Lyme Disease Coinfections

Lyme Disease and Coinfections: Everything You Need to Know


Lyme disease, an infectious disease caused by a tick-borne bacterium called Borrelia burgdorferi, has been in the public consciousness for some time. However, most aren’t aware that Lyme disease can have many coinciding coinfections, which in many cases makes diagnosis and treatment of this complex disease very difficult. In fact, since Lyme disease was officially classified in 1981, there have been dozens of new tick-borne pathogens discovered and more are still being uncovered.

Lyme disease is commonly brought on from tick bites. Ticks frequently carry several infectious organisms, all of which can be transmitted through just a single bite. These infections can confound with Lyme disease thus complicating the diagnosis. Part of the difficulty behind diagnosing particular coinfections is that many of their symptoms and clinical characteristics overlap with Lyme disease and other coinfections. Shockingly, research suggests as many as 50 percent of all Lyme disease cases have co-infections with some estimates being even higher. The dangers of Lyme disease’s coinfections lies in the fact that they often cause the affected person to suffer more severe symptoms and, in some cases, even prolongs their recovery process.

Because of the prevalence of Lyme disease and its coinfections, it is critical that you not only familiarize yourself with Lyme disease but also the different possible coinfections that might further complicate diagnosis and treatment. If your symptoms do not improve after standard Lyme disease treatment, you are likely dealing with coinfections which must be diagnosed separately.



The Symptoms of Lyme Disease

Lyme disease is caused by the spirochete bacteria Borrelia burgdorferi though there are over twenty different species of Borrelia bacteria known. Over a dozen of these species cause Lyme disease-like symptoms. The bacteria is commonly transmitted by ticks. Lyme disease impacts some 300,000 individuals each year, though this number is likely massively underreported.

In the majority of all Lyme disease cases, an infected tick bite creates the signature red bull’s-eye rash between 3 to 30 days, usually within a week of the bite. However, many do not even ever see this precautionary omen. A major concern for Lyme disease is that it can go misdiagnosed or undiagnosed for years, during which the impact of the untreated disease can make it increasingly more difficult to treat.

Lyme disease has three phases which typically occur as follows:

  1. Early Lyme Disease

    The localized Lyme disease symptoms occur within the first few weeks of the bite. Symptoms during this early phase includes:

    • The bull’s eye rash
    • Flu-like symptoms
    • Fatigue
    • Fevers and chills
    • Muscle and joint pain
    • Headache
    • Stiff neck
    • Swollen lymph nodes

    During this early period, Lyme disease has just started to infect the host and is still multiplying in the bloodstream. The chance of successful treatment during this phase is, of course, highest here since the infection is still very localized.

  2. Early Disseminated Lyme Disease

    If Lyme disease isn’t discovered during the initial localized phase, it then begins to spread. It will go on to affect the skin, joints, heart, and nervous system in the following weeks to months after the initial bite. Symptoms of this phase include:

    • Rashes (may or may not be at the site of the bite)
    • Pain
    • General weakness and fatigue
    • Numbness of the limbs
    • Facial numbness
    • Headaches
    • Fainting
    • Short-term memory loss
    • Brain fog
    • Pink eye
    • Heart palpitations

    Because the antibodies to B. burgdorferi can take two to six weeks after infection to be present in your blood, some tests for Lyme disease during even the early disseminated phase can test negative. However, your doctor should be monitoring your symptoms to ensure the disease is confirmed and treatment can begin immediately.

  3. Late Disseminated Lyme disease

    This is the final and most serious phase of Lyme disease which can occur months or even years after the initial bite. If left unchecked, Lyme disease in this late phase causes serious damage to the joint, nerves, and brain. Symptoms include:

    • Arthritis, usually in the knees (in fact, Lyme disease is commonly mistaken for juvenile rheumatoid arthritis)
    • Numbness or tingling of the hands, feet, and back
    • Chronic fatigue
    • Loss of control in facial muscles
    • Memory loss
    • Mood swings
    • Chronic sleep conditions
    • Difficulty speaking
    • Heart conditions

    One of the most complicating aspects of Lyme disease is that it is relatively ambiguous: it can look completely different depending on the person. To make matters worse, the disease can “skip” phases, with symptoms not immediately noticeable until stage 2 or 3 of the disease. When diagnosed too late, Lyme disease along with its many coinfections can become chronic long after Lyme disease itself is “cured.”


All the Possible Symptoms

Because Lyme disease has a tendency to skip around its phases and produce different symptoms depending on the person, one should instead consider looking at symptoms in their aggregate. Consider these most common symptoms and count how many of them you feel yourself, which may indicate a greater likelihood you have Lyme disease and/or its coinfections.

  1. Rashes (including the bull’s eye rash)
  2. Fever
  3. Fatigue
  4. Achy joints
  5. Headaches or dizziness
  6. Night sweats or difficulty sleeping
  7. Cognitive decline, specifically memory loss and “brain fog”
  8. Light sensitivity
  9. Facial palsy
  10. Balance issues
  11. Difficulty learning new information
  12. Heart conditions
  13. Mood changes
  14. Unexplained pain and sensations
  15. Nerve pain

If you believe you have Lyme disease, you should make an appointment with your doctor immediately. Because there are numerous coinfections which complicate matters, it’s best you find a doctor who is well-versed and familiar with Lyme disease. You can find a medical doctor who specializes in Lyme disease through the International Lyme and Associated Disease Society website.



Why Is Lyme Disease So Difficult to Treat?

A major factor contributing to the difficulty of diagnosis and treatment of Lyme disease is there is a longstanding conflict between two major authorities on the illness: the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS). The differences in diagnostics and treatment of Lyme disease exists because of the inherent complexity and poor evidence surrounding the disease. At the core of the disagreements between these two organizations is the effectiveness of antibiotics and whether or not the Borrelia bacteria can persist after rounds of antibiotics. This dispute has been ongoing as recently as March 2016 when the IDSA Guidelines were removed from the National Guidelines Clearinghouse within the U.S. Department of Health and Human Services for being out of compliance. New IDSA Guidelines are currently under review.

Sadly, for many years doctors didn’t realize there were co-infections occurring alongside Lyme disease which led to serious issues between doctors and patients. Patients were sometimes even told their symptoms were psychosomatic, resulting from psychological stress or a mood disorder, and were incorrectly prescribed antidepressants. Because lab work was coming back normal, doctors would adamantly maintain the condition was psychosomatic to the detriment of the patient.

Although medicine has made great strides in testing for Lyme disease and its coinfections in the past two decades, the fact remains that testing for Lyme and co-infections is still woefully lacking in many cases. Much of the recent success behind diagnosing and treating Lyme disease and its coinfections is dependent on the physician’s willingness to accept this disease as complex and lacking in concrete diagnostic tools. All too often there are stories of patients whose tests come back negative though clinical symptoms persist. This is an unfortunate and a common story with Lyme disease patients.

Today, the ELISA and Western blot are the two most common Lyme disease tests. Both measure Borrelia burgdorferi antibodies but are somewhat unreliable. Similarly, tests for coinfections are relatively unreliable.



The Most Common Lyme Disease Coinfections

As has already been discussed, coinfections with lyme disease are scarily common. In fact, over half of all individuals who have chronic lyme disease have at least one other coinfection. Also bear in mind that new tick-borne illnesses are continuing to be discovered.

Coinfections compound the symptoms of Lyme disease, making diagnosis and treatment overly-complex. Below is a comprehensive overview of current Lyme disease coinfections which have been identified thus far (Fig. 1) along with the rate of coinfections among those with chronic Lyme disease (Fig. 2).

Fig. 1: Lyme Disease Coinfections Chart from

Fig. 1: Lyme Disease Coinfections Chart from

Fig. 2: Lyme Disease Coinfection Rates from

Fig. 2: Lyme Disease Coinfection Rates from

Babesiosis, bartonellosis, ehrlichiosis, Mycoplasma infections, Rocky Mountain spotted fever, and anaplasmosis are considered to be the most common Lyme disease coinfections.


The coinfection known as babesiosis is caused by a malaria-like parasite called Babesia. It is the most common coinfection found with Lyme disease. Though there are over 100 species of the Babesia parasite which can cause babesiosis, only a few dozen affect humans. Of these species, most Lyme disease coinfections are caused by Babesia microti and Babesia duncani.

Babesia is considered to be among the common parasites found in the blood of mammals (livestock in particular) which is how it comes into contact with ticks. Similar to malaria, babesia infects the blood of anyone who catches it. The coinfection destroys red blood cells which is how it obtains nutrients and grows.

When a person is infected with babesiosis, they typically become very sick. Symptoms of a babesiosis include:

  • Sweats, especially at night
  • Shortness of breath
  • High fever
  • Fatigue
  • Malaise
  • Chills
  • Severe headache
  • Abdominal pain
  • Joint pain
  • Muscle pain
  • Jaundice
  • Nausea
  • Body aches
  • Depression
  • Weight loss
  • Vomiting

These symptoms can last weeks or even months. Babesios can also recur similar to malaria. In a series of relapses, symptoms of both Lyme disease and Babesiosis can flare up and recur over weeks, months, or even years. The treatment for babesiosis requires its own anti-malaria medications plus antibiotics. This is why the antibiotics commonly prescribed for Lyme disease are not effective in curing babesiosis.


Bartonellosis is caused by Bartonella bacteria and is the second-most common coinfection in Lyme disease patients. There are several species of these gram-negative bacteria that are capable of making humans sick.

For example, Bartonella henselae is infamously responsible for cat scratch fever, an illness characterized by flu-like symptoms caught from being scratched or bitten by an infected cat. However, the bacterium can be carried by not only a cat, but in virtually any animal’s lining of blood vessels.

Bartonellosis has its own specific infection cycle which causes patients to experience a flare-up of symptoms every week or so as the endothelial cells are released into the bloodstream. Although symptoms of bartonellosis on their own are considered relatively mild, combined with Lyme disease these regular flare ups can be painful and debilitating. Symptoms of bartonellosis include:

  • Streaked rashes resembling pregnancy stretch marks
  • Fevers
  • Fatigue
  • Headache
  • Poor appetite
  • Memory loss
  • Blurred vision
  • Numbness in limbs
  • Loss of balance
  • Unsteady gait
  • Triggers
  • Mood swings

The symptoms recur in cycle but some can remain persistent over time. It is even possible that a person with bartonellosis only experiences flu-like symptoms which may fool doctors into thinking the patient is healthy. Oftentimes, this causes a diagnosis for the remaining bacteria never being made.

To treat bartonellosis, specific antibiotics must be used: fluoroquinolones, rifampin and doxycycline are most commonly used to treat the coinfection.


Ehrlichiosis is an infection caused by three species of the Ehrlichia bacteria and another species of Anaplasma bacteria, all of which infect white blood cells. Ehrlichia chaffeensis is the most likely culprit, found predominantly in the southeast United States. It ranks as the third most common coinfection with Lyme disease.

It is possible to completely asymptomatic with an ehrlichiosis infection. However, when coupled with Lyme disease, symptoms can be severe. These symptoms generally come soon after the initial bite and resemble the flu. They include:

In some cases, a toxic shock-like syndrome has been reported by those suffering from the infection. If you possibly have Lyme disease, ehrlichiosis is most definitely a coinfection you should also being tested for.

The first line of first course of treatment for ehrlichiosis is doxycycline, a simple antibiotic.

Mycoplasma Infection

Mycoplasma are small bacteria made up of over 200 species many of which infect humans. They infect the white blood cells of the body and can inflict a number of illnesses including pneumonia and pelvic inflammatory disease.

There is some evidence to suggest that Mycoplasma infections are one of the most common coinfections with Lyme disease. However, accurate numbers on Mycoplasma are notorious difficult to find since they often tests. Additionally, they often test with Lyme disease making them elusive to account for separately.

Interestingly, Mycoplasma bacteria prefer collagen-rich sites within the body. This is largely why inflamed joints and arthritis-like symptoms are most common with Mycoplasma infections. Other symptoms of Mycoplasma include:

  • Headache
  • Sore throat
  • Fever
  • Cough
  • Fatigue
  • Joint pain

Because Mycoplasma bacteria do not have cell walls around their cell membrane, they are unaffected by most antibiotics. However, some antibiotics have proven to have significant success rate against Mycoplasma including fluoroquinolones, macrolides, and tetracycline.

Because of the difficulty in testing for them, Mycoplasma coinfections often go undiagnosed for an individual’s whole life. In fact, just because you test negative for Mycoplasma does not mean you are in the clear: Mycoplasma coinfections can remain a chronic, undetected illness especially if you previously had Lyme disease. Consider seeking treatment if any of the aforementioned systems are present and debilitating.

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is a serious and potentially life-threatening illness especially when coupled with Lyme disease as a coinfection. RMSF, however, can take months to develop into its deadly phase. Caused by the bacteria Rickettsia, the illness causes serious damage to internal organs over time which can be fatal in extreme cases.

The most common symptom of RMSF is a splotchy rash which appear 2-4 days after the fever symptoms begin. Although nearly everyone with RMSF will develop a rash, it doesn’t usually appear until later stages. This makes diagnosis difficult since the effects are only visible when the disease is well-developed in its late phase when there is much greater risk for permanent damage. Sometimes, Rocky Mountain is confused for Colorado tick fever, but they are very different illnesses.

The initial symptoms RMSF include:

  • Fever
  • Nausea
  • Vomiting
  • Severe headaches
  • Stomach pain
  • Muscle pain
  • Lack of appetite

Late-RMSF symptoms and long-term effects include:

  • Maculopapular rash
  • Abdominal rash
  • Petechial rash
  • Pink eye
  • Joint pain
  • Confusion or brain fog
  • Kidney failure
  • Gangrene
  • Enlargement of liver or spleen
  • Inflammation of brain, heart, or lungs

Unlike many other coinfections, RMSF does not usually lie dormant. Though, by the time it’s diagnosed it likely already caused severe and irreversible damage. If infection goes untreated long enough, patients with RMSF can suffer amputation, paralysis, mental disabilities, and can even be fatal in extreme cases.

Antibiotics are necessary to treat RMSF. The antibiotics used are typically doxycycline, tetracycline or chloramphenicol. Whenever Rocky Mountain spotted fever is suspected, most physicians will not wait for lab work to return to start antibiotics due to the severity of the disease and its rapid progression.


Anaplasmosis is an infection caused by the bacteria Anaplasma phagocytophilum. This gram-negative bacterium infects the red blood cells. Although the bacteria is commonly transferred via ticks, it can also be passed on through contaminated needles.

The first signs and symptoms of anaplasmosis typically occur a week or two after the initial infected bite. Symptoms of anaplasmosis include:

  • Fever
  • Headache
  • Cough
  • Confusion
  • Chills
  • Nausea
  • Malaise
  • Abdominal Pain
  • In some rare cases, rashes

Some individuals with anaplasmosis develop all of these symptoms, but just as many report just one or two of them. However, in most cases a rash is generally an indicator that anaplasmosis is occurring alongside Lyme disease or another tick-borne illness. The severity of anaplasmosis typically depends on one’s own immune system and other coinfections present in the patient. In worst case scenarios, anaplasmosis can be fatal.

Anaplasmosis is notoriously difficult to diagnose because tests frequently come back as a false negative. Routine hospital blood cultures will not detect anaplasmosis. For a proper diagnosis, there must be sufficient suspicion of an anaplasmosis infection and appropriate testing must be sent to specialized labs. The sheer complexity of diagnosis means its likely that anaplasmosis infections are underreported.

Treatment of anaplasmosis includes antibiotics such as doxycycline and tetracycline. The use of antibiotics other than these to treat anaplasmosis has been associated with higher risk of fatality.

Not all tick-borne illnesses are bacteria or parasites, they can also be viruses and in the case of tick paralysis, is a neurotoxin created by the salivary glands of the tick. One example of a coinfection caused by a virus is Powassan viral encephalitis.

Powassan Viral Encephalitis

Not all tick-borne illnesses are bacteria or parasites. They can also be viruses and, in some cases, ‘tick paralysis’ which is a neurotoxin created by the salivary glands of the tick. One example of a coinfection caused by a virus is Powassan viral encephalitis.

Powassan viral encephalitis is a tick-borne flavivirus named for the town Powassan in Ontario where it was identified after killing a young boy. There is no vaccine or antiviral medication for the illness and has a 10 percent fatality rate. Encephalitis results in an infection of the brain that causes serious symptoms including:

  • Fever
  • Headache
  • Vomiting
  • Weakness
  • Memory loss
  • Confusion
  • Seizures
  • Altered mental status
  • Brain swelling
  • Inability to comprehend and formulate language

Although the encephalitis viral coinfection is rare, it is incredibly dangerous and should never be taken lightly.

Other Less Common Lyme Disease Coinfections

  • Colorado tick Fever
  • Tick-borne relapsing fever
  • Q-fever
  • Typhus
  • Tularemia
  • Southern Tick-Associated Rash Illness (STARI)
  • Tick paralysis (caused by a neurotoxin created in a tick’s salivary gland, not an infectious disease)

As mentioned, there are always new coinfections being discovered so this list is by no means exhaustive.



The Prevalence of Coinfections and Lyme Disease: Is It Underreported?

Estimates vary, but some say as many as 75 percent of Lyme disease cases have coinfections. In fact, a paper released in March 2016 suggested that coinfections from ticks are the rule rather than the exception. Therefore, it’s best to believe that if you have Lyme disease, or any other tick borne illness for that matter, it is highly possible you also have a coinfection.

If you are bitten by a tick, the good news is that most tick-borne illnesses can be cured if treated quickly. Upon finding a tick on your body, you should thoroughly clean the area and remove the tick with forceps. If you live in a region with high incidence of tick-borne illnesses, seriously consider saving the tick to identify the type. Then, pay close attention to the bite and your health over the next few months. You should also notify your doctor and make an appointment with them a couple weeks later.

The reality is that tick-borne illnesses are on the rise. We need to be vigilant about spreading awareness and information. Please share this article with someone you know who spends a lot of time outdoors or would benefit from learning about Lyme disease and the risks of coinfections.



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