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Background Laboratory confirmation of early Lyme borreliosis (LB) is challenging. Serology is insensitive during the first days to weeks of infection, and blood polymerase chain reaction (PCR) offers similarly poor performance. Here, we demonstrate that detection of Borrelia burgdorferi (B.b.) cell-free DNA (cfDNA) in plasma can improve diagnosis of early LB. Methods B.b. detection in plasma samples using unbiased metagenomic cfDNA sequencing performed by a commercial laboratory (Karius Inc) was compared with serology and blood PCR in 40 patients with physician-diagnosed erythema migrans (EM), 28 of whom were confirmed to have LB by skin biopsy culture (n = 18), seroconversion (n = 2), or both (n = 8). B.b. sequence analysis was performed using investigational detection thresholds, different from Karius’ clinical test. Results B.b. cfDNA was detected in 18 of 28 patients (64%) with laboratory-confirmed EM. In comparison, sensitivity of acute-phase serology using modified 2-tiered testing (MTTT) was 50% (P = .45); sensitivity of blood PCR was 7% (P = .0002). Combining B.b. cfDNA detection and MTTT increased diagnostic sensitivity to 86%, significantly higher than either approach alone (P ≤ .04). B.b. cfDNA sequences matched precisely with strain-specific sequence generated from the same individual’s cultured B.b. isolate. B.b. cfDNA was not observed at any level in plasma from 684 asymptomatic ambulatory individuals. Among 3000 hospitalized patients tested as part of clinical care, B.b. cfDNA was detected in only 2 individuals, both of whom had clinical presentations consistent with LB. Conclusions This is the first report of B.b. cfDNA detection in early LB and a demonstration of potential diagnostic utility. The combination of B.b. cfDNA detection and acute-phase MTTT improves clinical sensitivity for diagnosis of early LB.

Background: Erythema migrans (EM), the skin rash of early Lyme borreliosis (LB), is an insensitive and non-specific physical finding. Confirmation of suspected cases is challenging, as serology and blood PCR are insensitive in early LB. Here, we demonstrate that detection of Borrelia burgdorferi (B.b.) cell-free DNA (cfDNA) in plasma can improve diagnosis of early LB. Methods: We compared B.b.cfDNA detection in plasma samples with serology and blood PCR in 40 patients with physician-diagnosed EM, 28 of whom were confirmed to have LB by skin biopsy culture (N=18), seroconversion (N=2) or both (N=8). Findings: B.b.cfDNA was detected in 18/28 patients (64%) with laboratory-confirmed EM. In comparison, sensitivity of acute-phase serology using modified two-tiered testing (MTTT) was 50% (P=0.45); sensitivity of blood PCR was 7% (P=0.0002). Combining B.b.cfDNA detection and MTTT increased diagnostic sensitivity to 86%, significantly higher than either approach alone (P < or = 0.04). B.b.cfDNA sequences matched precisely with strain-specific sequence generated from the same individual’s cultured B.b. isolate. B.b.cfDNA was not detected in plasma from 684 asymptomatic ambulatory individuals. Among 3000 hospitalized patients tested as part of clinical care, B.b.cfDNA was detected in only two individuals, both of whom had clinical presentations consistent with LB. Interpretation: This is the first report of B.b.cfDNA detection in early LB and a demonstration of potential diagnostic utility. The combination of B.b.cfDNA and acute-phase MTTT improves clinical sensitivity for diagnosis of early LB. Funding Statement: This work represents an unfunded collaboration between the academically-affiliated authors and Karius Inc. Declaration of Interests: JAB has received research support from Zeus Scientific, bioMerieux, Immunetics, Alere, DiaSorin, the Bay Area Lyme Foundation (BALF), and the National Institute of Allergy and Infectious Diseases (NIAID; Award 1R21AI119457-01) for LB-related research projects. NRP has received funding from BALF and NIAID (Award 1R21AI119457-01) for LB-related research. JEL has received payments from Sherlock Biosciences for consulting services. LB, AAA, DKH, SB, TB, DH and CH are employed by Karius, Inc. All other authors declare no competing interests. Ethics Approval Statement: The parent and current studies were approved by the Partners Healthcare Human Research Committee.

Background The conventional 2-tiered serologic testing protocol for Lyme disease (LD), an enzyme immunoassay (EIA) followed by immunoglobulin M and immunoglobulin G Western blots, performs well in late-stage LD but is insensitive in patients with erythema migrans (EM), the most common manifestation of the illness. Western blots are also complex, difficult to interpret, and relatively expensive. In an effort to improve test performance and simplify testing in early LD, we evaluated several modified 2-tiered testing (MTTT) protocols, which use 2 assays designed as first-tier tests sequentially, without the need of Western blots. Methods The MTTT protocols included (1) a whole-cell sonicate (WCS) EIA followed by a C6 EIA; (2) a WCS EIA followed by a VlsE chemiluminescence immunoassay (CLIA); and (3) a variable major protein-like sequence, expressed (VlsE) CLIA followed by a C6 EIA. Sensitivity was determined using serum from 55 patients with erythema migrans; specificity was determined using serum from 50 patients with other illnesses and 1227 healthy subjects. Results Sensitivity of the various MTTT protocols in patients with acute erythema migrans ranged from 36% (95% confidence interval [CI], 25%-50%) to 54% (95% CI, 42%-67%), compared with 25% (95% CI, 16%-38%) using the conventional protocol (P = .003-0.3). Among control subjects, the 3 MTTT protocols were similarly specific (99.3%-99.5%) compared with conventional 2-tiered testing (99.5% specificity; P = .6-1.0). Conclusions Although there were minor differences in sensitivity and specificity among MTTT protocols, each provides comparable or greater sensitivity in acute EM, and similar specificity compared with conventional 2-tiered testing, obviating the need for Western blots.

Background The first recognized cases of Borrelia miyamotoi disease (BMD) in North America were reported in the northeastern United States in 2013. Objective To further describe the clinical spectrum and laboratory findings for BMD. Design Case series. Setting Patients presenting to primary care offices, emergency departments, or urgent care clinics in 2013 and 2014. Participants Acutely febrile patients from the northeastern United States in whom the treating health care providers suspected and ordered testing for tick-transmitted infections. Measurements Whole-blood polymerase chain reaction (PCR) testing was performed for the presence of specific DNA sequences of common tickborne infections (including BMD). Serologic testing for B. miyamotoi was performed using a recombinant glycerophosphodiester phosphodiesterase (rGlpQ) protein. Clinical records were analyzed to identify the major features of acute disease. Results Among 11,515 patients tested, 97 BMD cases were identified by PCR. Most of the 51 case patients on whom clinical histories were reviewed presented with high fever, chills, marked headache, and myalgia or arthralgia. Twenty-four percent were hospitalized. Elevated liver enzyme levels, neutropenia, and thrombocytopenia were common. At presentation, 16% of patients with BMD were seropositive for IgG and/or IgM antibody to B. miyamotoi rGlpQ. Most (78%) had seropositive convalescent specimens. Symptoms resolved after treatment with doxycycline, and no chronic sequelae or symptoms were observed. Limitation Findings were based on specimens submitted for testing to a reference laboratory, and medical records of only 51 of the 97 case patients with BMD were reviewed. Conclusion Patients with BMD presented with nonspecific symptoms, including fever, headache, chills, myalgia, and arthralgia. Laboratory confirmation of BMD was possible by PCR on blood from acutely symptomatic patients who were seronegative at presentation. Borrelia miyamotoi disease may be an emerging tickborne infection in the northeastern United States. Primary funding source IMUGEN.

Human infection due to Babesia microti has been regarded as infrequent and a condition primarily affecting the elderly or immunocompromised. To determine whether risk in endemic sites may be increasing relative to that of Borrelia burgdorferi and to define its age-related clinical spectrum, we carried out a 10-year community-based serosurvey and case finding study on Block Island, Rhode Island. Less intensive observations were conducted in nearby sites. Incidence of babesial infection on Block Island increased during the early 1990s, reaching a level about three-fourths that of borrelial infection. The sera of approximately one-tenth of Block Island residents reacted against babesial antigen, a seroprevalence similar to those on Prudence Island and in southeastern Connecticut. Although the number and duration of babesial symptoms in people older than 50 years of age approximated those in people 20 to 49 years of age, more older adults were admitted to hospital than younger adults. Few Babesia-infected children were hospitalized. Babesial incidence at endemic sites in southern New England appears to have risen during the 1990s to a level approaching that due to borreliosis.

To determine whether a unique group of clinical and laboratory manifestations characterize certain major deer tick-transmitted human pathogens in North America, we compared the symptoms, short-term complications, and laboratory test results of New England residents who became ill due to > or =1 of these pathogens. Patients completed a uniformly structured questionnaire and submitted blood samples for serologic and polymerase chain reaction (PCR) testing after developing symptoms of Lyme disease, human babesiosis, or human granulocytic ehrlichiosis (HGE). Complete blood count with thin blood smear, PCR, and immunoglobulin M antibody tests helped differentiate the acute manifestations of these diseases. Physicians should consider use of tests designed to diagnose babesiosis and HGE in patients with Lyme disease who experience a prolonged flulike illness that fails to respond to appropriate antiborrelial therapy.

Babesiosis is a tick-borne, malaria-like illness known to be enzootic in southern New England. A course of clindamycin and quinine is the standard treatment, but this regimen frequently causes adverse reactions and occasionally fails. A promising alternative treatment is atovaquone plus azithromycin.We conducted a prospective, nonblinded, randomized trial of the two regimens in 58 subjects with non-life-threatening babesiosis on Nantucket, on Block Island, and in southern Connecticut. The subjects were assigned to receive either atovaquone (750 mg every 12 hours) and azithromycin (500 mg on day 1 and 250 mg per day thereafter) for seven days (40 subjects) or clindamycin (600 mg every 8 hours) and quinine (650 mg every 8 hours) for seven days (18 subjects).Adverse effects were reported by 15 percent of the subjects who received atovaquone and azithromycin, as compared with 72 percent of those who received clindamycin and quinine (P0.001). The most common adverse effects with atovaquone and azithromycin were diarrhea and rash (each in 8 percent of the subjects); with clindamycin and quinine the most common adverse effects were tinnitus (39 percent), diarrhea (33 percent), and decreased hearing (28 percent). Symptoms had resolved three months after the start of therapy in 65 percent of those who received atovaquone and azithromycin and 73 percent of those who received clindamycin and quinine (P=0.66), and after six months no patient in either group had symptoms. Three months after the completion of the assigned regimen, no parasites could be seen on microscopy, and no Babesia microti DNA was detected in the blood of any subject.For the treatment of babesiosis, a regimen of atovaquone and azithromycin is as effective as a regimen of clindamycin and quinine and is associated with fewer adverse reactions.

A tickborne pathogen, Borrelia miyamotoi, has recently been shown to cause disease in humans. A serologic survey showed that infection with this organism is not uncommon in the Northeast.

A 27-year-old woman who acquired cutaneous leishmaniasis in Central America was inadvertently treated with 10 times the intended daily dose of the pentavalent antimonial compound sodium stibogluconate (Pentostam): 8500 mg (143 mg/kg) instead of 850 mg. The patient felt "wiped out" during the 4-h infusion of the drug. After the mistake in dosing was discovered, she was vigorously hydrated and carefully monitored in an intensive care unit for greater than 48 h. Her vital signs were stable, and no arrhythmias were noted. Her alanine aminotransferase level rose briefly to 2.4 times the upper limit of normal, and her white blood cell count briefly fell 43% to a low of 3700/microliter. Her skin lesions subsequently healed without further therapy. Although sodium stibogluconate has been associated with a variety of side effects, in this case, a single high dose of the drug was tolerated without serious toxicity.

Babesiosis is a malaria-like illness caused by the intraerythrocytic parasite Babesia microti and transmitted by the same tick that transmits the Lyme disease spirochete. Both pathogens may be cotransmitted and are endemic in southern New England and New York, the northern Midwest and the far West. The epidemiology and clinical presentation of babesiosis and babesiosis/Lyme disease coinfection are well described in adults but not in children. Accordingly, we reviewed data from longitudinal, clinic-based serosurvey and case-finding studies of tick-borne illness in Connecticut, Massachusets and Rhode Island from 1990 through 1996. A total of 147 episodes of babesial infection were identified, 125 in adults and 22 in children. Approximately a third of children and adults with babesial infection reported symptoms. The most frequently reported symptoms in children were fever (25%), fatigue (19%) and headache (19%) and in adults, fatigue (20%), fever (17%) and myalgias (16%). Children and adults had a similar number of acute symptoms; the average number of symptoms were 4.0 and 4.8, respectively. Children recovered more rapidly, however, as none were ill for more than a month compared with 20% of adults. Coinfection with babesiosis and Lyme disease resulted in more prolonged illness; 17% of children and 26% of adults reported symptoms that lasted for more than a month. We conclude that the frequency of babesial infection is similar in children and adults but children have a shorter duration of illness. Both children and adults experience a more prolonged illness when babesiosis is accompanied by Lyme disease.

Noninvasive screening of the lower extremities for deep vein thrombosis was performed bilaterally on 1,118 patients. Impedance plethysmography alone was used in 868. Venography in 135 revealed an accuracy of 88%, with a false-negative rate of 5.3% and a false-positive rate of 18.6%. A combined ultrasonic Doppler and modified impedance technic was used in 250 patients. Venography in forty revealed an accuracy of 95%, with a false-positive rate of 10% and no undetected thrombi. The combined technic, emphasizing the more accurate modality in three anatomic areas, has proven sensitive, specific, and reliable as a screening test for deep venous thrombosis.