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BACKGROUND: Massachusetts residents are at risk from tick-borne pathogens, especially Borrelia burgdorferi, Anaplasma phagocytophilum and Babesia microti. Co-infection with two or more of these agents can increase severity of illness and complicate treatment and diagnosis. All three pathogens are transmitted by Ixodes scapularis, making multiple transmissions from a single tick bite possible.
METHODS: Surveillance data on cases of Lyme disease (LD), babesiosis, and human granulocytic anaplasmosis (HGA) for the years 2009-2013 were used. Confirmed and probable LD cases were first matched to anyone with laboratory evidence of HGA or babesiosis; epidemiologic characteristics of this subset of cases were produced. Symptom profiles were compared using only individuals that met confirmed or probable case definitions for both LD and one other tick-borne disease.
RESULTS: Between 2009 – 2013, there were 24,687 LD, 1,084 babesiosis and 1,170 HGA confirmed and probable cases reported. There were 294 cases of LD that also had evidence of infection with B. microti, 171 (58%) of them met the case definition for both diseases; 226 cases of LD had evidence of infection with A. phagocyophilum and 70 (21%) of them met both disease case definitions. 24% percent of B. burgdorferi/A. phagocytophilum co-infected cases were hospitalized, not significantly different from 33% of HGA cases. Twenty-one percent of Lyme/HGA cases reported neurological manifestations compared to 14% of LD (p=0.07) and <1% (p<0.01) of HGA patients. 89% percent of Lyme/HGA cases reported arthritis/arthralgia and 9% reported cardiac involvement compared to 55% (p<0.01) and 2% (p<0.01) in LD and 57% (p<0.01) and <1%(p<0.01) in HGA cases respectively. 55% percent of B. burgdorferi/B. microti co-infected cases were hospitalized compared to only 39% of babesiosis cases. 75% percent of Lyme/babesia cases reported arthritis/arthralgia compared to 55% of LD and 47% of babesiosis patients. 5% reported cardiac symptoms compared to 2% and <1% in LD and babesiosis cases respectively. All of these differences were significant at the p< 0.01 level.
CONCLUSIONS: LD cases with laboratory evidence of infection with A. phagocytophilum or B. microti showed expected gender, age, geographic, and month of transmission patterns. B. burgdorferi/B. microti co-infection resulted in severe disease requiring more hospitalization than patients with clinical babesiosis alone. Co-infection may increase certain manifestations over infection with a single pathogen. The cardiac involvement most commonly associated with Lyme disease was present more often in patients co-infected with another pathogen. Enhanced awareness of the risk and consequences of co-infection among providers would be desirable.