One Tick Bite Caused 3 Tick-Borne Diseases
Coinfections may occur after one tick exposure
Multiple pathogens can complicate diagnosis and treatment
Persistent symptoms may require broader evaluation
A single tick bite may transmit more than one infection. Coinfections involving Lyme disease, babesiosis, and anaplasmosis can complicate diagnosis, worsen symptoms, and delay recovery—particularly in older adults.
An older woman with COPD and hypertension was admitted to the hospital with dyspnea, fatigue, and a productive cough. She also had altered mental status, pallor, and peripheral edema. Lung examination revealed bibasilar crackles, according to Kumar and colleagues.¹
She was initially treated empirically for community-acquired pneumonia with ceftriaxone and azithromycin.
The patient reported no history of rash or known tick bite. However, laboratory testing later revealed infection with three tick-borne pathogens.
Transmission timing varies by pathogen, meaning multiple infections may occur even when the duration of tick attachment is uncertain.
One Tick Bite Led to Three Infections
The authors described the case as:
“We present a case of triple infection with babesiosis, Lyme disease, and anaplasmosis treated with antibiotics and red blood cell exchange (erythrocytapheresis).”¹
Babesiosis Caused Severe Illness
Babesiosis is caused by a parasite that infects red blood cells.
A peripheral blood smear showed parasites consistent with Babesia infection, prompting treatment with azithromycin and atovaquone.
Further testing revealed severe babesiosis with a parasitic load of 9.04%, requiring red blood cell exchange (erythrocytapheresis).
Repeat testing still showed a high parasite burden (6.54%), requiring a second exchange procedure.
Antimicrobial therapy was changed to clindamycin, quinine, and doxycycline for a total of 14 days.¹
Older adults may face higher risks of severe disease, delayed diagnosis, hospitalization, and complications from tick-borne coinfections.
For more on severe parasitic coinfections, see Babesia and Lyme disease coinfections.
Lyme Disease Was Also Present
Serologic testing was positive for Borrelia burgdorferi, the bacterium responsible for Lyme disease.
The patient was prescribed doxycycline for Lyme disease treatment.
Coinfections may complicate the interpretation of symptoms because fatigue, cognitive symptoms, and constitutional complaints overlap across multiple pathogens. See tick-borne coinfections for additional discussion.
Anaplasmosis Added Another Layer of Complexity
The patient’s anaplasma titers were positive, confirming a third tick-borne infection.
Anaplasmosis can contribute to fever, laboratory abnormalities, constitutional symptoms, and diagnostic confusion when present alongside Lyme disease and babesiosis.
Why Multiple Tick-Borne Diseases May Be Missed
Patients with multiple simultaneous infections may present atypically.
“Patients presenting with an atypical clinical picture of a single pathogen or a lack of improvement with antibiotics after 48 hours require further testing for the presence of other infections.”¹
Clinicians may consider broader testing when symptoms persist, laboratory abnormalities appear disproportionate, or recovery does not follow an expected pattern. Diagnostic uncertainty is common in patients with overlapping infections and may contribute to misconceptions about Lyme disease diagnosis.
A Second Case Supports Coinfection Concerns
Grant and colleagues described a 70-year-old man who presented with fever, ankle edema, and nausea after a presumed insect bite one month earlier.²
Testing revealed Lyme disease, Babesia microti, and anaplasmosis.
His symptoms resolved following treatment with doxycycline, atovaquone, and azithromycin.²
Frequently Asked Questions
What diseases can you get from one tick bite?
One tick bite may transmit multiple pathogens including Lyme disease, babesiosis, and anaplasmosis depending on geographic location and the organisms carried by the tick.
Can tick-borne diseases occur without a rash?
Yes. Patients with tick-borne infections may not recall a rash or tick bite, which can delay diagnosis.
When should coinfections be considered?
Coinfections may be considered when symptoms appear severe, recovery is delayed, laboratory abnormalities are unexplained, or response to treatment is incomplete.
Clinical Takeaway
Failure to improve after treatment, severe presentations, or unexplained laboratory abnormalities may justify considering multiple simultaneous tick-borne infections.
Related Articles
Learn more about overlapping infections and treatment considerations in these articles:
One bite, six diseases: all from the same tick
First-line combination therapy for tick-borne illnesses
Video: Co-infections of Lyme disease
References
- Kumar M, Sharma A, Grover P. Triple Tick Attack. Cureus. 2019;11(2):e4064.
- Grant L, Mohamedy I, Loertscher L. One man, three tick-borne illnesses. BMJ Case Reports. 2021;14:e241004. doi:10.1136/bcr-2020-241004
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 am Chronic for Lyme. Have suspected Babesia for year as well. One Babesia test was Negative. Lyme tests negative for 30+ years. ( Only positive as of 2021 for Lyme). How and where can I have accurate testing for all TBD’s? What would I expect to pay? Old & sick of this relentless battle. Thank you for any advice.
I have not found local labs or speciality labs as good as I would like. I have had to depend on clinical judgement.
I was recently treated empirically with doxy for presumed Lyme disease and anaplasmosis (tests were eventually positive for recent infection with both) complicated by an opportunistic strep infection (treated with penicillin). My symptoms were fever, unbearable headache, mild sore throat, muscle and joint aches, stiff neck, fatigue, and worsening neuropathy.
Last September, I had a severe concussion followed by a sinus infection and severe covid (October), untreated Lyme and anaplasmosis in late November, and in December, the death of my father and my 95-year-old demented mother’s moving in with me. I have a long history of dysautonomia, migraines, NTM infection (successfully treated, with some residual lung scarring), recurrent pyelonephritis and UTIs, and adrenal insufficiency. However, since this series of fun events, my neuropathy, fatigue, and muscle and joint pain have increased exponentially. My neurologist attributed it to my concussion and stress (without knowing about the tickborne infections), but my question is whether there would be any clinical benefit to another course of doxy or whether I should just accept these changes as the new normal and quit my whining? Thank you.
For background, I live in an area with a very high rate of tick-borne infections–Lyme, babesiosis, and anaplasmosis–so reinfectiom is doubtless inevitable.
I have patients with co-infection to include Babesia where the tests are negative. I have patients who have benefited from treating a co-infection clinically to include treatment for Babesia.