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Lyme Disease Coinfections: Symptoms, Testing, and Treatment Challenges
A single tick bite may transmit multiple infections
Coinfections can change symptoms, testing, and treatment response
Recognizing them early may alter recovery patterns
Lyme disease coinfections can complicate diagnosis, intensify symptoms, and alter recovery patterns following a tick bite.
Ticks may carry multiple infectious organisms simultaneously. As a result, some patients diagnosed with Lyme disease are also infected with other tick-borne pathogens.
These additional infections are commonly referred to as coinfections.
Coinfections can change symptom patterns, influence laboratory findings, and complicate treatment response. In some cases, they may contribute to more severe or persistent illness.
Different pathogens can affect different body systems. Some primarily affect red blood cells, while others target white blood cells, blood vessels, or the nervous system.
Because symptom overlap is common, coinfections are often difficult to recognize early in illness.
Why Coinfections Matter
Patients with Lyme disease do not always present with the same symptom patterns or recovery trajectories.
One reason may be the presence of coinfections transmitted during the same tick exposure.
Some patients experience disproportionately severe fatigue, night sweats, neurologic symptoms, autonomic dysfunction, or psychiatric symptoms that are not fully explained by Lyme disease alone.
Recognizing these overlapping infections may help explain why some patients remain significantly ill despite treatment directed at Borrelia burgdorferi.
Babesia
Babesia is a malaria-like parasite that infects red blood cells.
Patients commonly report profound fatigue, drenching night sweats, chills, shortness of breath, chest pressure, temperature dysregulation, or “air hunger.”
Symptoms may fluctuate and often worsen during physical stress or exertion.
Babesia may contribute to persistent fatigue and autonomic symptoms even after Lyme disease treatment has begun.
Bartonella
Bartonella is associated with a wide range of neurologic, vascular, and inflammatory symptoms.
Patients may report burning foot pain, neuropathy, anxiety, mood changes, headaches, cognitive dysfunction, vascular skin changes, or unusual sensory symptoms.
Some patients experience neuropsychiatric symptoms that overlap with autonomic dysfunction or small fiber neuropathy.
Anaplasmosis and Ehrlichiosis
Anaplasmosis and ehrlichiosis are bacterial infections that affect white blood cells.
These infections may cause high fever, muscle aches, headaches, abnormal liver function tests, low white blood cell counts, or low platelet counts.
Acute illness may resemble influenza or another systemic viral infection.
Some patients become significantly ill early in the disease course.
Powassan Virus
Powassan virus is a rare but potentially serious tick-borne viral infection.
Unlike bacterial coinfections, Powassan virus may cause encephalitis, severe neurologic symptoms, seizures, or long-term neurologic complications.
Although uncommon, its recognition highlights the broad infectious potential associated with tick exposure.
Why Coinfections Are Often Missed
Coinfections frequently overlap clinically with Lyme disease itself.
Patients may experience fatigue, headaches, dizziness, pain, cognitive dysfunction, or autonomic symptoms regardless of which pathogen is dominant.
Testing limitations also complicate diagnosis. Some infections are difficult to detect early, while others may fluctuate over time or produce nonspecific laboratory findings.
When symptoms are broad or evolving, clinicians may focus primarily on Lyme disease while overlooking additional pathogens.
Reviewing the limitations of Lyme disease testing may help explain why diagnosis can become complicated in multisystem illness.
Coinfections and Persistent Symptoms
Some patients continue to experience fatigue, cognitive problems, pain, dysautonomia, or other symptoms despite treatment for Lyme disease alone.
When coinfections are missed, patients may appear not to improve as expected even when a different pathogen is driving symptoms.
Coinfections may contribute to more persistent or multisystem illness patterns and may overlap with post-treatment Lyme disease syndrome (PTLDS).
For example, Babesia may contribute to drenching night sweats, air hunger, temperature dysregulation, and profound fatigue, while Bartonella may be associated with burning foot pain, neuropathic symptoms, vascular manifestations, or neuropsychiatric changes.
Recognizing these overlapping patterns may help explain why recovery trajectories differ significantly between patients.
Clinical Takeaway
Lyme disease coinfections may complicate diagnosis, testing interpretation, symptom patterns, and recovery trajectories.
When symptoms appear unusually severe, multisystem, neurologic, autonomic, or persistent despite treatment, evaluating for additional tick-borne infections may help explain the broader clinical picture.
Frequently Asked Questions
What are the most common Lyme disease coinfections?
Common tick-borne coinfections include Babesia, Bartonella, Anaplasma, Ehrlichia, and Powassan virus.
Can a single tick bite transmit multiple infections?
Yes. Some ticks can carry and transmit multiple pathogens simultaneously, leading to overlapping symptoms and more complex illness patterns.
Why are coinfections often missed?
Coinfections may produce nonspecific symptoms, overlap with Lyme disease itself, or fail to appear on standard testing early in illness.
Do coinfections affect recovery?
Yes. Coinfections may increase symptom severity, complicate diagnosis, alter treatment response, and contribute to prolonged recovery patterns.
Can coinfections affect Lyme disease testing?
Yes. Coinfections and immune dysregulation may complicate interpretation of Lyme disease testing, particularly early in illness or in patients with overlapping symptoms.
Can coinfections cause neurologic symptoms?
Yes. Some coinfections are associated with neuropathy, cognitive dysfunction, autonomic symptoms, headaches, mood changes, or other neurologic manifestations.
Related Articles
- Babesia Symptoms and Treatment
- Bartonella and Lyme Disease
- Anaplasmosis Symptoms and Diagnosis
- Ehrlichiosis and Tick-Borne Illness
- Powassan Virus
- Post-Treatment Lyme Disease Syndrome
References
- Krause PJ, Fish D, Narasimhan S, Barbour AG. Borrelia burgdorferi sensu lato, Babesia microti, and Anaplasma phagocytophilum: Tick-borne coinfections in the United States. Clin Microbiol Rev. 2018;31(4):e00018-18.
- Breitschwerdt EB, Maggi RG, Nicholson WL, Cherry NA, Woods CW. Bartonella sp. bacteremia in patients with neurological and neurocognitive dysfunction. J Clin Microbiol. 2008;46(9):2856-2861.
- Adler BL, Vernino S. Dysautonomia following Lyme disease: A key component of post-treatment Lyme disease syndrome?. Front Neurol. 2024;15:1344862.
- Ebel GD. Update on Powassan virus: emergence of a North American tick-borne flavivirus. Annu Rev Entomol. 2015;60:95-110.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
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