New Tick-Borne Borrelia Disease: Two more cases discussed Interview with:
Sam R. Telford III, ScD
Department of Infectious Disease and Global Health,
Tufts University, Cummings School of Veterinary Medicine,
200 Westboro Road, North Grafton, MA

Borrelia miyamotoi Infection Presenting as Human Granulocytic Anaplasmosis: A Case Report What are the main findings of the study?

Answer: The study presents two additional cases of BMD (Borrelia miyamotoi disease) that add to our knowledge of the spectrum of illness of this recently recognized zoonosis.  Our report of the North American index case in NEJM in January 2013 described a case-patient who was elderly and immunocompromised and it was not clear whether that case was just very unusual.  With our Annals report, we describe cases in immune-intact individuals and suggest that cases of BMD may have been under our noses all along, just presumptively diagnosed as HGA and successfully treated with doxycycline with no followup (e.g., lab confirmation of diagnosis of HGA Human Granulocytic Anaplasmosis).  Hence, individuals presenting with fever, headache, myalgia, and show leukopenia and elevated LFTs may have either HGA or BMD and confirmatory testing should be done accordingly.  It should be noted that all tick borne diseases are clinical diagnoses and treatment of an acute case should not depend on “lab tests”.  Both these infections are effectively managed by oral doxycycline, hence those with these signs and symptoms might be empirically treated with doxycyline, which would be important in areas where RMSF and tularemia (which also produce leukopenia and elevated LFTs) co-occur with deer tick -transmitted infections such as Lyme disease; waiting for “lab tests” to confirm RMSF or tularemia might lead to a negative outcome.  RMSF and tularemia are the most dangerous of the tick American tick borne diseases, although I would certainly place the very rare deer tick virus and Powassan virus in the same category. What should clinicians and patients take away from your report?

Answer: Anyone presenting with Lyme disease or HGA needs to have the other infections known to be transmitted by deer ticks (human babesiosis due to Babesia microti, deer tick virus, or ehrlichiosis due to Ehrlichia muris) in the northern U.S. ruled out.  Note that B. microti, a protozoan, is not susceptible to doxycycline; our blood supply is burdened by those who acquired babesiosis and have mild illness that was not recognized associated with successful treatment of recognized acute Lyme disease or HGA.  Such individuals may be subclinically infected and if they donate blood, may contaminate the blood supply.  Babesiosis is the most frequently recognized infection transmitted by transfusion.  So I certainly recommend that anyone presenting with acute Lyme disease or HGA have followup testing (tick borne infections are clinical diagnoses; treatment should depend on clinical suspicion and not wait for a “test”) for ALL of the known deer tick transmitted infections so that they may be recognized and clinically managed, if indicated.

The other message is that we need case reports like ours (and preferably, case series) so that we can determine the spectrum of illness.  That knowledge, as it emerges, will feed back on and enhance a clinician’s ability to diagnose the infection.  So the NEJM case report that we published established that a microbe known to exist in ticks can cause human disease; the Annals report suggests that there is at least one other presentation that clinicians should be looking for. What recommendations do you have for future research as a result of this study?

Answer: We need the publication of case series to better understand the clinical spectrum.  We also need to determine whether there is serological crossreactivity between the agents of Lyme disease and BMD, that is, to what extent does crossreactivity confound prevalence estimates from cross-sectional or prospective serosurveys?  We also need to rule out the possibility that BMD is a cause of “chronic Lyme disease” (as opposed to true chronic manifestations of Lyme such as Lyme arthritis or neuroborreliosis; nor PTLDS, post-treatment Lyme disease syndrome).


Hanumara Ram Chowdri, Joseph L. Gugliotta, Victor P. Berardi, Heidi K. Goethert, Philip J. Molloy, Sherri L. Sterling, Sam R. Telford, III; Borrelia miyamotoi Infection Presenting as Human Granulocytic AnaplasmosisA Case Report. Annals of Internal Medicine. 2013 Jul;159(1):21-27.