. BMC Infect Dis. 2020;20(1):458. Published 2020 Jun 30. doi:10.1186/s12879-020-05170-9
  7. Hao L, Yuan D, Guo L, et al. Molecular detection of Bartonella in ixodid ticks collected from yaks and plateau pikas (Ochotona curzoniae) in Shiqu County, China. BMC Vet Res. 2020;16(1):235. Published 2020 Jul 9. doi:10.1186/s12917-020-02452-x
  8. Breitschwerdt EB, Greenberg R, Maggi RG, Mozayeni BR, Lewis A, Bradley JM. Bartonella henselae Bloodstream Infection in a Boy With Pediatric Acute-Onset Neuropsychiatric Syndrome. J Cent Nerv Syst Dis. 2019;11:1179573519832014. Published 2019 Mar 18. doi:10.1177/1179573519832014
  9. Telford SR, Goethert HK, Molloy PJ, Berardi V. Blood Smears Have Poor Sensitivity for Confirming Borrelia miyamotoi Disease. J Clin Microbiol. 2019 Feb 27;57(3):e01468-18. doi: 10.1128/JCM.01468-18. PMID: 30626663; PMCID: PMC6425185.
  10. Telford SR, Goethert HK, Molloy PJ, Berardi V. Blood Smears Have Poor Sensitivity for Confirming Borrelia miyamotoi Disease. J Clin Microbiol. 2019 Feb 27;57(3):e01468-18. doi: 10.1128/JCM.01468-18. PMID: 30626663; PMCID: PMC6425185.


For more:

Spatial and Temporal Patterns of Borrelia Miyamotoi in NY Deer Ticks

Spatial and temporal patterns of the emerging tick-borne pathogen Borrelia miyamotoi in blacklegged ticks (Ixodes scapularis) in New York


Borrelia miyamotoi, a bacterium that causes relapsing fever, is found in ixodid ticks throughout the northern hemisphere. The first cases of human infection with B. miyamotoi were identified in 2011. In the eastern USA, blacklegged ticks (Ixodes scapularis) become infected by feeding on an infected vertebrate host, or through transovarial transmission. We surveyed B. miyamotoi prevalence in ticks within forested habitats in Dutchess County, New York, and identified possible reservoir hosts. To assess spatial variation in infection, we collected questing nymphal ticks at > 150 sites. To assess temporal variation in infection, we collected questing nymphs for 8 years at a single study site. We collected questing larval ticks from nine plots to estimate the amount of transovarial transmission. To evaluate potential reservoir hosts, we captured 14 species of mammal and bird hosts naturally infested with larval blacklegged ticks and held these hosts in the laboratory until ticks fed to repletion and molted to nymphs. We determined infection for all ticks using quantitative polymerase chain reaction.

  • The overall infection prevalence of questing nymphal ticks across all sites was ~ 1%, but prevalence at individual sites was as high as 9.1%.
  • We detected no significant increase in infection through time.
  • Only 0.4% of questing larval ticks were infected.
  • Ticks having fed as larvae from short-tailed shrews, red squirrels, and opossums tended to have higher infection prevalence than did ticks having fed on other hosts.

Further studies of the role of hosts in transmission are warranted. The locally high prevalence of B. miyamotoi in the New York/New England landscape suggests the importance of vigilance by health practitioners and the public.



A perfect example of how there can be high infection rates in humans but low infection rates in ticks.

Lyme Disease: Are We Looking For the Wrong Culprit?

http://  Approx. 18 Min

Oct. 1, 2020

Lyme Disease: Are We Looking For the Wrong Culprit?

Tatjana Mijatovic, PhD

The video describes the overall high expansion of undiagnosed Lyme disease cases worldwide and the possible link to screening only for B. burgdorferi and rarely testing for B. miyamotoi. Identify the utilization of phage-based testing and bacterial presence as related to testing choices and late/chronic stage patients Discuss how the overall high failure rate of tick-borne infection (TBI)-related testing underscores the necessity for novel approaches.

Background: Borrelia-related diseases (Lyme disease and relapsing fevers) are increasingly prevalent, severe, difficult to diagnose and treat. The high failure rate of tick-borne infection testing undermine treatments‘ strategy and monitoring.
Aims: The goal of this contribution is to bring the focus on the importance to enlarge borreliosis-related testing targets and shed some light on high prevalence of B. miyamotoi presence both in ticks and late stage undiagnosed patients.

Methods: Bacteriophages could become a diagnostic tool based on the principle that if there are phages it is because there are living bacteria. Phelix Charity together with Leicester University microbiology department have recently developed a Borrelia Phage-based PCR test searching for 3 major Borrelia groups (Borrelia burgdorferi sl (including B. burgdorferi ss, B. afzelii, B. garinii, B. spielmanii, etc), Borrelia miyamotoi and Relapsing fever group (B. recurrentis, B. hermsii, etc). This method is efficiently used to assess both human samples and ticks.

Results: Since July 2019, over 2100 results from patients originating various countries have been obtained. Testing included mainly late stage / chronic patients and the aggregated data are showing 30 % negative results and 70% positive among which over 60 % indicated the presence of specific Borrelia miyamotoi phages. Furthermore, ticks from 2019 and 2020 have been analyzed by the same method. The obtained results on ticks showed that over 60% were found positive for Borrelia miyamotoi and only 15% for B. burgdorferi sl.

Conclusion: This is the first large scale report on prevalence of B. miyamotoi in the ticks, as well as in late stages of borreliosis. Seen a high prevalence of B. miyamotoi in tested ticks, further supported by similar percentages found in tested patients, one can hypothesize that the high failure rate of current two-tier screening testing, searching for B. burgdorferi sl only, might be due to the wrong testing target. In other words, the overall high expansion of undiagnosed Lyme disease cases worldwide might be linked to the screening choice focusing only on B. burgdorferi sl and only rarely testing for B. miyamotoi while the later one seems to be much more prevalent. Further accumulation of data both from the patients and ticks should bring the answer to the question are we searching for a wrong culprit. Searching for actual bacterial presence using phage-based testing might pacify the debate and controversies on testing choices and late/chronic stage patients.



Since Borrelia miyamotoi is not a reportable illness to the CDC, no one has any clue about prevalence but reports are coming in continually that it’s highly likely to be a much bigger problem than ‘authorities’ believe.

For more:

Could Borrelia Miyamotoi Infections Explain Persistent Lyme Symptoms?


borrelia miyamotoi and lyme disease


“This is the first study to investigate the presence of B. miyamotoi antibodies in a clinical population experiencing persistent symptoms and suspected tick-borne illness,” writes Delaney and colleagues from Columbia University Irving Medical Center. [1] According to the findings, Lyme disease patients testing positive for Borrelia miyamotoi were more likely to present with sleepiness and pain.

Borrelia miyamotoi (BM) is another tick-borne pathogen and “unlike Lyme disease, erythema migrans rash, and arthralgias are uncommon,” the authors write in the journal Frontiers in Medicine. The infection is diagnosed with polymerase chain reaction (PCR) called glycerophosphodiester phosphodiesterase (GlpQ) enzyme immunoassay.

Investigators looked at the incidence of BM in 82 patients who were seeking a second opinion regarding persistent symptoms which included fatigue, pain, neurocognitive, and psychiatric problems.

In their study, 1 out of 4 Lyme disease patients tested positive for Borrelia miyamotoi,using a GlpQ test. The BM positive group were significantly more likely to suffer from sleepiness (according to the Epworth Sleepiness Scale) and from pain, as measured by the McGill VAS Pain Scale, and Zung Anxiety Scale.

Eight patients with Lyme disease and Borrelia miyamotoi were hospitalized.  “Eight of 21 (38%) reported hospitalization (seven medical and one psychiatric) since symptom onset, three for cardiac and two for neurologic abnormalities,” according to the authors.

All of the patients, except for one, with Lyme disease (LD) and Borrelia miyamotoi were treated with antibiotics.  “All 21 received prior antibiotic treatment, of whom 20 received at least 2 weeks of doxycycline or amoxicillin.”

Five of the 21 patients with LD and BM lived outside of the with Northeast/Mid-Atlantic states. “Two lived in California, two lived in Florida, and one lived in Illinois.”

Study insights

The study found that clinicians are not testing for Borrelia miyamotoi, as only 1 out of the 82 study participants were tested for the infection.

Furthermore, clinicians were often dismissive of a tick-borne illness.  “Many patients reported that their clinicians dismissed the possibility of tick-borne illness both at the onset and during the course of their illness and attributed symptoms to psychological stress,” writes Delaney.

The authors raise a public health concern:

“In Lyme disease, delayed diagnosis and treatment is associated with prolonged symptoms. The same may prove true for B. miyamotoi disease.”

Editor’s note: A co-infection with Borrelia miyamotoi may explain why some Lyme disease patients are sicker than others. Unfortunately, there are still problems with the reliability of  testing for Borrelia miyamotoi.  There is also uncertainty over the best treatment approach for the infection.

  1. Delaney SL, Murray LA, Aasen CE, Bennett CE, Brown E, Fallon BA. Borrelia miyamotoi Serology in a Clinical Population With Persistent Symptoms and Suspected Tick-Borne Illness. Front Med (Lausanne). 2020;7:567350.
Many great points:
  • Could Bm explain some with persistent symptoms (highly likely)
  • Many of the patients here don’t live in what are considered Lyme-endemic areas, blowing further holes into the whole – “you have to live in the North or Eastern U.S. to be infected” paradigm.  Drop those maps like a bad habit!
  • These people had SEVERE symptoms.  Nearly 40% were hospitalized!
  • Clinicians need to WAKE UP AND SMELL THE COFFEE.  Lyme/ MSIDS patients quickly learn that those who are coinfected are sicker for longer.  Mainstream medicine is in the Stone-Ages on this fact.  There’s a real pandemic but it ain’t COVID.
  • This letter to the editor highlights the problem with coinfections & abysmal testing:

Monitoring Roadkill for Borrelia Genospecies

Hedgehogs, Squirrels, and Blackbirds as Sentinel Hosts for Active Surveillance of Borrelia miyamotoi and Borrelia burgdorferi Complex in Urban and Rural Environments

Affiliations expand

PMID: 33266311DOI: 10.3390/microorganisms8121908

Free article


Lyme borreliosis (LB), caused by spirochetes of the Borrelia burgdorferi sensu lato (s.l.) complex, is one of the most common vector-borne zoonotic diseases in Europe. Knowledge about the enzootic circulation of Borrelia pathogens between ticks and their vertebrate hosts is epidemiologically important and enables assessment of the health risk for the human population. In our project, we focused on the following vertebrate species:

  • European hedgehog (Erinaceus europaeus)
  • Northern white-breasted hedgehog (E. roumanicus)
  • Eurasian red squirrel (Sciurus vulgaris)
  • Common blackbird (Turdus merula).

The cadavers of accidentally killed animals used in this study constitute an available source of biological material, and we have confirmed its potential for wide monitoring of B. burgdorferi s.l. presence and genospecies diversity in the urban environment.

High infection rates were observed in all four target host species; mixed infections by several genospecies were detected on the level of individuals, as well as in particular tissue samples.
  • 90% for E. erinaceus
  • 73% for E. roumanicus
  • 91% for S. vulgaris
  • 68% for T. merula

These findings show the usefulness of multiple tissue sampling as tool for revealing the occurrence of several genospecies within one animal and the risk of missing particular B. burgdorferi s.l. genospecies when looking in one organ alone.



You have to admire their tenacity!

And this needs to be done on human autopsies!  The high infection rates aren’t surprising because they are looking in multiple tissues.  This should be shared widely as a reason why human patients are not getting the attention they deserve.

This doctor shows how Lyme is in tissues and doesn’t hang out long in the blood:  This is why serology testing and short-term treatments don’t work.