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Last updated January 1, 2014

Disease-Specific Diagnosis Of Coinfecting Tickborne Zoonoses: Babesiosis, Human Granulocytic Ehrlichiosis, And Lyme Disease

P. Krause et al. Clin Infect Dis 2002;34:1184-91

Three different infections can be transmitted by the Ixodes tick, but specific information regarding the types of symptoms and their duration before presentation has not been well-described. In addition, although coinfection with two or perhaps three of these pathogens, Borrelia burgdorferi, Babesia microti or the agent of human granulocytic ehrlichiosis (HGE), has been described, it is not known whether clinical manifestations can help distinguish infection between single vs. concurrent infection.

The authors evaluated 192 patients with confirmed infection of a total of 310 who were originally seen for suspected tick-borne illness. Patients were residents of Block Island, RI, Nantucket, MA and southeastern Connecticut and completed a standardized questionnaire at the time of clinical presentation. Diagnosis of Lyme disease and babesiosis was based on established criteria; diagnosis of HGE required clinical symptoms consistent with HGE and anti-HGE antibody seroconversion with or without identification of morulae on thin blood smear or DNA evidence by specific PCR testing.

The authors found that 39% of their patients presented with concurrent infection; 81% had coinfection with Lyme disease and babesiosis. The majority of patients with Lyme disease had erythema migrans, and none of the patients with one of the other infections had a rash. The presence of flu-like symptoms without a rash was more suggestive of Lyme disease with a concurrent infection than of Lyme disease alone.

When evaluating 17 symptoms, individually and as a group, the triad of fever, chills and headache was seen in 44% of patients with Lyme disease coinfection compared with only 13% with Lyme disease alone. Based on this sample findings of disseminated Lyme disease (i.e. disseminated erythema migrans rash, arthritis, Bell's palsy, meningitis or carditis) were equally distributed between patients with Lyme disease alone and those with Lyme disease and concurrent infection, suggesting that concurrent infection does not increase the likelihood of acute dissemination of B. burgdorferi. For patients who had Lyme disease as a coinfecting agent, the presence of anemia and thrombocytopenia strongly suggested concurrent babesiosis, whereas leukopenia was seen with concurrent infection with HGE.

Comment by Kevin A. Slavin, M.D., Hackensack, NJ:
In endemic areas of the Northeast and Midwest, Lyme disease, babesiosis and HGE cause significant disease. Although previous studies have attempted to discern the likelihood of coinfection with two or more of these pathogens, this is one of the first studies to specifically evaluate whether concurrent infection can be determined based on clinical presentation. However, one must note the relatively small number of patients in each of the different disease group classifications and the skewed distribution. For example more patients had HGE and Lyme disease coinfection (seven) than had HGE alone (three). This makes it difficult to determine whether the differences noted by the authors are the result of true differences between those with single infection vs. those with coinfection.

Despite the small numbers of the subgroups, some conclusions can be drawn based on the findings of the larger groups. For example the authors' findings do suggest that if Lyme disease is diagnosed in a patient with flu-like symptoms and no erythema migrans rash, the practitioner may want to consider evaluation for concurrent infection. Of the different laboratory tests a complete blood count appears to be the most cost-effective method for screening for concurrent infection because HGE and babesiosis both have findings that were not seen in patients with Lyme disease as a single infection. In addition if there is a high index of suspicion for babesiosis or HGE, specific IgM testing should be performed in conjunction with a second specific method, such as PCR or microscopic examination of the peripheral blood.

Because coinfection with two or more pathogens can occur, the ability to distinguish the presence of Lyme disease, babesiosis or HGE based on clinical symptoms would be extremely useful in clinical practice. This study does suggest that this may be possible, but the overall small numbers preclude the ability to extrapolate to specific groupings of concurrent infections. A larger, more comprehensive study may be required to clearly discern whether clinical presentation alone can determine who should be evaluated for concurrent infection.


Pubmed abstract




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