Borrelia miyamotoi: An Emerging Tick-Borne Pathogen

Characteristics of Hard Tick Relapsing Fever Caused by Borrelia miyamotoi, United States, 2013-2019

Borrelia miyamotoi, transmitted by Ixodes spp. ticks, was recognized as an agent of hard tick relapsing fever in the United States in 2013. Nine state health departments in the Northeast and Midwest have conducted public health surveillance for this emerging condition by using a shared, working surveillance case definition. During 2013-2019, a total of 300 cases were identified through surveillance; 166 (55%) were classified as confirmed and 134 (45%) as possible. Median age of case-patients was 52 years (range 1-86 years); 52% were male. Most cases (70%) occurred during June-September, with a peak in August. Fever and headache were common symptoms; 28% of case-patients reported recurring fevers, 55% had arthralgia, and 16% had a rash. Thirteen percent of patients were hospitalized, and no deaths were reported. Ongoing surveillance will improve understanding of the incidence and clinical severity of this emerging disease.

Detection of Borrelia miyamotoi and Powassan Virus Lineage II (Deer Tick Virus) from Odocoileus virginianus Harvested Ixodes scapularis in Oklahoma

Odocoileus virginianus (white-tailed deer) is the primary host of adult Ixodes scapularis (deer tick). Most of the research into I. scapularis has been geographically restricted to the northeastern United States, with limited interest in Oklahoma until recently as the I. scapularis populations spread due to climate change. Ticks serve as a vector for pathogenic bacteria, protozoans, and viruses that pose a significant human health risk. To date, there has been limited research to determine what potential tick-borne pathogens are present in I. scapularis in central Oklahoma. Using a one-step multiplex real-time reverse transcription-PCR, I. scapularis collected from white-tailed deer was screened for Anaplasma phagocytophilum, Borrelia burgdorferi, Borrelia miyamotoi, Babesia microti, and deer tick virus (DTV). Ticks (n = 394) were pooled by gender and life stage into 117 samples. Three pooled samples were positive for B. miyamotoi and five pooled samples were positive for DTV. This represents a minimum infection rate of 0.8% and 1.2%, respectively. A. phagocytophilum, B. burgdorferi, and B. microti were not detected in any samples. This is the first report of B. miyamotoi and DTV detection in Oklahoma I. scapularis ticks. This demonstrates that I. scapularis pathogens are present in Oklahoma and that further surveillance of I. scapularis is warranted.

First detection of Borrelia miyamotoi infections in ticks and humans from the northeast of Inner Mongolia, China

Borrelia miyamotoi is a relapsing fever spirochete that can cause chills, fatigue, headache, myalgia, arthralgia, and even meningitis, damaging human health. B. miyamotoi has a wide distribution since its discovery in Ixodes persulcatus in 1994. The human B. miyamotoi disease was first described in Russia in 2011. However, the epidemiological information in China is limited. Here, we report the molecular detection of B. miyamotoi in the northeast of Inner Mongolia, China. A total of 774 adult ticks and 771 blood samples of patients were collected, from April 2017 to August 2019 in the northeast of Inner Mongolia, and tested for B. miyamotoi using real time-PCR. Gene sequences of 16S rRNA, fla, and glpQ were obtained to reconstruct the phylogenetic relationship of B. miyamotoi from humans and ticks. The results showed the total prevalence of B. miyamotoi in ticks was 1.3% of 774 ticks, with rates of 2.6% in I. persulcatus, 0.78% in Dermacentor nuttalli, 1.3% in D. silvarum, and 0.4% in Haemaphysalis longicornis. Thirteen (1.7%) patients were confirmed as positive for B. miyamotoi. Patients were mainly 50-60-years old and had a history of tick contact. They presented flu-like symptoms, including fever, headache, poor spirit, dizziness, nausea, vomiting, hypodynamic, chest distress, and myalgia. Phylogenetic analysis showed that the B. miyamotoi in the present study belonged to the Siberian type, distinct from European and American types and the I. ovatus isolate from Japan. This is the first report of B. miyamotoi detection in both ticks and humans in the northeast of Inner Mongolia, China, indicating B. miyamotoi is present in the area. These findings suggest that people have a risk of infection with B. miyamotoi in this region, where it should be included the differential diagnosis of tick-borne diseases.

Underrecognized Tickborne Illnesses: Borrelia Miyamotoi and Powassan Virus

Over the past 2 decades, tickborne disease has been increasingly recognized as a threat to humans as a result of the growing geographic range of ticks. This review describes 2 tickborne diseases, Borrelia miyamotoi and Powassan virus, that likely have a significant impact on humans, yet are underdiagnosed compared to most other tickborne diseases. We performed a literature search from 2015 to 2020. Borrelia miyamotoi is a tickborne pathogen that infects and co-infects ticks along with other pathogens, including Borrelia burgdorferi. Because B miyamotoi infects the same Ixodes ticks as B burgdorferi, B miyamotoi may cover a similar geographic range. B miyamotoi infection may be underdiagnosed for 2 reasons. First, a presumptive treatment approach to Lyme disease may result in B miyamotoi infection treatment without identification of the actual cause. Second, the absence of readily available testing and diagnostic criteria makes it difficult to diagnose B miyamotoi infection. Powassan virus is a tickborne flavivirus similar to the dengue virus. Powassan virus disease appears to have an asymptomatic or minimally symptomatic presentation in most people but can cause devastating and fatal encephalitis. The Powassan virus may be transmitted in less than 15 min of tick feeding. Powassan virus disease is a difficult diagnosis because testing capabilities are limited and because there may be co-infection with other tickborne pathogens.

Targeting Multicopy Prophage Genes for the Increased Detection of Borrelia burgdorferi Sensu Lato (s.l.), the Causative Agents of Lyme Disease, in Blood

The successful treatment of Lyme disease (LD) is contingent on accurate diagnosis. However, current laboratory detection assays lack sensitivity in the early stages of the disease. Because delayed diagnosis of LD incurs high healthcare costs and great suffering, new highly sensitive tests are in need. To overcome these challenges, we developed an internally controlled quantitative PCR (Ter-qPCR) that targets the multicopy terminase large subunit (terL) gene encoded by prophages that are only found in LD-causing bacteria. The terL protein helps phages pack their DNA. Strikingly, the detection limit of the Ter-qPCR was analytically estimated to be 22 copies and one bacterial cell in bacteria spiked blood. Furthermore, significant quantitative differences was observed in terms of the amount of terL detected in healthy individuals and patients with either early or late disease. Together, the data suggests that the prophage-targeting PCR has significant power to improve success detection for LD. After rigorous clinical validation, this new test could deliver a step-change in the detection of LD. Prophage encoded markers are prevalent in many other pathogenic bacteria rendering this approach highly applicable to bacterial identification in general.

Spatial and temporal patterns of the emerging tick-borne pathogen Borrelia miyamotoi in blacklegged ticks (Ixodes scapularis) in New York

Borrelia miyamotoi, a bacterium that causes relapsing fever, is found in ixodid ticks throughout the northern hemisphere. The first cases of human infection with B. miyamotoi were identified in 2011. In the eastern USA, blacklegged ticks (Ixodes scapularis) become infected by feeding on an infected vertebrate host, or through transovarial transmission. We surveyed B. miyamotoi prevalence in ticks within forested habitats in Dutchess County, New York, and identified possible reservoir hosts. To assess spatial variation in infection, we collected questing nymphal ticks at > 150 sites. To assess temporal variation in infection, we collected questing nymphs for 8 years at a single study site. We collected questing larval ticks from nine plots to estimate the amount of transovarial transmission. To evaluate potential reservoir hosts, we captured 14 species of mammal and bird hosts naturally infested with larval blacklegged ticks and held these hosts in the laboratory until ticks fed to repletion and molted to nymphs. We determined infection for all ticks using quantitative polymerase chain reaction. The overall infection prevalence of questing nymphal ticks across all sites was ~ 1%, but prevalence at individual sites was as high as 9.1%. We detected no significant increase in infection through time. Only 0.4% of questing larval ticks were infected. Ticks having fed as larvae from short-tailed shrews, red squirrels, and opossums tended to have higher infection prevalence than did ticks having fed on other hosts. Further studies of the role of hosts in transmission are warranted. The locally high prevalence of B. miyamotoi in the New York/New England landscape suggests the importance of vigilance by health practitioners and the public.

Glycerophosphodiester Phosphodiesterase Identified as Non-Reliable Serological Marker for Borrelia miyamotoi Disease

The relapsing fever group Borrelia miyamotoi is an emerging tick-borne pathogen. Diagnosis of infection is currently mainly based on serological methods detecting antibodies against B. miyamotoi glycerophosphodiester phosphodiesterase (GlpQ). Here, we scrutinized the reliability of GlpQ as a diagnostic marker and compared the seroprevalence in different study populations and by applying various immunoblotting methods. Antibodies were detected in the sera of 7/53 hunters and in 1/11 sera of Lyme neuroborreliosis patients. Furthermore, 17/74 sera of persons with high concentrations of anti-Borrelia burgdorferi sensu lato (α-Bbsl) antibodies reacted strongly with B. miyamotoi GlpQ in immunoblots. The B. miyamotoi GlpQ seroprevalence was 7/50 in α-Bbsl negative persons. In healthy blood donors from commercial suppliers and from the Austrian Red Cross, seroprevalences were 5/14 and 10/35, respectively. Strikingly, two B. miyamotoi PCR-positive cases from Austria had negative GlpQ serology, indicating poor sensitivity. Finally, when we analyzed sera of dogs, we found α-B. miyamotoi GlpQ antibody seroprevalence in tick-free dogs (n = 10) and in tick-exposed dogs (n = 19) with 2/10 and 8/19, respectively. Thus, our results indicate that GlpQ-based B. miyamotoi serology holds neither specificity nor sensitivity.

Evaluation of pathogen specific urinary peptides in tick-borne illnesses

Mass spectrometry enhanced by nanotechnology can achieve previously unattainable sensitivity for characterizing urinary pathogen-derived peptides. We utilized mass spectrometry enhanced by affinity hydrogel particles (analytical sensitivity = 2.5 pg/mL) to study tick pathogen-specific proteins shed in the urine of patients with (1) erythema migrans rash and acute symptoms, (2) post treatment Lyme disease syndrome (PTLDS), and (3) clinical suspicion of tick-borne illnesses (TBI). Targeted pathogens were Borrelia, Babesia, Anaplasma, Rickettsia, Ehrlichia, Bartonella, Francisella, Powassan virus, tick-borne encephalitis virus, and Colorado tick fever virus. Specificity was defined by 100% amino acid sequence identity with tick-borne pathogen proteins, evolutionary taxonomic verification for related pathogens, and no identity with human or other organisms. Using a cut off of two pathogen peptides, 9/10 acute Lyme Borreliosis patients resulted positive, while we identified zero false positive in 250 controls. Two or more pathogen peptides were identified in 40% of samples from PTLDS and TBI patients (categories 2 and 3 above, n = 59/148). Collectively, 279 distinct unique tick-borne pathogen derived peptides were identified. The number of pathogen specific peptides was directly correlated with presence or absence of symptoms reported by patients (ordinal regression pseudo-R2 = 0.392, p = 0.010). Enhanced mass spectrometry is a new tool for studying tick-borne pathogen infections.

Tick-Borne Diseases in the United States

BACKGROUND

Tick-borne diseases are an important cause of human morbidity and mortality in the United States. The past several decades have witnessed an increase in both the number of recognized tick-borne pathogens and the number of tick-borne disease cases, whereas tick surveys have revealed substantial geographic expansions of tick populations throughout the country. Multiple laboratory testing options exist for diagnosis of tick-borne diseases, including serology, microscopy, and molecular-based methods. The preferred approach varies by the specific disease, locally available test options, and the stage of illness at patient presentation. Accurate and timely detection of tick-borne illness is of utmost importance, as prompt treatment is strongly linked to better outcomes.

CONTENT

This review covers the clinical manifestations and preferred diagnostic approaches for important bacterial, viral, and parasitic tick-borne diseases in the United States, including Lyme disease, tick-borne relapsing fever, anaplasmosis, ehrlichiosis, spotted fever rickettsioses, and babesiosis. Infection with emerging pathogens such as Borrelia miyamotoi, Powassan virus, Heartland virus, Colorado tick fever virus, and Bourbon virus are also covered.

SUMMARY

Our understanding of tick-borne diseases in the United States continues to improve with the detection of novel pathogens and development of new diagnostic modalities. While conventional diagnostic methods, including serology and microscopy, will play an ongoing role in the diagnosis of tick-borne diseases, implementation of advanced molecular diagnostics will further broaden our understanding of these diseases by facilitating detection of emerging pathogens and providing more accurate and timely diagnosis.

Surveillance for Borrelia spp. in Upland Game Birds in Pennsylvania, USA

The Borrelia genus contains two major clades, the Lyme borreliosis group, which includes the causative agents of Lyme disease/borreliosis (B. burgdorferi sensu stricto and other related B. burgdorferi sensu lato genospecies), and the relapsing fever borreliosis group (B. hermsii, B. turicatae, and B. parkeri). Other unclassified reptile- and echidna-associated Borrelia spp. (i.e., B. turcica and 'Candidatus Borrelia tachyglossi', respectively) do not belong in either of these two groups. In North America, Borrelia spp. from both of the major clades are important pathogens of veterinary and public health concern. Lyme disease is of particular interest because the incidence in the northeastern United States continues to increase in both dogs and humans. Birds have a potentially important role in the ecology of Borrelia species because they are hosts for numerous tick vectors and competent hosts for various Borrelia spp. Our goal was to investigate the prevalence of Borrelia spp. in four free-living species of upland game birds in Pennsylvania, USA including wild turkey (Meleagris gallopavo), ruffed grouse (Bonasa umbellus), ring-necked pheasants (Phasianus colchicus), and American woodcock (Scolopax minor). We tested 205 tissue samples (bone marrow and/or spleen samples) from 169 individuals for Borrelia using a flagellin gene (flab) nested PCR, which amplifies all Borrelia species. We detected Borrelia DNA in 12% (24/205) of samples, the highest prevalence was in wild turkeys (16%; 5/31), followed by ruffed grouse (13%; 16/126) and American woodcock (3%; 1/35). All pheasants (n = 13) were negative. We sequenced amplicons from all positive game birds and all were B. burgdorferi sensu stricto. Our results support previous work indicating that certain species of upland game birds are commonly infected with Borrelia species, but unlike previous studies, we did not find any relapsing fever borreliae.

Advancing the Science of Tick and Tick-Borne Disease Surveillance in the United States

Globally, vector-borne diseases are an increasing public health burden; in the United States, tick-borne diseases have tripled in the last three years. The United States Centers for Disease Control and Prevention (CDC) recognizes the need for resilience to the increasing vector-borne disease burden and has called for increased partnerships and sustained networks to identify and respond to the most pressing challenges that face vector-borne disease management, including increased surveillance. To increase applied research, develop communities of practice, and enhance workforce development, the CDC has created five regional Centers of Excellence in Vector-borne Disease. These Centers are a partnership of public health agencies, vector control groups, academic institutions, and industries. This special issue on tick and tick-borne disease surveillance is a collection of research articles on multiple aspects of surveillance from authors that are affiliated with or funded by the CDC Centers of Excellence. This body of work illustrates a community-based system of research by which participants share common problems and use integrated methodologies to produce outputs and effect outcomes that benefit human, animal and environmental health.

Identification of immunoreactive linear epitopes of Borrelia miyamotoi

Borrelia miyamotoi is an emerging tick-borne spirochete transmitted by ixodid ticks. Current serologic assays for B. miyamotoi are impacted by genetic similarities to other Borrelia and limited understanding of optimal antigenic targets. In this study, we employed the TBD-Serochip, a peptide array platform, to identify new linear targets for serologic detection of B. miyamotoi. We examined a wide range of suspected B. miyamotoi antigens and identified 352 IgM and 91 IgG reactive peptides, with the majority mapping to variable membrane proteins. These included peptides within conserved fragments of variable membrane proteins that may have greater potential for differential diagnosis. We also identified reactive regions on FlaB, and demonstrate crossreactivity of B. burgdorferi s.l. C6 with a B. miyamotoi C6-like peptide. The panel of linear peptides identified in this study can be used to enhance serodiagnosis of B. miyamotoi.

A 4-Yr Survey of the Range of Ticks and Tick-Borne Pathogens in the Lehigh Valley Region of Eastern Pennsylvania

Questing ticks were surveyed by dragging in forested habitats within the Lehigh Valley region of eastern Pennsylvania for four consecutive summers (2015-2018). A high level of inter-annual variation was found in the density of blacklegged tick nymphs, Ixodes scapularis Say, with a high density of host-seeking nymphs (DON) in summer 2015 and 2017 and a relatively low DON in summer 2016 and 2018. Very few American dog ticks (Dermacentor variabilis Say) and Ixodes cookei Packard were collected. Lone star ticks (Amblyomma americanum L.) and longhorned ticks (Haemaphysalis longicornis Neumann) were not represented among the 6,398 ticks collected. For tick-borne pathogen surveillance, DNA samples from 1,721 I. scapularis nymphs were prepared from specimens collected in summers 2015-2017 and screened using qPCR, high resolution melting analysis, and DNA sequencing when necessary. The overall 3-yr nymphal infection prevalence of Borrelia burgdorferi was 24.8%, Borrelia miyamotoi was 0.3%, Anaplasma phagocytophilum variant-ha was 0.8%, and Babesia microti was 2.8%. Prevalence of coinfection with B. burgdorferi and B. microti as well as B. burgdorferi and A. phagocytophilum variant-ha were significantly higher than would be expected by independent infection. B. burgdorferi nymphal infection prevalence is similar to what other studies have found in the Hudson Valley region of New York, but levels of B. microti and A. phagocytophilum variant-ha nymphal infection prevalence are relatively lower. This study reinforces the urgent need for continued tick and pathogen surveillance in the Lehigh Valley region.