Correspondence

Coinfection with Borrelia burgdorferi and the Agent of Human Granulocytic Ehrlichiosis

N Engl J Med 2001; 345:150-151July 12, 2001

Article

To the Editor:

Lyme disease and human granulocyte ehrlichiosis are infections carried by the deer tick, Ixodes scapularis. Ticks may harbor both Borrelia burgdorferi and the human granulocytic ehrlichiosis bacterium, the causative agents of these diseases, and dual infections can occur.1 We assessed the risk of exposure to human granulocytic ehrlichiosis among 86 persons with serologic evidence of Lyme disease living in southern Connecticut and Rhode Island — areas in which Lyme disease and human granulocytic ehrlichiosis are relatively common. We used an enzyme-linked immunosorbent assay (ELISA) and immunoblotting (for IgM and IgG antibodies) with B. burgdorferi as the substrate for the serologic diagnosis of Lyme disease according to the criteria defined by the Centers for Disease Control and Prevention.2 An ELISA using recombinant HGE-44 (also known as P44), an immunodominant antigen of the human granulocytic ehrlichiosis bacterium, was performed to document exposure to the bacterium.3

Of 52 persons with positive IgG titers for B. burgdorferi, 2 (4 percent) had IgG antibodies that were specific for HGE-44; none of the persons had detectable titers of IgM antibodies against HGE-44. Of 34 persons who had positive IgM titers for B. burgdorferi, 7 (21 percent) had positive titers of IgM antibodies against HGE-44, suggesting recent exposure to both organisms, and 2 others (6 percent) had positive IgG titers against HGE-44.

Studies in Wisconsin and Minnesota and in New York State have suggested that the risk of dual infection with B. burgdorferi and the agent of human granulocytic ehrlichiosis is usually low — typically less than 3 percent and at most 13 percent.4-6 The risk of becoming infected by both of these agents after a tick bite or bites depends on the prevalence of B. burgdorferi and the agent of human granulocytic ehrlichiosis within the vector population, which varies among geographic locations. Our findings regarding the prevalence of positive IgG titers for both organisms are in general agreement with previous results; however, the IgG response to the agent of human granulocytic ehrlichiosis may not persist at detectable levels for a substantial period of time.7

Our data on IgM titers suggest that, in a region of New England in which Lyme disease is endemic, at least one of every five persons with seropositive early B. burgdorferi infection also has evidence of recent exposure to the agent of human granulocytic ehrlichiosis. Therefore, the diagnosis of human granulocytic ehrlichiosis should be considered in persons in the northeastern United States who are being evaluated for Lyme disease.

Sylvie J. De Martino, M.D.
Jason A. Carlyon, Ph.D.
Erol Fikrig, M.D.
Yale University School of Medicine, New Haven, CT 06520-8031
erol.fikrig@yale.edu

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Citing Articles (14)

Citing Articles

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   Rafal Tokarz, Komal Jain, Ashlee Bennett, Thomas Briese, W. Ian Lipkin. (2010) Assessment of Polymicrobial Infections in Ticks in New York State. Vector-Borne and Zoonotic Diseases 10:3, 217-221
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2. 2

   N. H. Cox, I. H. Coulson. 2010. Systemic Disease and the Skin. , 1-113.
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3. 3

   M. Tariq Bhatti. (2008) Optic Neuropathy From Viruses and Spirochetes. International Ophthalmology Clinics 47:4, 37-66
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   R. B. Stricker. (2007) Counterpoint: Long-Term Antibiotic Therapy Improves Persistent Symptoms Associated with Lyme Disease. Clinical Infectious Diseases 45:2, 149-157
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5. 5

   Anna Grzeszczuk, Nicole C. Barat, Johan S. Bakken, J. Stephen Dumler. 2007. Anaplasmosis in Humans. , 223-236.
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6. 6

   Claudia X. Moreno, Fred Moy, Thomas J. Daniels, Henry P. Godfrey, Felipe C. Cabello. (2006) Molecular analysis of microbial communities identified in different developmental stages of Ixodes scapularis ticks from Westchester and Dutchess Counties, New York. Environmental Microbiology 8:5, 761-772
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7. 7

   Igen Hongo, Karen C. Bloch. (2006) Ehrlichia infection of the central nervous system. Current Treatment Options in Neurology 8:3, 179-184
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   Raphael B. Stricker, Andrew Lautin, Joseph J. Burrascano. (2006) Lyme Disease: The Quest for Magic Bullets. Chemotherapy 52:2, 53-59
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   Raphael B Stricker, Andrew Lautin, Joseph J Burrascano. (2005) Lyme disease: point/counterpoint. Expert Review of Anti-infective Therapy 3:2, 155-165
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    Raphael B Stricker, Andrew Lautin. (2003) The Lyme Wars: time to listen. Expert Opinion on Investigational Drugs 12:10, 1609-1614
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    Allen C. Steere, Gail McHugh, Carolin Suarez, Jason Hoitt, Nitin Damle, Vijay K. Sikand. (2003) Prospective Study of Coinfection in Patients with Erythema Migrans. Clinical Infectious Diseases 36:8, 1078-1081
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12. 12

    Edward A. Belongia. (2002) Epidemiology and Impact of Coinfections Acquired from Ixodes Ticks. Vector-Borne and Zoonotic Diseases 2:4, 265-273
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13. 13

    Peter J. Krause, Kathleen McKay, Charles A. Thompson, Vijay K. Sikand, Ronald Lentz, Timothy Lepore, Linda Closter, Diane Christianson, Sam R. Telford, David Persing, Justin D. Radolf, Andrew Spielman, . (2002) Disease‐Specific Diagnosis of Coinfecting Tickborne Zoonoses: Babesiosis, Human Granulocytic Ehrlichiosis, and Lyme Disease. Clinical Infectious Diseases 34:9, 1184-1191
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14. 14

    Mary Elizabeth Wilson. (2002) Prevention of tick-borne diseases. Medical Clinics of North America 86:2, 219-238
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