Don’t count on a relapsing fever to diagnose Borrelia miyamotoi

You might assume a patient infected with Borrelia miyamotoi, a relapsing fever spirochete, to present with a relapsing fever. However, your assumption would be wrong 48 out of 50 times, according to a case series published in the Annals of Internal Medicine. [1] The authors found that only 2 out of 50 patients infected with the relapsing spirochete B. miyamotoi actually presented with a relapsing fever. [1]

Despite having the genetic apparatus, B. miyamotoi typically does not manifest with a relapsing fever. “Although evidence of antigenic variation, which drives the relapsing course of other relapsing fevers due to borrelia has not been demonstrated clinically or in an animal system thus far for B. miyamotoi [2], it has been shown that this species does have the genetic apparatus for this variation,” according to Sudhindra from the Division of Infectious Diseases, New York Medical College. [3]

Source: CDC

All but one of the 51 individuals in the case series presented with a fever. They did not, however, suffer from recurrent fevers. According to Sudhindra, “The low percentage of cases with a relapse of fever may be due to the frequent use of empiric antibiotic therapy early in the course of febrile illnesses in patients with tick exposures.” [3]

The individuals exhibited symptoms similar to those found in other tick-borne illnesses. The majority presented with headaches, myalgias, arthralgias, and malaise/fatigue. “More than 50% were suspected of having sepsis, and 24% required hospitalization,” states Molloy. [1]

The B. miyamotoi were identified as part of an active detection protocol among acutely ill patients in Massachusetts, Rhode Island, New Jersey, and New York. The researchers initially identified cases of B. miyamotoi by whole-blood polymerase chain reaction (PCR) for common tick-borne infections. B. miyamotoi was confirmed based on an immune response to a recombinant glycerophosphodiester phosphodiesterase (rGlpQ) protein. [1]

The rGlpQ test was negative for most of the cases of B. miyamotoi when initially treated. “Serologic testing using the rGlpQ EIA seems insensitive in diagnosing acute BMD infection given that it was positive for IgG or IgM in only 16% of the case patient samples at the time of clinical presentation,” states Molloy. The rGlpQ was positive after the fact in 86% of the patients during convalescence. [1]

Elevated liver enzyme levels, neutropenia, and thrombocytopenia were common in 75%, 60% and 51% respectively. “Borrelia miyamotoi disease may be clinically similar to or be confused with human anaplasmosis,” according to Molloy.

B. miyamotoi has emerged as a leading cause of hard tick-transmitted infections but lacks a clear diagnostic criteria. According to Molloy, “Infection with B. miyamotoi is the fifth recognized Ixodes-transmitted infection in the northeastern United States and should be part of the differential diagnosis of febrile patients from areas where deer tick–transmitted infections are endemic.”

Read more about Borrelia miyamotoi in another All Things Lyme blog.



  1. Molloy PJ, Telford Iii SR, Chowdri HR, Lepore TJ, Gugliotta JL, Weeks KE, Hewins ME, Goethert HK, Berardi VP: Borrelia miyamotoi Disease in the Northeastern United States: A Case Series. Ann Intern Med 2015.
  2. Telford SR, 3rd, Goethert HK, Molloy PJ, Berardi VP, Chowdri HR, Gugliotta JL, Lepore TJ: Borrelia miyamotoi Disease: Neither Lyme Disease Nor Relapsing Fever. Clin Lab Med 2015, 35(4):867-882.
  3. Sudhindra P, Wang G, Schriefer ME, McKenna D, Zhuge J, Krause PJ, Marques AR, Wormser GP: Insights into Borrelia miyamotoi infection from an untreated case demonstrating relapsing fever, monocytosis and a positive C6 Lyme serology. Diagn Microbiol Infect Dis 2016, 86(1):93-96.

10 Replies to "Don’t count on a relapsing fever to diagnose Borrelia miyamotoi"

  • Rob
    07/20/2019 (9:53 pm)

    Help – my 20 year old tested positive for Miyamotoi. He is allergic to Sulfa antibiotics and cephalosporins. He did a short course of azythromicin and then did 2 weeks of Biaxin 2x per day. During the 2 week period he felt better. (ONLY SYMPTOMS ARE BAD LEG PAIN THAT STARTED AND FEW MONTHS AGO). After he stopped the Biaxin (began to taper off) the leg pains came back. Was never on Doxycycline. Thoughts ??? Go back on Biaxin? For how long? Need Doxy? Mix of antibiotics? IV antibiotics?

    • Dr. Daniel Cameron
      07/22/2019 (12:57 am)

      There might be another co-infection. I would look at treatment with doxycycline. I would also consider an evaluation for Babesia. I also would look for illnesses not related to ticks.

  • leslie Sweeney
    06/06/2018 (12:14 am)

    I was just diagnosed with miyamotio. I am on doxy(twice a day) 100mg pills. Should I modify my diet or take any herbal supplements?

    • Dr. Daniel Cameron
      06/06/2018 (3:26 am)

      I focus of probiotics as well as avoidance of sugar and alcohol at my first step. You may have to look at a second antibiotic if doxycycline does not work as we don’t fully know what works for Borrelia miyamotoi or if another tick borne illness is present.

  • John Milner
    02/17/2018 (11:42 pm)

    I was positive on igenex immunoblot TBRF. one of the types they test for is miyamotoi. but there are others. is there a test available to determine which of the other “borrelias” i have ? not alot of info on proper protocols. i have also tested pos for borrelia burgdorf that was a few years ago. i think that i have irradicated that with abx treatment.

    • Dr. Daniel Cameron
      02/18/2018 (8:06 am)

      There are a growing number of test by a wide range of labs that are in production. I find it can be difficult to difficult to determine which tick-borne infections are present or resolved.

  • Cindy
    12/31/2017 (7:22 pm)

    What is the best treatment for Borrelia Miyamotoi?

    • Dr. Daniel Cameron
      01/10/2018 (1:42 pm)

      The evidence is weak. Doxycycline and Zithromax are common recommendations but the data in people is not in.

  • Kevin
    03/03/2017 (6:45 pm)

    I have been having some issues since November. I feel as if I may have Lyme disease. I have had several bites last year. Do you take GHI. ppo Emblemed health insurance? If not how much out of pocket does visit cost. Thanks
    Kevin Mitchell

    • Dr. Daniel Cameron
      03/06/2017 (1:54 am)

      Sorry to hear you are ill. Call the office at 914 666 4665 with any questions.

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