Lyme Disease Coinfections: Symptoms, Testing, and Treatment Challenges
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 additional tick-borne pathogens including Babesia, Bartonella, Anaplasmosis, Ehrlichiosis, or Powassan virus.
These infections are commonly referred to as coinfections.
Coinfections can change symptom patterns, influence laboratory findings, complicate treatment response, and contribute to more severe or persistent illness.
Different pathogens affect different body systems. Some primarily infect red blood cells, while others target white blood cells, blood vessels, or the nervous system.
Because symptom overlap is common, coinfections are frequently overlooked or misdiagnosed early in illness.
Studies suggest that 30% to 50% of Lyme disease patients may test positive for at least one coinfection.
Why Lyme Disease 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, drenching night sweats, neurologic symptoms, autonomic dysfunction, psychiatric symptoms, or air hunger 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.
Standard Lyme disease treatment may not adequately address coinfections. Babesia requires antiparasitic therapy, while Bartonella often requires different antibiotic combinations than Lyme disease alone.
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 neurologic, vascular, inflammatory, and neuropsychiatric symptoms.
Patients may report burning foot pain, neuropathy, anxiety, mood changes, headaches, cognitive dysfunction, vascular skin changes, stretch-mark-like rashes, or unusual sensory symptoms.
Some patients experience severe neuropsychiatric symptoms that overlap with autonomic dysfunction or small fiber neuropathy.
Anaplasmosis and Ehrlichiosis
Anaplasmosis and ehrlichiosis are bacterial infections affecting 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.
Powassan Virus
Powassan virus is a rare but potentially serious tick-borne viral infection.
Unlike bacterial coinfections, Powassan virus may cause encephalitis, seizures, severe neurologic symptoms, or long-term neurologic complications.
There is currently no specific antiviral treatment for Powassan virus.
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.
Babesia blood smears may miss chronic infection. Bartonella serology may have poor sensitivity. Anaplasmosis and Ehrlichiosis testing may become negative after antibiotic exposure.
Reviewing the limitations of Lyme disease testing may help explain why diagnosis becomes complicated in multisystem illness.
Because testing may be unreliable, clinical diagnosis based on symptom patterns often becomes essential.
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 neuropathic symptoms, vascular manifestations, or neuropsychiatric changes.
Clinical Takeaway
Lyme disease coinfections are common yet frequently overlooked because symptoms overlap with Lyme disease itself and testing may lack sensitivity.
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?
Babesia and Bartonella are among the most common Lyme disease coinfections, followed by Anaplasmosis and Ehrlichiosis.
Can a single tick bite transmit multiple infections?
Yes. Some ticks can carry and transmit multiple pathogens simultaneously.
Why are coinfections often missed?
Coinfections may overlap clinically with Lyme disease itself or fail to appear on standard testing.
Can coinfections affect recovery?
Yes. Coinfections may increase symptom severity and complicate treatment response.
Related Articles
- Babesia Symptoms and Treatment
- Bartonella and Lyme Disease
- Anaplasmosis Symptoms and Diagnosis
- Ehrlichiosis and Tick-Borne Illness
- Powassan Virus
References
- Krause PJ, et al. Concurrent Lyme disease and babesiosis. JAMA. 1996;275(21):1657-1660.
- Lantos PM, Wormser GP. Chronic coinfections in patients diagnosed with chronic Lyme disease: a systematic review. Am J Med. 2014;127(11):1105-1110.
- Maggi RG, et al. Bartonella spp. bacteremia in high-risk immunocompetent patients. Diagn Microbiol Infect Dis. 2011;71(4):430-437.
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
