Epidemiology and impact of coinfections acquired from Ixodes ticks

Ixodes scapularis and other ticks in the Ixodes ricinus complex may transmit multiple pathogens, but research on coinfections has been limited. Coinfections occur with varying frequency in ticks, but single infections are more common than dual infections. The proportion of I. scapularis or I. ricinus ticks coinfected with both Borrelia burgdorferi sensu lato and Anaplasma phagocytophila is generally low, ranging from < 1% to 6% in six geographic areas. A higher prevalence of tick coinfection (26%) has been reported in Westchester County, New York. Genetic variants of the human disease-causing strain of A. phagocytophila are present in some tick populations, and they may affect the risk of coinfection or clinical illness. The proportion of Ixodes ticks coinfected with B. burgdorferi and Babesia microti has ranged from 2% in New Jersey to 19% on Nantucket Island, Massachusetts. In humans, cross-sectional seroprevalence studies have found markers of dual infection in 9-26% of patients with a tick-borne infection, but such studies often fail to distinguish simultaneous coinfection from sequential infections. Several studies have prospectively assessed the occurrence of acute coinfection. Among patients with a confirmed tick-borne infection, coinfection rates as high as 39% have been reported. The most commonly recognized coinfection in most of the eastern United States is Lyme borreliosis (LB) and babesiosis, accounting for approximately 80% of coinfections. LB and human granulocytic ehrlichiosis coinfections are less common, occurring in 3-15% of patients with a tick-borne infection in Connecticut or Wisconsin. Studies of clinical outcomes suggest that patients with acute Babesia coinfection have more severe symptoms and a longer duration of illness than patients with LB alone, but the risk of spirochete dissemination is similar. Coinfections can modify the immune response and alter the severity of arthritis in animal models. Future coinfection research should focus on long-term clinical outcomes, the role of genetic variants, immunologic effects, and the potential role of Bartonella species as tick-borne pathogens.