THE TICK THAT BIT ME

9 things you need to know about Borrelia miyamotoi 02/18/2013

Several months ago, when the patient support group that I attend first began discussing Borrelia miyamotoi, a Google search (or Bing…whatever…) for those two odd words yeilded very little. Now, after the publishing of a few key papers in the New England Journal of Medicine, every major news outlet seems to be aware of this “new” Borrelia.

From a scientific perspective, Borrelia miyamotoi is interesting because it challenges a dichotomy that was established by researchers of tick-borne infectious diseases. When I first started reading about the Borrelia genus, I learned that Borrelia species could be sorted into two major categories: the Lyme disease-like group and the relapsing fever group. That is, Borrelia species like B. burgdorferi, B. afzelli, and B. garinii–which are genetically more similar, are carried by hard-bodied ticks, and cause the same pattern of symptoms (rash, joint pain, fatigue–were put in one group. Other species, like B. hermsii and B. parkeri–which differ genetically from these Lyme-like bacteria, are carried by soft-bodied ticks, and all cause relapsing fever symptoms–were put in the other group. One group for Lyme-like illness. Another group for relapsing fever-like illness. One group for hard-bodied ticks. Another group for soft-bodied ticks. The dichotomy is so clear that the ticks are sometimes referred to as “Lyme disease ticks” and “relapsing fever ticks.”

The funny thing about dichotomies is that they only create the illusion of two distinct categories. The reality is far more messy and characterized by shades of grey. Enter Borrelia miyamotoi. According to its genetics, it should go in the relapsing fever group, but it’s transmitted by the same hard-bodied ticks that carry Lyme disease. According to its symptoms, it falls somewhere in the middle. About 10% of people get a rash, like with Lyme disease, while others don’t. Some people get relapsing fevers, while others don’t. It’s all so very confusing!

A Borrelia family tree (technically called a phylogenetic tree) highlighting strains of B. miyamotoi. Note the groupings of the other Borrelia. Via Platonov AE, Karan LS, Kolyasnikova NM, Makhneva NA, Toporkova MG, et al. (2011) Humans infected with relapsing fever spirochete Borrelia miyamotoi, Russia. Emerg Infect Dis 17: 1816–1823.

As usual, both the researchers and the news media seem to be trying to downplay this. Some are unwittingly obscuring the issue altogether. “Paging Dr. House: There [sic] a new tick-transmitted spirochete in town…” writes Melissa Healey of the L.A. Times. “The New England Journal of Medicine on Thursday published two reports documenting its arrival on U.S. shores.” As if the bacteria hopped on a boat from Russia, and that’s how it got here! Forget the strong possibility that it was here all along and our scientists just failed to detect it. Forget the possibility that the countless numbers of people who tested negative for Lyme disease and were denied treatment could in fact have this similar infection.

Dr. Peter Krause, lead author on the NEJM study, says (in a video for Yale News) he doesn’t think people should panic about Borrelia miyamotoi. At the same time, he admits that this is an infection that is affecting people in both the eastern and western United States–not to mention people in Europe and Asia. “We expect this disease to be found everywhere the deer tick is found,” he states. So don’t panic, but it’s everywhere.

Okay, so Dr. Krause is right when he says people shouldn’t panic, but that doesn’t mean that we shouldn’t learn more about this new–or not so new, as the case may be–infection, especially since many of us could have it right now. Here are nine things I think you should know about Borrelia miyamotoi.

1. Symptoms: Borrelia miyamotoi causes symptoms of tick-borne relapsing fever (TBRF), an illness often misdiagnosed as Lyme disease, or not diagnosed at all. Tick-borne relapsing fever, when left untreated, has some symptom overlap with Lyme: arthralgias, myalgias, chronic fatigue, and cognitive problems; however, it differs from Lyme disease in that most patients with TBRF get repeated episodes of fever, and they don’t get erythema chronicum migrans (EM), the “classic Lyme” bull’s-eye rash. We can guess that the long-term effects of B. miyamotoi infection are similar to those of other Borrelia infections, even if researchers are reluctant to admit it. Dr. Peter Krause, one of the authors of the study published in the January 17 issue of the New England Journal of Medicine, told the L.A. Times: “This is a very new disease, but none of the patients have had this long-term [neurological] trouble or other long-term symptoms,[…] it’s possible that we just haven’t seen it yet.” Long-term neurological problems from a disease that most doctors didn’t know existed until a few months ago? I’d say it’s very possible.

2. Transmission: Borrelia miyamotoi is transmitted to humans from the bites of hard-bodied ticks. Examples of these ticks include Ixodes scapularis (deer tick), Ixodes pacificus (western blacklegged tick), Ixodes ricinus (castor bean tick), and Ixodes persulcatus (taiga tick). (The first two tick species listed are common in North America, and the second two are found in Europe and Asia.)

3. Why you’re just hearing about it now: The B. miyamotoi bacterium was discovered in ticks and mice in Japan back in 1995. (It’s named after Japanese entomologist Kenji Miyamoto, who first isolated the bacterium.) In 2001, Dr. Durland Fish discovered B. miyamotoi in ticks in Connecticut, but according to a 2011 New York Times report, he “was repeatedly refused a study grant [from NIH] until the Russians proved it caused illness.” In 2011, Russian scientists, in collaboration with the Yale team that included Krause and Fish, published research that showed that B. miyamotoi infects humans. The patients in the 2011 study were in Russia, so B. miyamotoi didn’t really come on the radar for U.S. doctors until January 2013, when a study on U.S. patients was published by Krause and colleagues in the New England Journal of Medicine.

4. Testing: To my knowledge, there is currently no commercially-available test for B. miyamotoi, be it PCR, IFA, or Western Blot. B. miyamotoi has been detected using assays (tests) that were developed by university researchers in order to study the bacterium. That means, unless your doctor is at Yale or another large institution, it’s not likely that he or she has access to a test for B. miyamotoi. So if you suspect you may be infected, what can you do? That brings me to my next point.

5. People with B. miyamotoi infection are likely to test negative for B. burgdorferi (Lyme disease), unless they also happen to be infected with B. burgdorferi. Doctors who are only screening patients for Lyme disease are not going to catch all of the other Borrelia infections, like B. miyamotoi.

6. Genetically, B. miyamotoi is more similar to other bacteria that cause TBRF, like Borrelia hermsii. Therefore, people with B. miyamotoi infection may test positive for B. hermsii, another relapsing fever spirochete.

7. As with any infection, B. miyamotoi infection can be more serious in the elderly and in patients with compromised immune systems. If you or a family member is denied treatment, especially in the case of severe or life-threatening symptoms (like high fever), my advice would be to go to a tertiary care center (like a university hospital) and ask to be tested for B. miyamotoi. At the very least, doctors at a research hospital should be able to do a blood smear to look for spirochetes (Borrelia). PCR and antibody tests may also be available.

8.Treatment: B. miyamotoi probably responds in a similar way to antibiotics as other Borrelia like B. hermsii and B. burgdorferi. Researchers claim that it can be treated with a few weeks of oral antibiotics, but that is probably only for mild, acute cases. My guess (as a non-medical-professional) is that B. miyamotoi is just as resilient as its Borrelia cousins and requires 4-6 weeks of daily IV antibiotics. If you’re new to this blog, you might be interested in reading about my experience being treated with IV antibiotics for B. hermsii (relapsing fever).

9. Recommended reading: To learn more about B. miyamotoi, check out the new fact sheet, which includes links to peer-reviewed studies.

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