Human granulocytic anaplasmosis in the United States from 2008 to 2012: a summary of national surveillance data

First Report on the Molecular Detection and Characterization of Rickettsia felis in Laelapidae (Acari: Mesostigmata) Mites in Malaysia

Rickettsiae are Gram-negative and obligate intracellular bacteria that cause rickettsioses. These pathogens are typically transmitted by arthropod vectors, such as ticks, mesostigmatid mites, and fleas. Rickettsiae are responsible for many emerging infectious diseases worldwide and are the second most frequently reported cause of non-malarial febrile illnesses in Southeast Asia. However, in Malaysia, studies on the prevalence and distribution of rickettsiae have primarily focused on humans, with limited data on these bacteria in vectors and small mammal hosts. Thus, this study aims to investigate the presence of Rickettsia spp. in small mammals and their associated mesostigmatid mites collected from potential rickettsioses areas in Selangor. Animal trapping was conducted across three different ecological study sites comprising a recreational area, agricultural land, and coastal area. A total of 41 small mammals and 363 mesostigmatid mites were collected and identified. Ten percent of the total individual mites were processed for morphological examination, and the remaining mites were then pooled by hosts, with five individual mites per tube, for DNA extraction. The collected samples, comprising blood, animal tissue, and pooled mites, were subjected to DNA extraction and were screened for Rickettsia spp. via nested polymerase chain reaction (PCR), targeting the citrate synthase-encoding gene (gltA) and outer membrane protein B gene (ompB). Interestingly, two pools (3.33%) of Laelaps spp. recovered from Maxomys whiteheadi and Bandicota indica, collected from a recreational area, tested positive for Rickettsia spp. Sequence analysis and phylogenetic tree of the ompB gene revealed the presence of Rickettsia felis in both laelapid mite pools. To our knowledge, this study provides the first molecular detection of R. felis in Laelaps spp. in Malaysia.

Antibodies to Anaplasma phagocytophilum in Patients with Human Granulocytic Anaplasmosis Confirmed by Both Polymerase Chain Reaction and Culture

BACKGROUND/AIMS

Sera from patients from a single medical institution in New York State with human granulocytic anaplasmosis established by a positive polymerase chain reaction test (PCR) for Anaplasma phagocytophilum were used to assess the performance of serologic testing. All cases were also confirmed by culture in order to eliminate any false positive PCR samples.

METHODS

A nested PCR was performed targeting the heat shock operon of A. phagocytophilum. Culture was done using the HL-60 promyelocytic cell line. Serologic testing was performed to detect IgG/A/M using an indirect immunofluorescence assay that incorporated a human isolate of A. phagocytophilum as the source of the antigen.

RESULTS

From 1997 to 2009, 38 human granulocytic anaplasmosis patients were evaluated. On the baseline serum sample 21 (55.3%; 95% CI: 38.3%-71.4%) had a positive serologic test; 7 samples (33.1%) were positive at a titer of 80-320 and 14 samples (66.7%) at a titer of at least 640. Sixteen (94.1%) of the 17 with a negative baseline test had follow-up testing performed. All 16 tested positive on a convalescent phase serum sample obtained from 6 to 45 days later.

CONCLUSION

PCR testing is the most commonly used direct diagnostic test to diagnose human granulocytic anaplasmosis. Our findings demonstrate that only approximately 55% of the PCR and culture positive cases were also seropositive on blood samples obtained at the same time point, indicating that serologic testing performed at the time of presentation has limited sensitivity. However, all of the 16 evaluable seronegative patients developed antibodies to A. phagocytophilum during convalescence.

Culture and other direct detection methods to diagnose human granulocytic anaplasmosis

OBJECTIVES

We sought to assess the performance of 3 laboratory tests on blood specimens for direct detection of Anaplasma phagocytophilum, the cause of human granulocytic anaplasmosis (HGA), in patients tested at a single medical institution in New York State.

METHODS

Direct tests included microscopic blood smear examination for intragranulocytic inclusions, polymerase chain reaction (PCR), and culture using the HL-60 cell line. The HGA cases testing positive by only 1 direct test were not included, unless HGA was confirmed by acute or convalescent serology using an indirect immunofluorescent assay.

RESULTS

From 1997 to 2009, 71 patients with HGA were diagnosed by at least 1 of the 3 direct test methods. For the subgroup of 55 patients who were tested using all 3 methods, culture was positive for 90.9% (50/55) vs 81.8% (45/55) for PCR vs 63.6% (35/55) for blood smear (P =.002). Most cultures (79.3%) were detected as positive within 1 week of incubation.

CONCLUSIONS

Although using culture to detect A phagocytophilum is likely not amenable for implementation in most hospital laboratories, in our experience, culture had the highest yield among the direct tests evaluated.

Human granulocytic anaplasmosis with rash and rhabdomyolysis: A case report

Human granulocytic anaplasmosis (HGA) is a tick-borne infection caused by Anaplasma phagocytophilum. Only seven cases of HGA have been reported in Japan to date. We report the case of a 61-year-old female farmer who developed HGA with rash and rhabdomyolysis. The patient had fever and erythema covering the entire body, including the palms. An induration with an eschar was observed on the right leg, indicating that the patient had been bitten by a tick. Elevated serum creatinine and creatinine kinase levels and hematuria indicated rhabdomyolysis. We suspected Japanese spotted fever, a tick-borne illness caused by Rickettsia Japonica, and administered minocycline and ciprofloxacin for a week. Transient neutropenia and thrombocytopenia were observed, but the symptoms improved. Polymerase chain reaction (PCR) and antibody tests for R. japonica and Orientia tsutsugamushi, which causes scrub typhus, were both negative. The PCR test for severe fever with thrombocytopenia syndrome virus was also negative. Antibodies against A. phagocytophilum-related proteins were detected by western blotting, indicating seroconversion of IgG with paired serum samples, and the patient was diagnosed with HGA. HGA should be suspected in acute febrile patients with a history of outdoor activity and cytopenia, with or without a rash. A testing system and the accumulation of cases in Japan are necessary for the early diagnosis and appropriate treatment of HGA.

Ticked Off: A Case of Disappearing Cell Lines

Human granulocytic anaplasmosis (HGA) is transmitted by the black-legged tick Ixodes scapularis and presents with fever, thrombocytopenia, leukocytopenia, and elevated transaminases. If left untreated, HGA can progress to hemophagocytic lymphohistiocytosis (HLH), which can be fatal. Here, we discuss a case of a woman diagnosed with anaplasmosis who was treated promptly. A 63-year-old female presented with a two-day history of fever and fatigue. She denied any history of hiking but confirmed an avid gardening hobby. She did not report any tick bites or rashes. Upon presentation, she was febrile but hemodynamically stable. Her laboratory results showed elevated liver function tests (LFTs) and bicytopenia, with a white blood cell count (WBC) of 0.77 k/mcL (normal = 4.4-11.3 k/mcL), an absolute neutrophil count (ANC) of 150/µL (normal = >500/µL), and a platelet count of 50 k/mcL (normal = 145-445 k/mcL). Her liver function tests (LFTs) were elevated, including alanine aminotransferase (ALT) of 75 U/L (normal = 0-40 U/L) and aspartate aminotransferase (AST) of 66 U/L (normal = 0-40 U/L). Her lab results had been normal one month prior during routine testing. She was tested for Lyme antibodies, Ehrlichia antibodies, and anaplasmosis via a polymerase chain reaction (PCR) test. She was started on doxycycline, and within two days, her counts began to recover. Her Lyme antibody titers and Ehrlichia antibody tests were negative, but she tested positive for Anaplasma phagocytophilum antibodies, confirming anaplasmosis. She was discharged home, and on follow-up, her WBC had risen to 4.6 k/mcL (normal = 4.4-11.3 k/mcL), and platelets increased to 84 k/mcL (normal = 145-445 k/mcL). Human granulocytic anaplasmosis is a rickettsial disease that typically presents with symptoms such as fatigue, malaise, fever, thrombocytopenia, and leukopenia. It carries a small but significant risk of progressing to HLH if not treated early in its course. Human granulocytic anaplasmosis has a presentation similar to ehrlichiosis and is differentiated based on PCR testing for deoxyribonucleic acid (DNA); however, since treatment is the same for both diseases, patients are often started on doxycycline before confirmatory test results are available. Physicians working in tick-endemic areas must maintain a high suspicion for rickettsial illnesses, as these patients often present with vague symptoms and can be undiagnosed if not properly evaluated.

Frequency of tick bites and associated care-seeking behaviors in the United States

Tick-borne diseases are commonly reported in the United States, but frequency of tick bites and care-seeking behaviors following tick bites are poorly understood. We used nationally representative survey data to describe the frequency of tick bites among people living in the United States and how often, where, and why care-seeking associated with tick bites occurs. We found that over 31 million people (nearly 1 in 10) living in the United States might experience a tick bite each year and highlight regional trends in associated care-seeking behaviors. These findings emphasize the need for effective tick bite prevention education and regionally tailored healthcare provider recommendations for management of tick-borne diseases.

Meta-analysis of tick-borne and other pathogens: Co-infection or co-detection? That is the question

This literature-based review aims to distinguish studies describing co-infection with tick-borne pathogens from those describing co-detection or co-exposure scenarios. The review analyzed 426 papers and identified only 20 with direct evidence of co-infection in humans and animals, highlighting the need for accurate terminology and proposing definitions for co-infection, co-exposure and co-detection. Current diagnostic methods - including serology and molecular techniques - have limitations in accurately identifying real co-infections, often leading to misinterpretation. The review highlights the importance of developing laboratory models to better understand tick-borne pathogen interactions, and advocates improved diagnostic strategies for tick screening by testing their RNA for co-infections. Moreover, the establishment of additional animal models for pathogen co-infection will help develop our understanding of selection pressures for various traits of tick-borne pathogens (such as virulence and transmissibility) over time. This comprehensive analysis provides insights into the complexity of tick-borne pathogen co-infections and calls for precise diagnostic terms to improve the clarity and effectiveness of future research.

Human granulocytotropic anaplasmosis-A systematic review and analysis of the literature

Human granulocytotropic anaplasmosis (HGA) is a zoonotic tick-borne bacterial infection caused by Anaplasma phagocytophilum. While most cases are reported from North America, HGA has been recognized as an emerging disease in several regions of the world in recent decades. Most available data comes from case reports, case series and retrospective studies, while prospective studies and clinical trials are largely lacking. To obtain a clearer picture of the currently known epidemiologic distribution, clinical and paraclinical presentation, diagnostic aspects, complications, therapeutic aspects, and outcomes of HGA, we systematically reviewed the literature and analyzed and summarized the data. Cases of HGA are reported from all continents except from Antarctica. HGA primarily presents as an unspecific febrile illness (88.5% of the cases) often accompanied by thrombocytopenia (71.8% of the cases), abnormal liver injury tests (66.7% of the cases), and leukopenia (49.8% of the cases). Although we found complications reported in a total of 40.5% of the reviewed cases and severe and even life-threatening complications are not infrequent (e.g. acute renal failure 9.8%, multi organ failure 7.5%, ARDS 6.3%, a.o.), sequelae are rare (2.1% of the cases) and lethality is low (3.0% of the cases). Treatment with doxycycline shows a rapid response, with the fever subsiding in the majority of patients within one day of starting treatment. Unlike in human monocytotropic ehrlichiosis (HME), reports of opportunistic infections complicating HGA are rare. HGA during pregnancy does not appear to be associated with unfavorable outcomes. In addition, our analysis provides some evidence that HGA may differ in clinical aspects and laboratory characteristics in different regions of the world. Overall, the data analyzed indicates a non-negligible bias in reporting/publication, so a certain degree of caution is required when generalizing the data.

A case of transfusion-transmission Anaplasma phagocytophilum from leukoreduced red blood cells

BACKGROUND

Anaplasma phagocytophilum is a tick-borne bacterium and the cause of human granulocytic anaplasmosis (HGA). Here, we report a case of transfusion-transmitted (TT)-HGA involving a leukoreduced (LR) red blood cell (RBC) unit.

CASE REPORT

A 64-year-old woman with gastric adenocarcinoma and multiple myeloma who received weekly blood transfusions developed persistent fevers, hypotension, and shortness of breath 1 week after receiving an RBC transfusion. Persistent fevers, new thrombocytopenia, and transaminitis suggested a tick-borne infection.

RESULTS

The absence of blood parasites on thick and thin blood smears suggested that malaria and Babesia infection were not present, and the recipient tested negative for antibodies to Borrelia burgdorferi. Blood testing by polymerase chain reaction (PCR) for Ehrlichia and Anaplasma species identified A. phagocytophilum. Treatment with doxycycline resolved the infection; however, the recipient expired due to complications of her known malignancies. The recipient lived in a nursing home and did not have pets or spend time outdoors. The donor was a female in her 70s from Maine who was diagnosed with HGA 3 weeks after donating blood and whose LR-RBCs from the donation were transfused to the recipient 9 days following collection.

CONCLUSION

This is a confirmed case of TT-HGA. Although rare, TT-HGA has been reported with LR-RBCs and platelets. In endemic areas, testing for tick-borne associated infections should be considered when investigating post-transfusion complications.

Myocarditis Secondary to Human Monocytotrophic Ehrlichiosis

Ehrlichiosis is a tick-borne illness that has been recognized as a source of human infection with increased incidence in the United States over the last decade. The usual presentation is with acute febrile illness, myalgia, malaise with confusion, and central nervous system abnormalities, along with laboratory data concerning transaminitis and hematological abnormalities. Though many complications have been associated with Ehrlichiosis, very few cardiac complications have been reported. We report a rare presentation of Ehrlichiosis in a 63-year-old female who presented with acute fever, transaminitis, and renal failure followed by the development of myocarditis. As part of the diagnostic work-up, an examination of the peripheral smear revealed intracytoplasmic granules in monocytes, which were later confirmed through serology to have Ehrlichia chaffeensis (E. chaffeensis). Given the high degree of initial clinical suspicion, the patient was started on empiric doxycycline and fully recovered with no disease-associated sequelae.

Epidemiological, clinical, and laboratory characteristics of human granulocytic anaplasmosis in North India

Human granulocytic anaplasmosis (HGA) is an emerging, rickettsial tick-borne disease caused by Anaplasma phagocytophilum. Sero-epidemiological data demonstrate that this pathogen has a worldwide distribution. The diagnosis of HGA requires a high index of clinical suspicion, even in endemic areas. In recent years, HGA has increasingly been reported from Asia and described in China, Japan, and Korea. We serologically and molecularly screened 467 patients with clinical suspicion of Anaplasmosis. The present study describes the epidemiology, clinical, and laboratory details of 6 confirmed and 43 probable cases of human granulocytic anaplasmosis. One of the HGA patients developed secondary invasive opportunistic Aspergillus fumigatus and Acinetobacter baumanii infection during the illness, which resulted in a fatal infection. The HGA patients without severe complications had excellent treatment responses to doxycycline. The emergence of this newly recognized tick-borne zoonotic HGA in North India is a significant concern for public health and is likely underdiagnosed, underreported, and untreated. Hence, it is also essential to establish a well-coordinated system for actively conducting tick surveillance, especially in the forested areas of the country.IMPORTANCEThe results of the present study show the clinical and laboratory evidence of autochthonous cases of Anaplasma phagocytophilum in North India. The results suggest the possibility of underdiagnosis of HGA in this geographical area. One of the HGA patients developed secondary invasive opportunistic Aspergillus fumigatus and Acinetobacter baumanii infection during the illness, which resulted in a fatal infection.

Forest-associated habitat variables influence human-tick encounters in the southeastern United States

Due to the increased frequency of human-tick encounters and expanding ranges of ticks in the United States, there is a critical need to identify environmental conditions associated with tick populations and their likelihood to contact human hosts. In a passive tick surveillance partnership with the US Department of Agriculture Forest Inventory and Analysis (FIA) program, we identified environmental variables associated with tick encounters by forestry personnel. Ticks were identified by species and life stage, and site-specific variables were associated with each tick using FIA forest inventory datasets and generalized linear models with negative binomial distributions. Of the 55 FIA variables available, we identified biotic and abiotic environmental variables associated with Amblyomma americanum L. (carbon in litter material and standing dead tree aboveground dry biomass), Dermacentor variabilis Say (seedling species unevenness and elevation), and Ixodes scapularis L. (carbon in dead woody material and seedling species unevenness). We propose conducting future treatment-control studies using these forestry-related environmental variables to test their ability to alter tick abundance at sites. Land management decisions not only affect common flora and fauna, but changes to these habitats can also alter the way ticks parasitize hosts and use vegetation to find those hosts. These results can be used with land management decisions to prevent future human-tick encounters and highlight risk areas.

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.

Identifying suitable habitat for Ixodes scapularis (Acari: Ixodidae) infected with Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), Babesia microti (Piroplasmida: Babesiidae), and Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) to guide surveillance efforts in the eastern United States

Understanding the distribution of infected ticks is informative for the estimation of risk for tickborne diseases. The blacklegged tick, Ixodes scapularis (Acari: Ixodidae), is the primary vector for 7 medically significant pathogens in United States. However, knowledge of the ranges of these pathogens in host-seeking ticks is incomplete, particularly for those occurring at low prevalence. To aid in prioritizing costly field sampling efforts, we estimated ranges of suitable habitat for Anaplasma phagocytophilum, Babesia microti, and Borrelia miyamotoi in the eastern United States based on existing county-level surveillance records. The resulting suitability maps were compared against those developed previously for Bo. burgdorferi s.s., which shares similar ecology but has been detected in a greater number of counties. The overall accuracy of the habitat suitability models was high (AUC ≥ 0.92) for all 4 pathogens. The most important predictors were related to temperature and moisture. The upper midwestern and northeastern states were predicted to be highly suitable for all 4 pathogens. Based on our models, we prioritized sampling in 431, 275, and 539 counties currently lacking pathogen records that our models classified as suitable for A. phagocytophilum, Ba. microti, and Bo. miyamotoi, respectively. As a second-tier priority, we identified 311 (A. phagocytophilum), 590 (Ba. microti), and 252 (Bo. miyamotoi) counties, based on high suitability scores for Bo. burgdorferi. Our models can be used to improve cost-effectiveness of field sampling efforts aimed at improving accuracy and completeness of pathogen distribution maps.

Complete bacterial profile and potential pathogens of cat fleas Ctenocephalides felis

Fleas are important ectoparasites and vectors associated with a wide range of pathogenic diseases, posing threats to public health concerns, especially cat fleas that spread worldwide. Understanding the microbial components is essential due to cat fleas are capable of transmitting pathogens to humans, causing diseases like plague and murine typhus. In the present study, metagenomic next-generation sequencing was applied to obtain the complete microbiota and related functions in the gut of Ctenocephalides felis. A total of 1,870 species was taxonomically recognized including 1,407 bacteria, 365 eukaryotes, 69 viruses, and 29 archaea. Proteobacteria was the dominant phylum among the six samples. Pathogens Rickettsia felis, Acinetobacter baumannii, Coxiella burnetii, and Anaplasma phagocytophilum were taxonomically identified and had high abundances in all samples. The resistance gene MexD was predominant in microbial communities of all cat fleas. We also performed epidemiological surveys of pathogens R. felis, A. baumannii, C. burnetii, and A. phagocytophilum among 165 cat fleas collected from seven provinces in China, while only the DNAs of R. felis (38/165, 23.03%) and C. burnetii (2/165, 1.21%) were obtained. The data provide new insight and understanding of flea intestinal microbiota and provided novel information for preventing and controlling fleas and their transmitted diseases.

Acute myopericarditis due to human granulocytic anaplasmosis

We present a case of a 54-year-old gentleman with a history of hypertension and chronic HIV who presented with fever and epigastric pain, found to have elevated troponin-I levels and diffuse ST-segement elevations on ECG without clinical evidence of ischemia concerning for myopericarditis. Initial laboratory findings also included thrombocytopenia and elevated aminotransferases as well as computed tomography imaging revealing splenic infarcts. Given plausible exposure to ticks, this led to the eventual diagnosis of anaplasmosis confirmed on PCR assay. Cardiac MRI images confirmed myocardial involvement, which resolved with antibiotic treatment. While rare, cardiac involvement is possible sequelae of anaplasmosis infection as illustrated by this case.

Case report: human granulocytic anaplasmosis causes acute myopericarditis with atrial fibrillation

Background

Tick-borne illness are becoming increasingly common, in a spreading geographic area. Lyme disease is a well-known cause of cardiovascular disease, but anaplasmosis has previously had relatively little reported association with conduction and myocardial disease.

Case Summary

A 65-year-old man with fever and malaise was admitted to the intensive care unit in shock. Electrocardiogram showed new atrial fibrillation and conduction abnormalities. Transthoracic echocardiogram demonstrated normal left ventricular ejection fraction but significant right ventricle dysfunction. Cardiac magnetic resonance imaging findings were consistent with myopericarditis. Workup revealed human granulocytic anaplasmosis without Lyme. He recovered with doxycycline.

Conclusion

To our knowledge, this is one of the first reported cases of anaplasmosis causing electrical conduction and myocardial disease with haemodynamic instability in an isolated infection. Treatment with appropriate antibiotics and supportive care allowed the patient to recover to his functional baseline within a month from being discharged from the hospital. Recognition of anaplasmosis in the absence of Lyme disease as a potential cause of electrical and myocardial disease is important in the context of increasing anaplasmosis incidence across the United States.

Human Granulocytic Anaplasmosis

Human granulocytic anaplasmosis (HGA) is a bacterial infection caused by Anaplasma phagocytophilum and transmitted by the bite of the black-legged (deer tick) in North America. Its incidence is increasing. HGA can be transmitted after 24 to 48 hours of tick attachment. The incubation period is 5 to 14 days after a tick bite. Symptoms include fever, chills, headache, and myalgia. Complications include shock, organ dysfunction, and death. Mortality is less than 1% with appropriate treatment. Doxycycline is first line treatment for all ages. Start it empirically if symptoms and risk factors suggest HGA. PCR is the confirmatory test of choice.

Experimental Infection of Mice and Ticks with the Human Isolate of Anaplasma phagocytophilum NY-18

Anaplasma phagocytophilum is the causative agent of tick-borne fever (TBF) and human granulocytic anaplasmosis (HGA) and is currently considered an emerging disease in the USA, Europe, and Asia. The increased prevalence of A. phagocytophilum as a human pathogen requires the detailed characterization of human isolates and the implementation of appropriate animal models. In this study, we demonstrated that the dynamics of infection with the human isolate of A. phagocytophilum NY-18 was variable in three different strains of mice (SCID, C3H/HeN, BALB/c). We further evaluated the ability of Ixodes ricinus to acquire and transmit A. phagocytophilum NY-18 and compared it with Ixodes scapularis. Larvae of both tick species effectively acquired the pathogen while feeding on infected mice. The infection rates then decreased during the development to nymphs. Interestingly, molted I. ricinus nymphs were unable to transmit the pathogen to naïve mice, which contrasted with I. scapularis. The results of our study suggest that I. ricinus is not a competent vector for the American human Anaplasma isolate. Further studies are needed to establish reliable transmission models for I. ricinus and European human isolate(s) of A. phagocytophilum.

Effect of Urbanization on Presence, Abundance, and Coinfection of Bacteria and Protozoa in Ticks in the US Great Plains

Urbanization alters components of natural ecosystems which can affect tick abundance and tick-borne disease prevalence. Likely due to these changes, tick-borne pathogen prevalence has increased in many U.S. urban areas. Despite the growing public health importance of tick-borne diseases, little is known about how they are influenced by urbanization in North America, especially in the central U.S. where several pathogens occur at or near their highest levels of incidence nationally. To determine whether urban development influences tick infection with bacteria and protozoa, we collected ticks at 16 parks across a gradient of urbanization intensity in Oklahoma City, Oklahoma, USA and tested them using a variety of PCR assays. Adult ticks tested positive for Rickettsia parkeri, R. amblyommatis, R. rhiphicephali, 'Candidatus R. andeanae', Ehrlichia chaffeensis, E. ewingii, Panola Mountain Ehrlichia, 'Borrelia lonestari', Theileria cervi, Babesia spp. Coco, and Cytauxzoon felis. These results indicate the presence of a high diversity of tick-borne bacteria and protozoa across an expanding urban area in the U.S. Great Plains. Although there appeared to be some risk of encountering tick-borne microorganisms across the entire urbanization gradient, E. chaffeensis, E. ewingii, and T. cervi-infected ticks and microbe diversity decreased with increasing urbanization intensity. We identified a low rate of coinfection between different microorganisms, with coinfected ticks mainly collected from sites in the least-urbanized areas. This study suggests the need for awareness of tick-borne disease risk throughout urban areas in the central U.S., and highlights a need for studies of tick host habitat use and movement in cities.

Anaplasmosis-Related Fatality in Vermont: A Case Report

Human granulocytic anaplasmosis is an acute febrile tick-borne illness caused by the bacterium Anaplasma phagocytophilum. An anaplasmosis-related fatality in a Vermont resident with multiple comorbidities is described. Clinicians should be aware of the risk factors for severe outcomes of this emerging disease and promptly treat when suspected.

A Comparative Spatial and Climate Analysis of Human Granulocytic Anaplasmosis and Human Babesiosis in New York State (2013-2018)

Human granulocytic anaplasmosis (HGA) and human babesiosis are tick-borne diseases spread by the blacklegged tick (Ixodes scapularis Say, Acari: Ixodidae) and are the result of infection with Anaplasma phagocytophilum and Babesia microti, respectively. In New York State (NYS), incidence rates of these diseases increased concordantly until around 2013, when rates of HGA began to increase more rapidly than human babesiosis, and the spatial extent of the diseases diverged. Surveillance data of tick-borne pathogens (2007 to 2018) and reported human cases of HGA (n = 4,297) and human babesiosis (n = 2,986) (2013-2018) from the New York State Department of Health (NYSDOH) showed a positive association between the presence/temporal emergence of each pathogen and rates of disease in surrounding areas. Incidence rates of HGA were higher than human babesiosis among White and non-Hispanic/non-Latino individuals, as well as all age and sex groups. Human babesiosis exhibited higher rates among non-White individuals. Climate, weather, and landscape data were used to build a spatially weighted zero-inflated negative binomial (ZINB) model to examine and compare associations between the environment and rates of HGA and human babesiosis. HGA and human babesiosis ZINB models indicated similar associations with forest cover, forest land cover change, and winter minimum temperature; and differing associations with elevation, urban land cover change, and winter precipitation. These results indicate that tick-borne disease ecology varies between pathogens spread by I. scapularis.

Ehrlichiosis and Anaplasmosis among Transfusion and Transplant Recipients in the United States

Physicians should be aware that these infections are rare but can have severe outcomes.

Ehrlichiosis and anaplasmosis are emerging tickborne diseases that can also be transmitted through blood transfusions or organ transplants. Since 2000, ehrlichiosis and anaplasmosis cases in the United States have increased substantially, resulting in potential risk to transplant and transfusion recipients. We reviewed ehrlichiosis and anaplasmosis cases among blood transfusion and solid organ transplant recipients in the United States from peer-reviewed literature and Centers for Disease Control and Prevention investigations. We identified 132 cases during 1997–2020, 12 transfusion-associated cases and 120 cases in transplant recipients; 8 cases were donor-derived, and in 13 cases illness occurred <1 year after transplant. Disease in the remaining 99 cases occurred ≥1 year after transplant, suggesting donor-derived disease was unlikely. Severe illness or death were reported among 15 transfusion and transplant recipients. Clinicians should be alert for these possible infections among transfusion and transplant recipients to prevent severe complications or death by quickly treating them.

Ehrlichiosis and anaplasmosis subcommittee report to the Tick-borne Disease Working Group

Ehrlichioses and anaplasmosis have undergone dramatic increases in incidence, and the geographic ranges of their occurrence and vectors have also expanded. There is marked underreporting of these diseases owing to deficient physician awareness and knowledge of the illnesses as well as limited access to appropriate diagnostic tests. Human monocytic ehrlichiosis and anaplasmosis are life threatening diseases with estimated case fatality rates of 2.7 and 0.3%, respectively. However, knowledge of their full range of signs and symptoms is incomplete, and the incidence of subclinical infections is unknown. Currently available laboratory diagnostic methods are poorly utilized, and with the exception of nucleic acid amplification tests are not useful for diagnosis during the acute stage of illness when timely treatment is needed. The Ehrlichiosis and Anaplasmosis Subcommittee of the Tick-Borne Disease Working Group recommended active clinical surveillance to determine the true incidence, full clinical spectrum, and risk factors for severe illness, as well as standardized surveillance of ticks for these pathogens, and enhanced education of primary medical caregivers and the public regarding these diseases. The subcommittee identified the needs to develop sensitive, specific acute stage diagnostic tests for local clinical laboratories and point-of-care testing, to develop approaches for utilizing electronic medical records, data mining, and artificial intelligence for assisting early diagnosis and treatment, and to develop adjunctive therapies for severe disease.

Protozoan and Microbial Pathogens of House Cats in the Province of Tekirdag in Western Turkey

Domestic felines’ re-emerging infectious and neglected zoonotic diseases are a significant focus of global “One Health” efforts. This study aimed to rapidly diagnose 14 pathogens, including zoonoses by using PCR primers in 167 client-owned symptomatic cats, routinely accepted to the Veterinary Clinics of Tekirdag. The prevalence of pathogens investigated were as follows: Babesia canis canis (24%), Babesia microti (2.4%), Hepatozoon felis (10.8%), Cytauxzoon felis (6.6%), Bartonella henselae (40.1%), Anaplasma platys (30.5%), Anaplasma phagocytophilum (7.2%), Rickettsia felis (26.3%), Borrelia burgdorferi (21%), and hemotropic Mycoplasma sp. (11.4%). There was a significant difference between the prevalence of the pathogens (χ² = 152.26, df = 9, p < 0.001). There was also a statistical difference between the gender of the cats in terms of the prevalence of all pathogens considered together (χ² = 4.80, df = 1, p = 0.028), where the female cats showed a higher prevalence. This was not the case for the different age groups (χ² = 2.92, df = 1, p = 0.088). The lowest infection was observed for B. microti (p < 0.001), while the highest infection was observed for B. henselae (p < 0.01). Leishmania donovani, Plasmodium spp., Ehrlichia chaffeensis, and Neoehrlichia mikurensis PCR test results were negative in all samples. In conclusion, house cats of Tekirdag are apparently highly susceptible to some neglected zoonoses important for “One Health”, and their prevalence in the region is most probably underestimated. Hence, applying PCR tests to assist fast clinic diagnosis in routine, may be an efficient option to protect the public as well as the cats from severe diseases.

Clinical Decision Support Trees Can Help Optimize Utilization of Anaplasma phagocytophilum Nucleic Acid Amplification Testing

Anaplasmosis, a tick-borne illness caused by Anaplasma phagocytophilum (AP), presents with nonspecific clinical symptoms, including fever and headache, and is often accompanied by laboratory abnormalities of leukopenia, thrombocytopenia, and mildly elevated liver function tests (LFTs). Laboratory confirmation of acute infection occurs with nucleic acid amplification testing (NAAT). This retrospective cohort study aimed to develop a clinical decision support algorithm to aid in decision-making about test ordering. A data set was constructed with AP NAAT results and time-adjacent complete blood count and LFT results for adult patients tested for AP in a 12.5-year period. A second, smaller data set matched each patient with a positive AP NAAT to two patients with negative tests. Chart review for clinical symptoms was performed on this smaller data set. A decision tree algorithm was deployed to identify patient clusters with negative AP NAAT results. A total of 137/1,204 (11%) patients tested positive by NAAT for AP. In the larger, laboratory-only data set (n = 1,204), patients with a platelet count of >177 × 10³/μl and age of <48 years had a negative AP NAAT (204/1,204, 17%, P < 0.05). In the smaller, cohorted data set with chart review (n = 402), patients with a platelet count of >188 × 10³/μl and no fever or chills also did not have positive AP NAAT (58/402, 14%, P < 0.05). We generated two decision trees that can help determine the utility of AP NAAT using readily available clinical and laboratory data. These have the potential to significantly reduce unnecessary AP testing.

Epidemiology and Spatial Emergence of Anaplasmosis, New York, USA, 2010‒2018

Human granulocytic anaplasmosis, a tickborne disease caused by the bacterium Anaplasma phagocytophilum, was first identified during 1994 and is now an emerging public health threat in the United States. New York state (NYS) has experienced a recent increase in the incidence of anaplasmosis. We analyzed human case surveillance and tick surveillance data collected by the NYS Department of Health for spatiotemporal patterns of disease emergence. We describe the epidemiology and growing incidence of anaplasmosis cases reported during 2010–2018. Spatial analysis showed an expanding hot spot of anaplasmosis in the Capital Region, where incidence increased >8-fold. The prevalence of A. phagocytophilum increased greatly within tick populations in the Capital Region over the same period, and entomologic risk factors were correlated with disease incidence at a local level. These results indicate that anaplasmosis is rapidly emerging in a geographically focused area of NYS, likely driven by localized changes in exposure risk.

Rhabdomyolysis and Multisystem Organ Failure Due to Fulminant Ehrlichiosis Infection

A previously healthy 51-y-old male presented to his local emergency department with subjective fevers, myalgias, dyspnea, and generalized weakness that had been progressive for several weeks. He was initially diagnosed with bilateral pneumonia, septic shock, and rhabdomyolysis requiring transfer to a tertiary care facility. He was treated for sepsis with broad-spectrum antibiotics, steroids, and a fluid bolus before transfer. Once he arrived at the tertiary care facility, he developed respiratory failure requiring intubation and ventilatory support. Ceftriaxone and metronidazole were started in the intensive care unit to cover common causes of community-acquired versus aspiration pneumonia, and doxycycline was included to cover tick-borne disease based on a history of tick exposure from working in his rural yard. Blood polymerase chain reaction testing later confirmed ehrlichiosis. The patient had a prolonged hospital course requiring ventilatory support and vasopressors, followed by a 4-wk stay in a rehabilitation unit after discharge. Wilderness medical providers should counsel their patients on prevention of tick bites and keep tickborne illness in the differential for acute illness, based on local epidemiology.

Ticking on Pandora's box: a prospective case-control study into 'other' tick-borne diseases

BACKGROUND

Tick-borne pathogens other than Borrelia burgdorferi sensu lato - the causative agent of Lyme borreliosis - are common in Ixodes ricinus ticks. How often these pathogens cause human disease is unknown. In addition, diagnostic tools to identify such diseases are lacking or reserved to research laboratories. To elucidate their prevalence and disease burden, the study 'Ticking on Pandora's Box' has been initiated, a collaborative effort between Amsterdam University Medical Center and the National Institute for Public Health and the Environment.

METHODS

The study investigates how often the tick-borne pathogens Anaplasma phagocytophilum, Babesia species, Borrelia miyamotoi, Neoehrlichia mikurensis, spotted fever group Rickettsia species and/or tick-borne encephalitis virus cause an acute febrile illness after tick-bite. We aim to determine the impact and severity of these tick-borne diseases in the Netherlands by measuring their prevalence and describing their clinical picture and course of disease. The study is designed as a prospective case-control study. We aim to include 150 cases - individuals clinically suspected of a tick-borne disease - and 3 matched healthy control groups of 200 persons each. The controls consist respectively of a group of individuals with either a tick-bite without complaints, the general population and of healthy blood donors. During a one-year follow-up we will acquire blood, urine and skin biopsy samples and ticks at baseline, 4 and 12 weeks. Additionally, participants answer modified versions of validated questionnaires to assess self-reported symptoms, among which the SF-36, on a 3 monthly basis.

DISCUSSION

This article describes the background and design of the study protocol of 'Ticking on Pandora's Box'. With our study we hope to provide insight into the prevalence, clinical presentation and disease burden of the tick-borne diseases anaplasmosis, babesiosis, B. miyamotoi disease, neoehrlichiosis, rickettsiosis and tick-borne encephalitis and to assist in test development as well as provide recommendations for national guidelines.

TRIAL REGISTRATION

NL9258 (retrospectively registered at Netherlands Trial Register, trialregister.nl in in February 2021).

Human granulocytic anaplasmosis in a Single University Hospital in the Republic of Korea

To date, only a few studies have analyzed the clinical characteristics and genetic features of human granulocytic anaplasmosis (HGA) in South Korea. Thus, in this study, we investigated the clinical characteristics of HGA and methods used for clinical diagnosis. The clinical characteristics of patients with HGA were studied retrospectively. We reviewed the medical charts of 21 confirmed patients with HGA admitted to the Chosun University Hospital, located in Gwangju, South Korea. Twenty-one HGA patients visited the hospital 2-30 days (median 7 days) after the onset of symptoms. Fourteen patients (66.7%) had fever, which was alleviated 2 h (range 0-12.75 h) after starting treatment with doxycycline. Of the 18 patients who underwent peripheral blood (PB) smear test, only one (5.6%) had morulae. Additionally, only 4/17 patients (23.5%) had morulae in the PB smear reconducted after the confirmation of anaplasmosis. All 21 patients recovered without significant complications. As per results of the blood tests conducted at the time of admission, 7/21 (33.3%) and 5/21 (23.8%) patients showed at least 1:16 and 1:80 of IgM and IgG titers, respectively. Most HGA patients in Korea recovered without significant complications. The indirect immunofluorescence antibody diagnosis or morulae identification for HGA in this study had low sensitivity in the early stage of the disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

A Case of Anaplasmosis during a Warm Minnesota Fall

A healthy 33 year old male presented in December with a 3 week history of fever and fatigue. He had been deer-hunting in northern Minnesota 1 month prior and had sustained a tick bite. Extensive laboratory investigations and a lumbar puncture were conducted. He was empirically with doxycycline and had rapid improvement in his symptoms. Subsequently, PCR and serologic testing returned positive for Anaplasma phagocytophlium. Anaplasmosis is a tick-borne illness caused by the bacterium Anaplasma phagocytophilum and is typically seen in the warmer months. This patient’s presentation in December was uncommon for a tick-borne illness in Minnesota. Regional weather records demonstrated unseasonably warm temperatures during the patient’s trip. Ixodes ticks are known to be sensitive to temperature and humidity, which likely contributed to increased tick activity, leading to disease transmission. This case highlights the importance for clinicians to be aware of local weather patterns and how this might influence seasonal disease presentations.

Transient Arrhythmia in a Patient With Human Granulocytic Anaplasmosis: An Uncanny Presentation

This is a case of a 69-year-old male, with well-controlled rheumatoid arthritis and benign prostatic hyperplasia, who presented with fever and generalized weakness. He was found to have atrial fibrillation on his second emergency department visit and later diagnosed with human granulocytic anaplasmosis (HGA). Atrial fibrillation subsided with the commencement of HGA-specific treatment. This is the first case of HGA and atrial fibrillation reported in the English literature. It highlights the importance of being vigilant for unusual presentations of tick-borne diseases in the endemic areas.

Use of Routine Complete Blood Count Results to Rule Out Anaplasmosis Without the Need for Specific Diagnostic Testing

BACKGROUND

Anaplasmosis presents with fever, headache, and laboratory abnormalities including leukopenia and thrombocytopenia. Polymerase chain reaction (PCR) is the preferred diagnostic but is overutilized. We determined if routine laboratory tests could exclude anaplasmosis, improving PCR utilization.

METHODS

Anaplasma PCR results from a 3-year period, with associated complete blood count (CBC) and liver function test results, were retrospectively reviewed. PCR rejection criteria, based on white blood cell (WBC) and platelet (PLT) counts, were developed and prospectively applied in a mock stewardship program. If rejection criteria were met, a committee mock-refused PCR unless the patient was clinically unstable or immunocompromised.

RESULTS

WBC and PLT counts were the most actionable routine tests for excluding anaplasmosis. Retrospective review demonstrated that rejection criteria of WBC ≥11 000 cells/µL or PLT ≥300 000 cells/µL would have led to PCR refusal in 428 of 1685 true-negative cases (25%) and 3 of 66 true-positive cases (5%) involving clinically unstable or immunocompromised patients. In the prospective phase, 155 of 663 PCR requests (23%) met rejection criteria and were reviewed by committee, which endorsed refusal in 110 of 155 cases (71%) and approval in 45 (29%), based on clinical criteria. PCR was negative in all 45 committee-approved cases. Only 1 of 110 mock-refused requests yielded a positive PCR result; this patient was already receiving doxycycline at the time of testing.

CONCLUSIONS

A CBC-based stewardship algorithm would reduce unnecessary Anaplasma PCR testing, without missing active cases. Although the prospectively evaluated screening approach involved medical record review, this was unnecessary to prevent errors and could be replaced by a rejection comment specifying clinical situations that might warrant overriding the algorithm.

Functional inhibition or genetic deletion of acid sphingomyelinase bacteriostatically inhibits Anaplasma phagocytophilum infection in vivo

Anaplasma phagocytophilum infects neutrophils to cause granulocytic anaplasmosis. It poorly infects mice deficient in acid sphingomyelinase (ASM), a lysosomal enzyme critical for cholesterol efflux, and wild-type mice treated with desipramine that functionally inhibits ASM. Whether inhibition or genetic deletion of ASM is bacteriostatic or bactericidal for A. phagocytophilum and desipramine's ability to lower pathogen burden requires a competent immune system were unknown. Anaplasma phagocytophilum-infected severe combined immunodeficiency disorder (SCID) mice were administered desipramine or PBS, followed by the transfer of blood to naïve wild-type mice. Next, infected wild-type mice were given desipramine or PBS followed by transfer of blood to naïve SCID mice. Finally, wild-type or ASM-deficient mice were infected and blood transferred to naïve SCID mice. The percentage of infected neutrophils was significantly reduced in all desipramine-treated or ASM-deficient mice and in all recipients of blood from these mice. Infection was markedly lower in ASM-deficient and desipramine-treated wild-type mice versus desipramine-treated SCID mice. Yet, infection was never ablated. Thus, ASM activity contributes to optimal A. phagocytophilum infection in vivo, pharmacologic inhibition or genetic deletion of ASM impairs infection in a bacteriostatic and reversible manner and A. phagocytophilum is capable of co-opting ASM-independent lipid sources.

Surge in Anaplasmosis Cases in Maine, USA, 2013-2017

Incidence of human granulocytic anaplasmosis is rising in Maine, USA. This increase may be explained in part by adoption of tick panels as a frequent diagnostic test in persons with febrile illness and in part by range expansion of Ixodes scapularis ticks and zoonotic amplification of Anaplasma phagocytophilum.

Pattern Recognition Receptors in Innate Immunity to Obligate Intracellular Bacteria

Host pattern recognition receptors (PRRs) are crucial for sensing pathogenic microorganisms, launching innate responses, and shaping pathogen-specific adaptive immunity during infection. Rickettsia spp., Orientia tsutsugamushi, Anaplasma spp., Ehrlichia spp., and Coxiella burnetii are obligate intracellular bacteria, which can only replicate within host cells and must evade immune detection to successfully propagate. These five bacterial species are zoonotic pathogens of clinical or agricultural importance, yet, uncovering how immune recognition occurs has remained challenging. Recent evidence from in-vitro studies and animal models has offered new insights into the types and kinetics of PRR activation during infection with Rickettsia spp., A. phagocytophilum, E. chaffeensis, and C. burnetii, respectively. However, much less is known in these regards for O. tsutsugamushi infection, until the recent discovery for the role of the C-type lectin receptor Mincle during lethal infection in mice and in primary macrophage cultures. This review gives a brief summary for clinical and epidemiologic features of these five bacterial infections, focuses on fundamental biologic facets of infection, and recent advances in host recognition. In addition, we discuss knowledge gaps for innate recognition of these bacteria in the context of disease pathogenesis.

First identification of Anaplasma phagocytophilum in both a biting tick Ixodes nipponensis and a patient in Korea: a case report

BACKGROUND

Human granulocytic anaplasmosis (HGA) is a tick-borne infectious disease caused by Anaplasma phagocytophilum. To date, there have been no reported cases of A. phagocytophilum infection found in both the biting tick and the patient following a tick bite.

CASE PRESENTATION

An 81-year-old woman presented with fever following a tick bite, with the tick still intact on her body. The patient was diagnosed with HGA. The tick was identified as Ixodes nipponensis by morphological and molecular biological detection methods targeting the 16S rRNA gene. The patient's blood was cultured after inoculation into the human promyelocytic leukemia cell line HL-60. A. phagocytophilum growth was confirmed via culture and isolation. A. phagocytophilum was identified in both the tick and the patient's blood by Anaplasma-specific groEL- and ankA-based nested polymerase chain reaction followed by sequencing. Moreover, a four-fold elevation in antibodies was observed in the patient's blood.

CONCLUSION

We report a case of a patient diagnosed with HGA following admission for fever due to a tick bite. A. phagocytophilum was identified in both the tick and the patient, and A. phagocytophilum was successfully cultured. The present study suggests the need to investigate the possible incrimination of I. nipponensis as a vector for HGA in Korea.

Increasing Incidence of Anaplasmosis in the United States, 2012 Through 2016

Anaplasmosis is a tick-borne disease that is primarily caused by the rickettsial bacterium Anaplasma phagocytophilum. Anaplasmosis is a febrile disease with common symptoms, including headaches, fever, and lethargy, but it can cause serious organ failure and even death if left untreated. Human infections are reported annually to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System (NNDSS). This report analyzed the cases of anaplasmosis reported by the NNDSS from 2012 to 2016. In total, there were 15,778 reported A. phagocytophilum infections, and the incidence rate was 7.27 cases per million persons per year, with the number of reported cases increasing each year. The demographic group most affected was middle-aged and elderly white males. Infections were most abundant in the coastal northeast and northern midwest regions. Our study provides useful results for a basic understanding of incidence, distribution, and severity of A. phagocytophilum infections.

Ixodes spp. from Dogs and Cats in the United States: Diversity, Seasonality, and Prevalence of Borrelia burgdorferi and Anaplasma phagocytophilum

Ixodes spp. are commonly found on dogs and cats throughout the world. In the eastern United States, 16S rDNA sequence of Ixodes scapularis, the predominant species, reveals two clades-American and Southern. To confirm the species and clades of Ixodes spp. ticks submitted from pets, we examined ticks morphologically and evaluated 16S rDNA sequence from 500 ticks submitted from 253 dogs, 99 cats, 1 rabbit, and 1 ferret from 41 states. To estimate pathogen prevalence, flaB of Borrelia burgdorferi (Bb) sensu stricto and 16S rDNA of Anaplasma phagocytophilum (Ap) were amplified and sequenced. Most Ixodes spp. from the Northeast (n = 115/115; 100%) and the Midwest (n = 77/80; 96.3%) were I. scapularis, American clade. Borrelia spp. were identified in 34 of 192 (17.8%) and Ap in 5 of 192 (2.6%) I. scapularis. Two Ixodes cookei and one Ixodes texanus were identified from Ohio, Illinois, and Michigan. In contrast, 156 of 261 (59.8%) Ixodes spp. from the Southeast were I. scapularis, American clade; 86 of 261 (33.0%) were I. scapularis, Southern clade; 9 of 261 (3.4%) were Ixodes affinis; and 10 of 261 (3.8%) were I. cookei. Southern clade was significantly more common in Florida and less common in the upper South (p < 0.0001). One I. scapularis (1/242; 0.4%) from the Southeast (Kentucky) tested positive for Bb and 6 of 242 (2.5%) were positive for Ap. In the West, most (34/44; 77.3%) Ixodes spp. were Ixodes pacificus, with Ixodes angustus (n = 6) submitted from dogs in Alaska, Washington, and Oregon and Ixodes haerlei (n = 4) preliminarily identified from a dog in Montana. Pathogens were not detected in any ticks from the West. Although I. scapularis, American clade, predominated in the Northeast and Midwest, additional Ixodes spp. were found on dogs and cats in other regions and pathogens were less commonly detected. The role of less common Ixodes spp. as disease vectors, if any, warrants continued investigation.