Relapsing Fever vs Lyme Disease: Could It Be Borrelia miyamotoi?
Fever after a tick bite can be confusing.
Not every Borrelia infection is Lyme disease.
Borrelia miyamotoi may be missed.
Relapsing fever symptoms are often associated with Borrelia infections that cause repeated episodes of fever. But one tick-borne infection, Borrelia miyamotoi, does not always follow the classic relapsing fever pattern.
This can make diagnosis difficult. Patients may present with fever, headache, fatigue, muscle aches, abnormal blood counts, or elevated liver enzymes—symptoms that overlap with Lyme disease and other tick-borne infections.
What Is Borrelia miyamotoi?
Borrelia miyamotoi is a tick-borne Borrelia species transmitted by hard ticks, including Ixodes scapularis, the same tick that can transmit Lyme disease, Babesia, and Anaplasma.
Unlike Lyme disease, B. miyamotoi is more closely related to relapsing fever Borrelia species. However, many patients do not develop obvious recurrent fever episodes.
Start here: Lyme coinfections
Does Borrelia miyamotoi Cause Relapsing Fever?
B. miyamotoi has the genetic machinery associated with antigenic variation, a process that helps other relapsing fever Borrelia species evade the immune system and cause recurring fever episodes.
However, in clinical practice, B. miyamotoi often does not present with a clear relapsing fever pattern.
Sudhindra and colleagues described this diagnostic challenge, noting that although B. miyamotoi has the genetic apparatus for antigenic variation, consistent clinical evidence of classic relapsing fever has been limited.
Why Relapsing Fever May Not Actually Relapse
In a case series of 51 patients with B. miyamotoi disease, nearly all presented with fever. But recurrent fever was uncommon.
One explanation is that many patients with fever and tick exposure receive empiric antibiotics early, which may interrupt the expected fever relapse pattern.
This means clinicians should not rule out B. miyamotoi simply because a patient does not report repeated fever episodes.
Borrelia miyamotoi Symptoms Can Mimic Other Tick-Borne Diseases
Patients with B. miyamotoi may develop symptoms that resemble Lyme disease, Anaplasma, Babesia, or even sepsis.
Common symptoms reported in the case series included:
- Fever
- Headache
- Muscle aches
- Joint pain
- Malaise
- Fatigue
More than half of the patients were initially suspected of having sepsis, and nearly one-quarter required hospitalization.
Abnormal Labs May Offer Clues
B. miyamotoi disease may also cause laboratory abnormalities that overlap with other tick-borne infections.
In the Molloy case series, elevated liver enzymes, neutropenia, and thrombocytopenia were common findings.
These abnormalities may lead clinicians to suspect human anaplasmosis, another Ixodes-transmitted infection.
Related guide: Types of Lyme disease tests
Why Borrelia miyamotoi Diagnosis Can Be Difficult
Diagnosis can be challenging because early antibody testing may be negative.
In the Molloy case series, serologic testing using rGlpQ was positive in only a minority of patients at the time of clinical presentation. The test became positive much more often during convalescence, after the acute illness had passed.
This reflects a common diagnostic challenge in tick-borne disease: the sickest moment may not be the easiest moment to confirm the diagnosis by antibody testing.
Relapsing Fever vs Lyme Disease: Why the Difference Matters
Relapsing fever and Lyme disease can overlap clinically, but they are not the same illness.
Lyme disease is caused by Borrelia burgdorferi. Borrelia miyamotoi disease is caused by a different Borrelia species and may present with fever, fatigue, abnormal labs, and systemic illness rather than the classic Lyme rash.
For patients in deer tick endemic areas, B. miyamotoi should be considered when fever follows a tick exposure, especially when Lyme disease testing does not fully explain the illness.
Can You Have Relapsing Fever Without Relapsing?
Yes. In Borrelia miyamotoi infection, many patients experience fever without the classic relapsing pattern. Early antibiotic treatment and differences in immune response may prevent repeated fever episodes.
Clinical Takeaway
Relapsing fever symptoms after a tick bite should not be ignored, even when the fever does not clearly relapse.
Borrelia miyamotoi may cause fever, headache, fatigue, muscle aches, elevated liver enzymes, low white blood cells, and low platelets. It may be mistaken for Lyme disease, Anaplasma, Babesia, or sepsis.
When patients present with fever after tick exposure, clinicians should consider a broader tick-borne disease evaluation—not only Lyme disease testing.
Related Reading
References
Molloy, P. J., Telford, S. R., III, Chowdri, H. R., Lepore, T. J., Gugliotta, J. L., Weeks, K. E., Hewins, M. E., Goethert, H. K., & Berardi, V. P. (2015). Borrelia miyamotoi disease in the northeastern United States: A case series. Annals of Internal Medicine.
Telford, S. R., III, Goethert, H. K., Molloy, P. J., Berardi, V. P., Chowdri, H. R., Gugliotta, J. L., & Lepore, T. J. (2015). Borrelia miyamotoi disease: Neither Lyme disease nor relapsing fever. Clinics in Laboratory Medicine, 35(4), 867–882.
Sudhindra, P., Wang, G., Schriefer, M. E., McKenna, D., Zhuge, J., Krause, P. J., Marques, A. R., & Wormser, G. P. (2016). Insights into Borrelia miyamotoi infection from an untreated case demonstrating relapsing fever, monocytosis and a positive C6 Lyme serology. Diagnostic Microbiology and Infectious Disease, 86(1), 93–96.
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
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
Sorry to hear you are ill. Call the office at 914 666 4665 with any questions.
What is the best treatment for Borrelia Miyamotoi?
The evidence is weak. Doxycycline and Zithromax are common recommendations but the data in people is not in.
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.
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.
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?
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.
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?
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.