### Microbiology The Lyme-y strains: *B*. *burgdorferi*, *B*. *lonestari*, *Borrelia* *mayonii*, named after its discoverers, the always modest Mayo Clinic. In Europe, there is *B*. *burgdorferi*, *Borrelia* *garinii*, *Borrelia* *afzelii*. The relapsing fever strains: *B*. *hermsii*, *B*. *recurrenti*, *Borrelia* *turicatae*, *B*. *hispanica*, and others. There is also a *Borrelia* from bats and spread to humans from bat ticks.[^1] Nanananananananananana bat ticks. I remain amazed that Bruce Wayne does nothing about those bats. US and European Lyme are NOT the same clinically or immunologically. [^2] Testing with US assays will likely miss the European strains. ### Epidemiologic Risks **The Lyme-y Strains** *B*. *burgdorferi*, *B*. *lonestari*, and *B*. *hermsii* spread by tick bites, for US Lyme, the tick needs to be attached and slurping up blood greater than 4 hours to pass on the *B*. *burgdorferi*. *B*. *burgdorferi* is predominantly in the US NE and midwest, including urban Chicago. West coast pockets in California including Los Angeles. But. One of many illnesses whose range is changing as the ticks move, probably due to global warming. The ticks are on the move and with them tick borne illnesses. [^3] [^4] Lyme may not be a rural disease; urban green spaces can be a source. *B*. *burgdorferi* was wound on the treeless islands in the Western Isles of Scotland.[^5] *B*. *lonestari* is found in the American SE. Where you hike may determine your risk: cattle and goat fields have fewer ticks and the ticks are less likely to have *Borrelia*[^6], but who wants to hike in a cow pasture? *Borrelia* *mayonii*: Lyme like illness. [^7] So far it is only been found in the upper Midwest. *Borrelia* *miyamotoi*: worldwide with Japan, Russia, Europe, US (California, found in small animals [^8] and China all with cases. **The Relapsing Fever Strains:** Relapsing fever strains are found throughout the world. *B*. *recurrentis* from being bit by human body louse. *B*. *hermsii* is endemic to the Western United States including the Bitterroot Valley of western Montana[^9] and southern British Columbia.[^10] It is spreading into Eastern Arizona. [^11] *B*. *miyamotoi* is where ever there is Lyme, but in a lower percentage of ticks, around 1 to 5%. Not uncommon in the NE & Midwest US. It can be found in ticks in virtually all of Canada.[^12] It is also in Europe and Japan. [^13] There are also strains in California. There are 3 genotypes, 1 each for North America, Europe, and Japan. *Borrelia* *turicatae* is the cause of relapsing fever in Texas and dogs, coyotes, and raccoons may be part of the source.[^14] [^15] *Borrelia* *persicavin* Central Asia. [^16] PCR can find unexpected *Borrelia* like *Candidatus* *B*. *johnsonii* a species previously detected in the bat tick. [^17] There is also *Candidatus* *Borrelia* *kalaharica* from ticks in Southern Africa.[^18] There is also a relapsing fever *Candidatus* *B*. *fainii* in Zambia, found in shrew mites and bats. [^19] ### Syndromes **Relapsing Fever *Borrellia*** Relapsing fever, is, well, a relapsing fever. Patients have fever, chills, headache, muscle aches for a couple of days that remit for a few days and then recur. This cycles around 5 to 7 times. The organism is changing its cell wall to evade the immune system but runs out of options and is finally eradicated. Diagnosis is made by looking at the CBC and seeing the organisms, They look cool. In the era of automated CBC's I wonder if cases are being missed. Most of the cases I have seen have been made by the CBC tech looking at the differential and serendipitously finding the organism, including a case from Mexico. *Borrelia* *miyamotoi*: Meningoencephalitis (chronic)[^20]and an acute/relapsing febrile illness with myalgias, headache, neutropenia, thrombocytopenia, and elevated LFT's just like # human granulocytic anaplasmosis.[^21] It can also cause in an acute meningitis in Sweden. [^22] The duration of *B*. *miyamotoi* spirochetemia is relatively short so PCR not reliable[^23] and the C6 peptide assay for Lyme cross-reacts. [^24] To confuse the diagnosis*B*. *miyamotoi*, *B*. *hermsii* and *B*. *burgdorferi* all cross-react with current serologies. [^25] **Lyme-y *Borrellia*** *B*. *burgdorferi* causes Lyme disease. In Europe there is *Borrelia* garinii and *Borrelia* afzelii as well. Of the two, *B*. garinii causes typical early Lyme neuroborreliosis [^26] and Bannwarth syndrome (a lymphocytic meningoradiculitis with pain that acts like a disc rupture. [^27] *B*. afzelii is more indolent and may not present typically. [^28] Lyme has three stages, as if patients like to follow the rules. Stage 1: Local spreading target lesions aka *erythema* *chronica* *migrans*. The skin lesions can be multiple and may not be present. The European versions, especially *B*. afzelii, are more likely to cause a lymphocytoma, a painless erythematous swelling typically found on the ear lobe, nipples, or testes. [^29] Stage 2: Disseminated with oligoarticular arthritis, carditis (heart block is the most common manifestation) and/or meningitis, with Bells palsy is a common manifestation. Stage 3: Chronic with arthritis and encephalitis. Those with a Bell's palsy can have aseptic meningitis, painful neuropathy, more symptomatic systemically aka Bannwarths syndrome. There is encephalitis, encephalopathy that occurs in chronic (untreated) Lyme disease and post-treatment Lyme disease syndrome, and of the four, there is no post-treatment chronic Lyme disease .[^30] [^31] Long term symptoms after treatment are not due to untreated, viable organisms, but perhaps from "intact, nonviable *B*. *burgdorferi*, as well as their remnants, possess pharmacological/inflammatory properties that persist in cartilage tissue for long periods of time after infection. [^32] I am a bit skeptical residual body parts will cause symptoms that prolonged and severe. Depressive symptoms, at least in Europe, are not a manifestation of Lyme.[^33] And when followed long term, patients treated for Lyme have no more medical complaints than non-Lyme patients. [^34] [^35] "Question Is there an association between seropositivity to *Borrelia* *burgdorferi* and incidental neuropsychiatric disorders and functional decline in older adults?." And the answer was no. [^36] This was a French study. After treatment culture-proven Lyme, fatigue is uncommon, perhaps in 9% of patients [^37] This is a common sequella of many infections; they are bad for you and not everyone bounces back. And there may be an association with normal pressure hydrocephalus.[^38] You make the diagnosis of Lyme by (of course) history and physical and blood tests. One would think it would be straightforward, but nerp. See the chapter entitled "Serologies" for an enhanced rant on the problems with blood tests. The standard approach to diagnosis in the US is the two-step: a screening Elisa then a confirmatory Western blot. The US assay not accurately diagnose the European versions of the disease. For European, and perhaps the US as well, you need to order a C6 ELISA [^39], and perhaps for US cases as well.[^40] Also the C6 cross-reacts with *Borrelia* *miyamotoi*. [^41] Two EIA tests are also an FDA approved way to make the diagnosis[^42] as long as > ... new serologic assays include blind testing against a comprehensive challenge panel, and that new assays should only be recommended if their specificity, sensitivity, and precision equaled or surpassed the performance of tests used in the recommended two-test procedure. CSF CXCL13 levels, a cytokine, may be helpful in diagnosing CNS disease:[^43] > CSF CXCL13 is a sensitive and specific marker of neuroborreliosis in individuals with *Borrelia*-specific intrathecal antibody production. However, it does not distinguish individuals strongly suspected of having neuroborreliosis, but lacking confirmatory intrathecal antibodies, from those with other neuroinflammatory conditions.[^44] There is more bad information out there about Lyme than any other infectious disease. The blood test is excellent, but there are labs that offer, let us say, unusual tests to diagnose Lyme. And a fair number of people seem to be committed to having this disease regardless of the supporting data. There are many labs that offer alternative Lyme testing, often in my experience beloved by ND's (it is short for Not a Doctor) that have not been validated.  And remember, if you live in an area with no Lyme (like PDX) a positive test is likely a false positive.[^45] You know that headache inducing Bayes Theorum/prior plausibility thing. But try getting the patient to agree. So beware: > CDC and the Food and Drug Administration (FDA) have become aware of commercial laboratories that conduct testing for Lyme disease by using assays whose accuracy and clinical usefulness have not been adequately established. These tests include urine antigen tests, immunofluorescent staining for cell wall--deficient forms of *Borrelia* *burgdorferi*, and lymphocyte transformation tests. In addition, some laboratories perform polymerase chain reaction tests for *B*. *burgdorferi* DNA on inappropriate specimens such as blood and urine or interpret Western blots using criteria that have not been validated and published in the peer-reviewed scientific literature.[^46] Know your testing facility, they are not all equal. In areas of low prevalence, alternative labs, which will often find positive Lyme testing, are almost certainly false positive .[^47] In the study, the alternative lab was Lab A.  I wish I knew which one, although I have my suspicions. In areas of low Lyme disease, patients with 'chronic Lyme' have the same phenotype of chronic fatigue patients and false-positive Lyme serologies. [^48] There is "cross-reactivity of Lyme screening among syphilis-positive sera but not false-positive syphilis screening tests from previous *Borrelia* *burgdorferi* infection.[^49] With European Neuroborreliosis, > patients did not have increased long-term risks of dementia, Alzheimer's disease, Parkinson's disease, motor neuron diseases, epilepsy, or Guillain-Barré.[^50] *B*. *lonestari*: causes a erythema chronic migrans like illness with no systemic, secondary or long term problems. Southern Tick Associated Rash Illness (STARI). However this organism has only been isolated in one case of STARI, so probably is not the cause after the Lone Star Tick Bite. STARI has been reported as far north as NY.[^51] *Borrelia* *mayonii* was discovered by the Mayo Clinic in 2015 as a rare cause of Lyme in the US and they modestly named it after themselves. Can't hold the Mayo. There is ECM in the Caribbean of unknown etiology.[^52] ### Treatment ***B*. *lonestari*** Doxycycline. Maybe **Lyme** Treatment depends in the stage of the disease, allergies etc. As mentioned in the introduction, given how specific reccomendations change over time, I defer to you doctor. However, doxycycline and most beta-lactams nuke the organism. However, since the guidelines were published, there was an article that suggests > patients treated for <=10 days with antibiotic therapy for early Lyme disease have long-term outcomes similar to those of patients treated with longer courses. Treatment failure after appropriately targeted short-course therapy, if it occurs, is exceedingly rare. [^53] And longer iv antibiotics does not help with European Lyme either.[^54] Oral doxycycline or iv ceftriaxone for two weeks has the same results at 12 months for European ECM. [^55] For European CNS infection, oral doxycycline is equal to intravenous ceftriaxone for the treatment of European adults with Lyme neuroborreliosis.[^56] **Louse borne Relapsing Fever** Tetracycline or erythromycin as a single po dose are equally effective alternative therapy. **Tick-borne Relapsing Bever** Post-exposure treatment to prevent TBRF due to *Borrelia* *persica* (in Israel) use doxycycline, tetracycline or erythromycin, 0.5 g every 6 hours for 5 to 10 days, because of the higher rate of treatment failures and relapses in these patients. Meningitis or encephalitis should be treated with iv penicillin G, cefotaxime, or ceftriaxone, for 14 days or more. A single dose of 100 mg doxycycline taken up to 72 hours after exposure to ticks is 100% effective in preventing relapsing fever. Antibiotic treatment typically induces a Jarisch-Herxheimer reaction, common in the treatment of all spirochetsial diseases. Patients get fevers, chills, muscle pain and low blood pressure as the organism falls apart and dies, turning on an inflammatory response. ### Notes There are two schools of thought for the treatment of Lyme: the IDSA and the ILADS. I am strongly in the IDSA camp, but have some ever so slight doubts with testing. I just wonder if serology based on NE strains will find strains far removed from the NE. But all good data suggests no such thing as chronic Lyme after therapy. [^57] BTW: long term po amoxicillin po adds NOTHING for Lyme . [^58] Nor does prolonged antibiotic treatment help cognition in patients with Lyme borreliosis. [^59] And long term iv antibiotics for a disease that does not exist is not benign: > Of IV-treated patients, 7.3% experienced an incident all-cause inpatient stay and 11.3% an incident all-cause emergency department visit, compared with, respectively, 2.2% and 3.4% of those treated with oral antibiotics and 0.9% and 1.9% of nontreated patient. [^60] If carefully evaluated, up to 80% of patients with chronic Lyme will have an alternative, non-infectious, diagnosis and they do NOT get better with antibiotics. [^61] That is not to say those with 'chronic' Lyme are not ill. They are. It is just usually not due to Lyme or other infectious diseases. While many infections can cause post-infectious fatigue, many of the prolonged symptoms after Lyme treatment are likely due to other medical issues that might not be considered due to premature closure. [^62] And Lyme kills almost no one.[^63] Although I would hate to be the exception. > Among patients referred to an academic Infectious Diseases practice for Lyme disease, incorrect diagnoses, and unnecessary antibiotic treatment were common, both for Lyme disease and for coinfections. [^64] To paraphrase Louie, I'm shocked, shocked to find Lyme misdiagnosis going on here.[^65] To get a hint of the wackaloon therapies offered to patients with chronic Lyme, see Unorthodox Alternative Therapies Marketed to Treat Lyme Disease[^66] And these therapies are not without harm. Long term iv antibiotics leads to serious line infections [^67] [^68] Recurrent Lyme is always reinfection, not a relapsing infection. [^69] With the rare exception of *B*. *microti*, co-infections with Lyme are very rarely seen. [^70] Relapsing fever *Borrelia* produces new outer membrane proteins to avoid immunity directed against the original infecting strain. The patient improves until the *Borrelia*, with all-new surface proteins, multiplies to cause another relapse. It can only accomplish this change 5 to 7 times before it finally dies. Elie Metchnikoff, one of the pioneers of immune system research and a Nobel Prize winner, proved the blood-borne nature of relapsing fever in 1881 by injecting himself with the organism in an unsuccessful suicide attempt. They sequenced the genome of a *B*. *recurrentis* in a 15th-century skeleton from Oslo [^71]. One of the typical careful and thoughtful evaluations of the medical literature I have received: >Yawn. "Doctors" like you are really a scourge on the medical profession. Too obtuse to think outside the box and convinced they are smarter than their "delusional" patients. The only good news: The Universe has a way of teaching those who lack knowledge and empathy---rather definitively---and before you have the chance to hurt too many others. In other words "Doctor," that haughty attitude of yours will eventually end up in the trash heap where it belongs. See there is this little thing called contemporary research. Dr. Eva Sapi. Or Dr. Richard Horowitz. And if you're really feeling inspired, the Charles E. Holman Foundation might help you through your fog of idiocy. Good luck. I have a feeling the chronic Lyme and those co-infections you so merrily dismiss will be gracing you or your family in the near future. Dense and completely lacking in common sense. Ripe for the teaching. And you are to be taken seriously or held in high esteem again...why? "Edgy" ? uh hmmm. Sure. Lol. ### Science Based Medicine [Lyme Testing](https://sciencebasedmedicine.org/lyme-testing/) From 1/28/2016 [Lyme Testimony](https://sciencebasedmedicine.org/lyme-testimony/) From May 15, 2015 [More Lyme ‘Guidelines’](https://sciencebasedmedicine.org/more-lyme-guidelines/) From October 2, 2015 [Lyme: Two Worlds Compared and Contrasted](https://sciencebasedmedicine.org/lyme-two-worlds-compared-and-contrasted/) From March 20, 2015 ### Puswhisperers [The Same but Different](http://www.pusware.com/PW2/SameButDifferent.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop280) [Lying liars and their lying lies.](http://www.pusware.com/PW2/LyingLiars.html) [Why I Am Not Upset When Bambi\'s Mother Is Shot](http://www.pusware.com/PW3/Bambi.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop382.mp3) [Bayes-en at the moon.](http://www.pusware.com/PW3/BayesEn.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop421.mp3) [Serendipitous Diagnosis](http://www.pusware.com/PW3/SerendipitousDiagnosis.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop456.mp3) [A Swell Joint](http://www.pusware.com/PW4/SwellJoint.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop482.mp3) [Go West Young Vector](http://www.pusware.com/PW6/YoungVector.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop815.mp3) [Relapsing Price Gouging](http://www.pusware.com/PW9/RelapsingPriceGouging.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop1052.mp3) [Nail Freak](http://www.pusware.com/PW9/NailFreak.html) [Audio. The Gobbet 'o Pus Podcast](http://www.pusware.com/gobbet/gop1111.mp3) ### Rationalizations [^1]: Gill JS, Ullmann AJ, Loftis AD, Schwan TG, Raffel SJ, Schrumpf ME, Piesman J. Novel relapsing fever spirochete in bat tick. Emerg Infect Dis. 2008 Mar;14(3):522-3. doi: 10.3201/eid1403.070766. PMID: 18325285; PMCID: PMC2570806. [^2]: Cerar, T., Strle, F., Stupica, D., Ruzic-Sabljic, E., McHugh, G., Steere, A. C....Strle, K. (2016). Differences in Genotype, Clinical Features, and Inflammatory Potential of Borrelia burgdorferi sensu stricto Strains from Europe and the United States. _Emerging Infectious Diseases_, _22_(5), 818-827. https://doi.org/10.3201/eid2205.151806. [^3]: Clow KM, Leighton PA, Ogden NH, Lindsay LR, Michel P, Pearl DL, Jardine CM. Northward range expansion of Ixodes scapularis evident over a short timescale in Ontario, Canada. PLoS One. 2017 Dec 27;12(12):e0189393. doi: 10.1371/journal.pone.0189393. PMID: 29281675; PMCID: PMC5744917. [^4]: Hickling, G. J., Kelly, J. R., Auckland, L. D., & Hamer, S. A. (2018). Increasing Prevalence of Borrelia burgdorferi sensu stricto–Infected Blacklegged Ticks in Tennessee Valley, Tennessee, USA. _Emerging Infectious Diseases_, _24_(9), 1713-1716. https://doi.org/10.3201/eid2409.180343. [^5]: Millins, C., Leo, W., MacInnes, I., Ferguson, J., Charlesworth, G., Nayar, D....Biek, R. (2021). Emergence of Lyme Disease on Treeless Islands, Scotland, United Kingdom. _Emerging Infectious Diseases_, _27_(2), 538-546. https://doi.org/10.3201/eid2702.203862. [^6]: Richter D, Matuschka FR. Differential risk for Lyme disease along hiking trail, Germany. Emerg Infect Dis. 2011 Sep;17(9):1704-6. doi: 10.3201/eid1709.101523. PMID: 21888798; PMCID: PMC3322059. [^7]: Pritt BS, Mead PS, Johnson DKH, Neitzel DF, Respicio-Kingry LB, Davis JP, Schiffman E, Sloan LM, Schriefer ME, Replogle AJ, Paskewitz SM, Ray JA, Bjork J, Steward CR, Deedon A, Lee X, Kingry LC, Miller TK, Feist MA, Theel ES, Patel R, Irish CL, Petersen JM. Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: a descriptive study. Lancet Infect Dis. 2016 May;16(5):556-564. doi: 10.1016/S1473-3099(15)00464-8. Epub 2016 Feb 6. Erratum in: Lancet Infect Dis. 2016 Jun;16(6):636. PMID: 26856777; PMCID: PMC4975683. [^8]: Salkeld, D. J., Nieto, N. C., Bonilla, D. L., Yoshimizu, M. H., & Padgett, K. A. (2018). Borrelia miyamotoi Infections in Small Mammals, California, USA. _Emerging Infectious Diseases_, _24_(12), 2356-2359. https://doi.org/10.3201/eid2412.171632. [^9]: Christensen, J., Fischer, R. J., McCoy, B. N., Raffel, S. J., & Schwan, T. G. (2015). Tickborne Relapsing Fever, Bitterroot Valley, Montana, USA. _Emerging Infectious Diseases_, _21_(2), 217-223. https://doi.org/10.3201/eid2102.141276. [^10]: Schwan TG, Raffel SJ, Schrumpf ME, Porcella SF. Diversity and distribution of Borrelia hermsii. Emerg Infect Dis. 2007 Mar;13(3):436-42. doi: 10.3201/eid1303.060958. PMID: 17552097; PMCID: PMC2725891. [^11]: Mafi, N., Yaglom, H. D., Levy, C., Taylor, A., O’Grady, C., Venkat, H....Ampel, N. M. (2019). Tick-Borne Relapsing Fever in the White Mountains, Arizona, USA, 2013–2018. _Emerging Infectious Diseases_, _25_(4), 649-653. https://doi.org/10.3201/eid2504.181369. [^12]: Dibernardo A, Cote T, Ogden NH, Lindsay LR. The prevalence of Borrelia miyamotoi infection, and co-infections with other Borrelia spp. in Ixodes scapularis ticks collected in Canada. Parasit Vectors. 2014 Apr 15;7:183. doi: 10.1186/1756-3305-7-183. PMID: 24731287; PMCID: PMC4001108. [^13]: Crowder, C. D., Carolan, H. E., Rounds, M. A., Honig, V., Mothes, B., Haag, H....Eshoo, M. W. (2014). Prevalence of Borrelia miyamotoi in Ixodes Ticks in Europe and the United States. _Emerging Infectious Diseases_, _20_(10), 1678-1682. https://doi.org/10.3201/eid2010.131583. [^14]: Armstrong BA, Kneubehl A, Krishnavajhala A, Wilder HK, Boyle W, Wozniak E, Phillips C, Hollywood K, Murray KO, Donaldson TG, Teel PD, Waldrup K, Lopez JE. Seroprevalence for the tick-borne relapsing fever spirochete Borrelia turicatae among small and medium sized mammals of Texas. PLoS Negl Trop Dis. 2018 Oct 29;12(10):e0006877. doi: 10.1371/journal.pntd.0006877. PMID: 30372445; PMCID: PMC6224114. [^15]: Esteve-Gasent MD, Snell CB, Adetunji SA, Piccione J. Serological detection of Tick-Borne Relapsing Fever in Texan domestic dogs. PLoS One. 2017 Dec 12;12(12):e0189786. doi: 10.1371/journal.pone.0189786. PMID: 29232415; PMCID: PMC5726638. [^16]: Muigg, V., Seth-Smith, H., Goldenberger, D., Egli, A., Nickel, B., Dürig, R....Neumayr, A. (2020). Tick-Borne Relapsing Fever Caused by Borrelia persica in Traveler to Central Asia, 2019. _Emerging Infectious Diseases_, _26_(4), 824-826. https://doi.org/10.3201/eid2604.191771. [^17]: Luke C Kingry and others, Surveillance for and Discovery of _Borrelia_ Species in US Patients Suspected of Tickborne Illness, _Clinical Infectious Diseases_, Volume 66, Issue 12, 15 June 2018, Pages 1864–1871, [https://doi.org/10.1093/cid/cix1107](https://doi.org/10.1093/cid/cix1107) [^18]: Stete, K., Rieg, S., Margos, G., Häcker, G., Wagner, D., Kern, W. V....Fingerle, V. (2018). Case Report and Genetic Sequence Analysis of Candidatus Borrelia kalaharica, Southern Africa. _Emerging Infectious Diseases_, _24_(9), 1659-1664. https://doi.org/10.3201/eid2409.171381. [^19]: Qiu Y, Nakao R, Hang'ombe BM, Sato K, Kajihara M, Kanchela S, Changula K, Eto Y, Ndebe J, Sasaki M, Thu MJ, Takada A, Sawa H, Sugimoto C, Kawabata H. Human Borreliosis Caused by a New World Relapsing Fever Borrelia-like Organism in the Old World. Clin Infect Dis. 2019 Jun 18;69(1):107-112. doi: 10.1093/cid/ciy850. PMID: 30423022. [^20]: Gugliotta JL, Goethert HK, Berardi VP, Telford SR 3rd. Meningoencephalitis from Borrelia miyamotoi in an immunocompromised patient. N Engl J Med. 2013 Jan 17;368(3):240-5. doi: 10.1056/NEJMoa1209039. PMID: 23323900; PMCID: PMC4018741. [^21]: Chowdri HR, Gugliotta JL, Berardi VP, Goethert HK, Molloy PJ, Sterling SL, Telford SR. Borrelia miyamotoi infection presenting as human granulocytic anaplasmosis: a case report. Ann Intern Med. 2013 Jul 2;159(1):21-7. doi: 10.7326/0003-4819-159-1-201307020-00005. PMID: 23817701. [^22]: Henningsson, A. J., Asgeirsson, H., Hammas, B., Karlsson, E., Parke, Å., Hoornstra, D....Hovius, J. W. (2019). Two Cases of Borrelia miyamotoi Meningitis, Sweden, 2018. _Emerging Infectious Diseases_, _25_(10), 1965-1968. https://doi.org/10.3201/eid2510.190416. [^23]: Karan, L., Makenov, M., Kolyasnikova, N., Stukolova, O., Toporkova, M., & Olenkova, O. (2018). Dynamics of Spirochetemia and Early PCR Detection of Borrelia miyamotoi. _Emerging Infectious Diseases_, _24_(5), 860-867. https://doi.org/10.3201/eid2405.170829. [^24]: Phillip J Molloy and others, Seroreactivity to the C6 Peptide in _Borrelia miyamotoi_ Infections Occurring in the Northeastern United States, _Clinical Infectious Diseases_, Volume 66, Issue 9, 1 May 2018, Pages 1407–1410, [https://doi.org/10.1093/cid/cix1023](https://doi.org/10.1093/cid/cix1023) [^25]: Krause PJ, Carroll M, Fedorova N, Brancato J, Dumouchel C, Akosa F, et al. (2018) Human _Borrelia miyamotoi_ infection in California: Serodiagnosis is complicated by multiple endemic _Borrelia_ species. PLoS ONE 13(2): e0191725. https://doi.org/10.1371/journal.pone.0191725 [^26]: Ogrinc K, Lotrič-Furlan S, Maraspin V, Lusa L, Cerar T, Ružič-Sabljič E, Strle F. 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