Tick-Borne Pathogens Detected in the Blood of Immunosuppressed Norwegian Patients

Living in a Tick-Endemic Area

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Hanne Quarsten, Department of Medical Microbiology, Sørlandet Hospital Health Enterprise,
NO-4615 Kristiansand, Norway
Tore Salte, Department of Clinical Medicine, Sørlandet Hospital Health Enterprise, NO-4615
Kristiansand, Norway

t
Åslaug R. Lorentzen, Department of Neurology, Sørlandet Hospital Health Enterprise, NO-

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4615 Kristiansand and The Norwegian National Advisory Unit on Tick-Borne Diseases, NO-
4809 Arendal, Norway.

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Inger J.W. Hansen, Department of Clinical Medicine, Section of Rheumatology, Sørlandet
Hospital Health Enterprise, NO-4615 Kristiansand, Norway

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Runar Hamre, Department of Clinical Medicine, Sørlandet Hospital Health Enterprise, NO-
4615 Kristiansand, Norway
Kristine J.N. Forselv, Department of Neurology, Sørlandet Hospital Health Enterprise, NO-
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4615 Kristiansand, Norway
Øivind Øines, Department of Food Safety, Animal Welfare and Animal Health Oslo
Norwegian Veterinary Institute, NO-0106 Oslo, Norway
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Christine Wennerås, Department of Infectious Diseases, University of Gothenburg,

Sahlgrenska Academy, 413 90 Göteborg and Department of Clinical Microbiology,
Sahlgrenska University Hospital, 413 46 Göteborg, Sweden
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Sølvi Noraas, Department of Medical Microbiology Sørlandet Hospital Health Enterprise,

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NO-4615 Kristiansand, Norway

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Current affiliation: Tore Salte, Diagnostic Center, Stavanger University Hospital, NO-4068
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Stavanger, Norway
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Corresponding author: Hanne Quarsten, Department of Medical Microbiology, Sørlandet

Hospital Health Enterprise, 4615 Kristiansand, Norway. Fax:+47 38 07 34 91
phone +47 38 07 35 12 email: hanne.quarsten@sshf.no

Summary: Patients treated with biologicals and living in a tick-endemic area seem to have a
high risk of contracting Ca. Neoehrlichia mikurensis infection, which if left untreated is
associated with thromboembolic complications.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of
America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
Abstract
Background. The knowledge regarding the occurrence and the clinical implications of tick-

borne infections in immunosuppressed patients living in tick-endemic areas is limited.

Methods. Adult patients with autoimmune conditions requiring immunosuppressive treatment

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such as infliximab and rituximab, were invited to participate in the study when they attended

the hospital for treatment and/or control of the disease. Whole blood samples were analysed

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by real-time PCR for Borrelia burgdorferi s.l., Borrelia miyamotoi, Anaplasma

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phagocytophilum, Rickettsia spp., Candidatus Neoehrlichia mikurensis and Babesia spp.

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Results. The occurrence of tick-borne pathogens in the blood of patients (n=163) with

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autoimmune conditions requiring immunosuppressive treatment were evaluated. Pathogen

DNA was detected in 8.6% (14/163) of the patients. The predominant pathogen was
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Candidatus Neoehrlichia mikurensis (12/14), which was carried in the blood of infected
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patients for 10-59 days until treatment with doxycycline. Borrelia burgdorferi sensu lato and

Rickettsia spp. were detected in one patient each. The B. burgdorferi-infected patient
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presented with fever, whereas the remaining patients were judged to have subclinical
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infections. Borrelia miyamotoi, Anaplasma phagocytophilum, and Babesia spp. were not
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detected in any patient.

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Conclusions. Patients treated with biologicals and living in a tick-endemic area seem to have

a high risk of contracting Ca. Neoehrlichia mikurensis infection which if left untreated could
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result in thromboembolic complications.

Keywords: Tick-borne disease, Candidatus Neoehrlichia mikurensis, Borrelia burgdorferi

sensu lato, Rickettsia spp.

2
Background

The main vector for tick-borne pathogens in Europe is Ixodes ricinus, known for transmitting
infections caused by Borrelia burgdorferi sensu lato (borreliosis) and Anaplasma
phagocytophilum (anaplasmosis). Whereas borreliosis has a great impact on human health in
Europe, anaplasmosis cases are less frequently reported (https://www.ecdc.europa.eu). I.

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ricinus may also transmit less established pathogens such as Rickettsia spp., Candidatus
Neoehrlichia mikurensis, Borrelia miyamotoi and Babesia. Relatively few human cases
caused by these microbes have been reported in Europe [1-7], which may partly be explained
by diagnostic challenges. None of these pathogens can be detected by routine culture
methods, and the microscopic (Babesia), serological (A. phagocytophilum and Babesia) and

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molecular assays (A. phagocytophilum, Babesia, B. miyamotoi, Ca. Neoehrlichia mikurensis)

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presently available for diagnosis are only available at certain specialized clinical laboratories
in Europe. Another explanation for the few reported disease cases may be because the human

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immune system normally eliminates these pathogens such that most cases are asymptomatic
or present as mild infections that go unrecognized.

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Individuals with a weakened immune system are vulnerable to infections. A rapidly
expanding group are patients treated with biological therapies (e.g., tumor necrosis factor
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(TNF)-α and CD20 inhibitors) for autoimmune diseases such as inflammatory bowel disease,
multiple sclerosis and rheumatoid arthritis. Reports on the health burden of tick-borne
infectious diseases in this group of patients are limited. Rituximab (CD20 inhibitor)-treated
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patients with erythema migrans seem to be at higher risk of disseminated disease compared
with immune competent individuals [8] Similarly, lymphoma patients using rituximab are
susceptible to persistent/relapsing babesiosis (caused by Babesia) due to impairment of B-cell
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immunity [9]. Immunocompromised subjects, including those treated with rituximab, are also
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reported to have impaired ability to produce B. burgdorferi-specific antibodies [10-14],

which may compromise both host defense and the ability to diagnose borreliosis. Among the
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less-familiar tick-borne pathogens, infections by Ca. Neoehrlichia mikurensis, B. miyamotoi

and Babesia are chiefly associated with immunocompromised hosts [5, 15, 16]. Most
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reported European cases of babesiosis (50) and neoehrlichiosis (100) caused by Ca.
Neoehrlichia mikurensis, were diagnosed in immunocompromised individuals [5, 6, 17-19].
Infections caused by B. miyamotoi may give rise to relapsing fever with mild symptoms in
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immunocompetent persons, whereas severe disease as meningoencephalitis is predominantly

diagnosed in immunocompromised individuals [16, 20-22].

The aim of this study was to evaluate the occurrence and clinical characteristics of tick-borne
infections in patients treated with biologicals/immunosuppressive agents living in a tick-
endemic area in southern Norway. Patients were recruited to the study, most of them during
the peak season of tick-borne infection in Norway, while they attended the outpatient hospital
clinic for control of their disease regardless if infection was suspected or not.

3
Methods

Patients

Patients were recruited at the Department of Neurology and Department of Clinical Medicine

at Sørlandet Hospital (located in the southern part of Norway) during two periods, September

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- December 2018 (n=144) and March- May 2019 (n=19). Adult patients (> 18 years old) on

immunosuppressive medication for autoimmune diseases were invited to participate in the

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study when they attended the hospital for treatment and/or control of the disease independent

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of having signs of infection or not. Individuals treated with infliximab or rituximab were

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primarily chosen because the biologicals have different mechanisms of action and are

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administered as infusions at the hospital. Nurses responsible for the infusions recruited most

patients with gastrointestinal and rheumatic disease and medical doctors recruited patients
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with neurological conditions on rituximab. Patients answered a questionnaire at the time of
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study inclusion regarding the type and duration of health issues the preceding four months,

history of tick-bites and tick-borne infections, and current activities associated with risk of
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being tick-bitten. EDTA blood and serum were collected from all participants. Follow-up
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samples were usually taken 1-2 weeks after infection was diagnosed, in most cases when
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starting with antibiotics. All patients had to provide a negative sample at no fixed time, either
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after or without treatment.

Clinical data such as main diagnosis, co-morbidities, current health issues including fever,
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type of immunosuppressive treatment and laboratory test results (C-reactive protein (CRP),
white blood cell count (WBC) and blood-hemoglobin (Hgb)), were retrieved from the
patients’ medical charts. Blood samples used for routine laboratory tests were usually drawn
up to four days (153/163) and maximum up to 11 days (10/163) prior to inclusion.

4
Control samples

Blood samples from adult patient (n=85) submitted to Sørlandet hospital with suspected
neurological infection during the years 2013-2014, excluding patients diagnosed with Lyme
neuroborreliosis, were used as controls. Six had autoimmune disease and none were treated
with infliximab or rituximab.

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Ethical statements

The study (2018/658) and use of the controls (2014/179; 23121) was approved by the
Norwegian Regional Committee for Medical and Health Research Ethics, the South-Eastern
region. All participants provided written informed consent.

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DNA Sample preparation

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DNA was isolated from EDTA blood of patients and controls as described (Supplementary
Materials).

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Real-time PCR

Real-time PCR for detection of B. burgdorferi (two assays), B. miyamotoi, A.

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phagocytophilum, Rickettsia spp., and Ca. Neoehrlichia mikurensis (two assays, designated
CNM-I and II) and a triplex real-time PCR for detection of Babesia microti, B. divergens and
B. venatorum were used in this study (Supplementary Table 1 and Supplementary Materials).
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Serology

Detection of B. burgdorferi and Rickettsia spp. antibodies was perform as described (See
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Supplementary Materials). Serological assays for detection of Ca. Neoehrlichia mikurensis

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antibodies are not available at present.

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Statistics

The Chi-square and Fisher’s exact tests (applied when comparing two variables with two
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categories where at least one cell size is <5) were used to compare categorical variables by
using the tool at https://www.socscistatistics.com. The Mann-Whitney U test was used to
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compare age in different test groups. P-values <0.05 were considered significant.

5
Results

Patients

The study comprised 163 immunosuppressed patients with systemic rheumatic,

gastrointestinal and neurological autoimmune diseases (Table 1). The patients were recruited

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to the study and donated blood whilst attending a hospital outpatient clinic to receive
intravenous treatment with biological and/or for treatment monitoring. Two-thirds of the
patients were treated with the TNF- inhibitor infliximab, one quarter with the B-cell
depleting agent rituximab, and the remainder were given vedolizumab, alemtuzumab,
tocilizumab and other immunosuppressants (Table 1). The study covered roughly 80% and

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20% of the gastrointestinal and rheumatic hospital patients currently treated with infliximab

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or rituximab, respectively, and approximately 50% of the neurological patients treated with
rituximab during the project period.

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Detection of tick-borne pathogen DNA in patients and controls

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DNA from the whole blood and plasma/buffy coat fractions from each patient was analyzed
by real-time PCR for detection of six tick-borne pathogen genera. Pathogen DNA was
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detected in 8.6% (14/163) (Table 2) in either the plasma/buffy coat fractions alone or both
blood fractions of the patient samples (Supplementary Table 2). Ca. Neoehrlichia mikurensis
DNA was detected in 7.4% (12/163) of the patients by using two independent Ca.
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Neoehrlichia mikurensis-specific PCRs (CNM-I and CNM-II assays) with concordant results.
B. burgdorferi and Rickettsia spp. DNA were identified in one patient each. Neither A.
phagocytophilum, B. miyamotoi nor Babesia spp. DNA were detected in any of the samples.
d

The prevalences of Ca. Neoehrlichia mikurensis DNA in immunosuppressed patients

(12/163) and controls (1/85) were significantly different (p=0.038).
e

Serological findings in infected patients

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The patient with B. burgdorferi DNA in blood also had B. burgdorferi specific IgM and IgG
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antibodies consistent with an acute B. burgdorferi infection (IgM and IgG were 350 and
850% above their cut-offs, respectively). The patient with Rickettsia spp. DNA in blood was
analyzed for R. rickettsii and R. typhi -specific IgM and IgG antibodies in serum and was
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found to have R. rickettsii IgM slightly above the cut-off (positive at dilution 1:128 with
cut-off of 1:64) and no detectable IgG in sera taken 12 days apart. Serology could not
confirm a rickettsial infection.

6
Comparison of risks of tick-borne infection in patient groups

Grossly every tenth patient belonging to the different disease (rheumatic, gastrointestinal and
neurological) groups and similarly in the treatment (infliximab and rituximab) groups was
found to be carrying a tick-borne pathogen. There were no statistical differences in infection
rates between the studied patient categories (Table 2).

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Clinical picture and follow-up of infected patients

Self-reported health complaints the four months prior to inclusion in the study and clinical
data retrieved from patient medical charts were used to assess the clinical manifestations of
the infected patients (Table 3). Seven of the fourteen patients were treated with antibiotics

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within 15 days based on the initial pathogen findings (Figure). Four asymptomatic patients

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(no. 4, 9, 10 and 11) with low-level (cycle threshold values at limit of detection of PCR) of
Ca. Neoehrlichia mikurensis DNA were retested after a minimum of one week. Bacterial

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DNA was detected again, and they were all subsequently treated with antibiotics. One of
them (no. 9) tested positive as late as 53 days after the first finding.

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Another patient (no. 6) initially declined treatment with antibiotics despite suffering from
headache, nausea, dizziness and fatigue for months prior to inclusion in the study. Retesting
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of the patient`s blood on day 21 gave inconclusive results. However, when a positive signal
of Ca. Neoehrlichia mikurensis DNA again was detected on day 59 the patient agreed to be
treated. Ca. Neoehrlichia mikurensis and B. burgdorferi infections were treated with 200 mg
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doxycycline daily for three and two weeks, respectively. Pathogen DNA was not detected in
any patients after antibiotic therapy. Two patients were not treated, one with Ca. Neoehrlichia
mikurensis (no. 14) and one with Rickettsia (no. 8) DNA detected in blood, both with
d

negative retests. Patient no. 14 only submitted a blood samples for retesting 140 days after
inclusion, by which time the infection was no longer detectable. Patient no. 8 had over time
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experienced complaints coupled to biological therapy but had no symptoms indicative of an

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ongoing infection. She reported no recent travels to Rickettsia-endemic areas or exposure to

ticks the preceding months.
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One patient (no. 2) diagnosed with B. burgdorferi bacteremia, had signs of acute disease. She
had multiple sclerosis and presented with low-grade fever (rectal temperature of 37.7 C),
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general joint pain and increasing serum-CRP (45 and 74 mg/L two weeks before and at the
time of inclusion, respectively); subsequently her second dose of rituximab was postponed.
She was tick-bitten four weeks before but had not seen any skin rash. The patient recovered
after doxycycline treatment. An infliximab-treated patient with psoriatic arthritis (no. 9)
infected with Ca. Neoehrlichia mikurensis had weakly elevated serum-CRP (10 mg/L) at the
time of inclusion, which had normalized by the time she started antibiotic treatment on day
61 due to a positive retest on day 53.

Three patients with subclinical Ca. Neoehrlichia mikurensis infections experienced improved
health after doxycycline treatment (Table 3). Patients no. 1 reported recovery from fatigue,
whereas patients no.10 and 13, both of whom reported no new health complaints during the
7
four months preceding inclusion in the study, experienced improvement from symptoms such
as stiffness, low energy level/fatigue, arms feeling heavy and facial rash. Eight Ca.
Neoehrlichia mikurensis-infected patients did not experience any changes in general health
status after antibiotic treatment at all.

There are no statistical difference between patients infected and not infected with Ca.

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Neoehrlichia mikurensis when it comes to having elevated CRP (> 5 mg/L), WBC outside the

normal value range (4.0 to 11.0 × 109/L) or self-reported symptoms (p=0.420, 1.00 and 0.340,

respectively).

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Characteristics of infected, non-infected and controls

The study cohort had a female to male ratio of 1.6:1 and a median age of 48 years. However,

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there were no statistically significant differences connected with age (p = 0.66) or gender (p
=0.81) regarding the risk of becoming infected with a tick-borne pathogen. Neither were

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there any differences between the infected and non-infected patients regarding degree of tick
exposure or behavior to protect against tick-bites (Table 4). The control group had a skewed
female to male ratio of 1:1.5 compared with the study cohort (p= 0.001), whereas the median
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age of 48 years was the same.

Discussion
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Tick-borne bacterial pathogen DNA was detected in the blood of close to every tenth
immunocompromised patient receiving biologicals for an autoimmune disease in a high-
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endemic region of tick-borne infections in Norway. The most frequent pathogen was Ca.
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Neoehrlichia mikurensis (12/14), followed by B. burgdorferi and Rickettsia spp., which were
detected in one patient each. A. phagocytophilum, B. miyamotoi and Babesia were not
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detected at all.
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Ca. Neoehrlichia mikurensis is the second most prevalent I. ricinus pathogen in the project
area with a prevalence rate up to 17-25%, second to B. burgdorferi with a prevalence rate of
approximately 30% [23-25]. Differences in infection efficiency, tissue tropism and magnitude
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of bacteremia may explain the higher incidence of Ca. Neoehrlichia mikurensis infections
than B. burgdorferi infections in the blood of the study patients. Although Borrelia may stay
in blood for weeks during the early phase of infection, the concentration seems to be very low
[26] and possibly as few as one spirochete/10 mL blood [27]. In contrast, Ca. Neoehrlichia
mikurensis infects the vascular endothelium [28] and may give rise to a level of DNA-emia
as high as 106 gene copies/mL in immunocompromised individuals [6, 29]. Months-long
carriage of Ca. Neoehrlichia mikurensis DNA in the blood has been detected in
immunocompetent individuals [29-30]. We complement the findings by showing this also
features in immunocompromised patients; Ca. Neoehrlichia mikurensis DNA was carried in
the blood of infected patients for up to two months until treatment with doxycycline. The
8
ability of Ca. Neoehrlichia mikurensis to cause a prolonged blood stream infection most
likely explains the high prevalence of the pathogen in the blood of the study patients. The
ability of Ca. Neoehrlichia mikurensis to cause persistent asymptomatic bloodstream
infection raises concerns about neoehrlichiosis being a transfusion-transmitted infection such
as babesiosis [31].

Ca. Neoehrlichia mikurensis causes symptomatic disease in immunocompromised hosts [6],

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whereas in immunocompetent infected individuals, the clinical presentations range from no
symptoms to febrile disease [7, 29-30, 32]. In this study, immunocompromised patients
presented with asymptomatic neoehrlichiosis as well, given that several patients did not
experience any relief of symptoms after antibiotic treatment. Lack of symptoms and no
abnormal inflammation markers in infected study patients may be due to attenuated

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inflammation and immune processes. The net state of immune suppression is primarily
depended on the intensity of immunosuppressive treatment, however, other factors as

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underlying conditions, other types of medication, presence or absence of metabolic factors
and chronic viral infections may influence to varying degree [33]. On the other hand,

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Neoehrlichiosis is described to give rise to a systemic inflammatory syndrome that can be
mistaken for symptoms caused by an underlying disease [6]. The subclinical cases in our
study reported diffuse constitutional symptoms such as increasing fatigue, pain and night
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sweats that may or may not have been due to the Ca. Neoehrlichia mikurensis infection. Two
study patients experienced relief from symptoms after treatment with doxycycline, symptoms
initially thought to be a part of their chronic disease. In contrast, two other study patients did
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not report any change in their health situation despite having measurable signs of infection;
one with elevated CRP and one with a fever episode some days before diagnosis. The
tolerance of health complaints among chronically ill patients may put them at risk for
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disregarding symptoms possibly arising from a subclinical infection, which if allowed to

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become manifest could result in thromboembolic and vascular complications associated with
overt cases of neoehrlichiosis [15].
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Infliximab (TNF- inhibitor) therapy was as common among the infected patients as
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treatment with rituximab (antibody against CD20 on B-cells). Since rituximab is a recognized
risk factor for severe neoehrlichiosis it is likely that B-cell immunity is crucial in the defense
against the infection [15]. This is similar to what observed for rituximab treated lymphoma
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patients infected by B. microti, who are susceptible for persistent and relapsing disease [9].
Here, we demonstrate that TNF- inhibitor treated patients also appear to be susceptible to
prolonged subclinical/asymptomatic Ca. Neoehrlichia mikurensis infections given that two
patients on infliximab who were not immediately given antibiotics, tested positive for
pathogen DNA more than 50 days after the initial diagnosis. It remains to be clarified, if
infliximab therapy confers the same risk of developing severe neoehrlichiosis as rituximab
therapy, although it seems less likely as no such reports have been published.

Neoehrlichosis in immunocompromised patients should be treated with antibiotics if infection

is not cleared within a few weeks regardless of symptoms or not, due to the risk of long-term
9
carriage, activation of acute disease and thrombosis. To reduce the need for treatment it may
be important focusing on prevention of tick-bites and increased testing of susceptible patient
groups in endemic areas. Most infected immunocompetent individuals will be able to clear
the infection without antibiotics, and treatment may only be necessary if symptoms of acute
illness manifests.

The prevalence of A. phagocytophilum, B. miyamotoi and Babesia spp. in I. ricinus in the

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southern part of Norway is low [23, 34, 35]. This is probably part of the explanation for why
we found no infections caused by these pathogens. Our data is in accordance with the low
seroprevalence rates of antibodies to Babesia microti (2.1%) and Rickettsia helvetica/coronii
(4.2%) in a municipality in the study region [36]. More puzzling is the high A.
phagocytophilum seroprevalence of approximately 10% in this area and elsewhere in Norway

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[36-38], in view of the relatively low density of A. phagocytophilum in ticks [23, 39].
Possible explanations may be that anaplasmosis is common, but has an asymptomatic or mild

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presentation, and/or that Ca. Neoehrlichia mikurensis, which is considerably more prevalent
at many locations than A. phagocytophilum, may give rise to A. phagocytophilum cross-
reactive antibody responses [17, 29, 40].

Conclusions
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Our data suggest that patients treated with infliximab or rituximab and living in the southern
part of Norway have a high risk of contracting infection with Ca. Neoehrlichia mikurensis,
most of them as asymptomatic carriers. More data on the implications of long-term carriage
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of this emerging tick-borne pathogen is required to clarify the need for diagnostic monitoring
and antibiotic treatment of different patient groups.
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10
Notes

Acknowledgement. We thank the nurses at the Department of Clinical Medicine at Sørlandet

hospital for their commitment and help in recruitment of study patients.

Fundings. None

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Potential conflict of interest. All No reported conflicts of interest. All authors have
submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the

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editors consider relevant to the content of the manuscript have been disclosed.

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11
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Table 1. Disease groups and biological therapy modalities

Immune suppressive therapy (no. of patients)

Infliximab Rituximab Vedolizu- Alemtuzu- Tocilizu- Others*

mab mab mab

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TNF- CD20- 47- CD52- IL6R-
inhibitor inhibitor integrin inhibitor inhibitor
inhibitor
Disease groups
Rheumatic conditions (n=58)

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Rheumatoid arthritis (n=31) 16 13 1 1

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Spondyloarthropaty (n=15) 15
Systemic lupus 3
erythematosus (n=3)

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Other connective tissue 9
diseases (n=9)

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Gastrointestinal disease n=84
Crohn's disease (n=48) 45 3
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Ulcerative colitis (n=34) 32 2
Others (n=2) 2

Neurological conditions (n=21)

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Multiple sclerosis (n=18) 16 2

Myasthenia gravis (n=2) 1 1
Others (n=1) 1
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All patients (n=163) 110 43 5 2 1 2

* Azathioprine, methotrexate and/or prednisolone alone or in combination.
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Abbreviations: TNF, tumor necrosis factor; CD, cluster of differentiation; IL, interleukin; R, receptor.
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Table 2. Detection of tick-borne infections and comparison of risks between disease and
treatment groups

Tick-borne infection caused by

Candidatus Borrelia Rickettsia All pathogens

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Neoehrlichia burgdorferi species
mikurensis sensu lato
Comparison Comparison
of groups of groups

n (%) p value* n (%) n (%) n (%) p value*

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All study patients (n=163) 12 (7.4) 1 (0.6) 1 (0.6) 14 (8.6)
All infected patients 12 (86) 1 (7.1) 1 (7.1) 14
(n=14) (100)

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Disease groups
Rheumatic (n=58) 4 (6.9) 1 (1.7) 5 (8.6)
Gastrointestinal 7 (8.3) 0.843** 7 (8.3) 0.985**

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(n=84)
Neurological (n=21) 1 (4.8) 1 (4.8) 2 (9.5)
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Treatment groups
Infliximab (n=100) 10 (10) 10 (10)
Rituximab (n=43) 2 (4.7) 0.511*** 1 (2.3) 1 (2.3) 4 (9.3) 1.00***
Other (n=20)
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Borrelia miyamotoi, Anaplasma phagocytophilum and Babesia were not detected in any patient.
All percentages given in parenthesis are calculated from the denominator given in the first column.
*
Chi-square or Fischer’s exact tests were used.
**
Comparison of the three disease groups.
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***
Comparison of the infliximab and rituximab treatment groups.
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Table 3. Symptoms of immunosuppressed patients with tick-borne pathogen DNA in blood

Patient Age Sex Diagnosis Immune therapy Pathogen DNA Self-reported symptoms (regular font) and
no. (y) (duration in detected clinics recorded at hospital (italics)
y/mo or no. of
doses)

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At inclusion After treatment
1 47 F Crohn's Infliximab Ca. Neoehrlichia Increasing fatigue Recovery
disease (>2 y) mikurensis
2 40 F Multiple Rituximab Borrelia Pain and fatigue Recovery
sclerosis (one dose) burgdorferi Fever, CRP↑ CRP
3 47 M Crohn's Infliximab Ca. Neoehrlichia Fatigue No change

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disease (one dose) mikurensis Fever 9 days earlier,

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postponed infusion of
infliximab
4 44 F Multiple Rituximab Ca. Neoehrlichia None No change

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sclerosis (one dose) mikurensis
5 68 M Rheumatoid Rituximab Ca. Neoehrlichia Pain in the neck, back, No change
arthritis (>4 y) mikurensis ankles and hips

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6 26 F Ulcerative Infliximab Ca. Neoehrlichia Headache, nausea, No change (Less
colitis (>1 y) mikurensis dizziness and fatigue headache?)

7 64 F Ulcerative Infliximab Ca. Neoehrlichia None No change

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colitis (>6 y) mikurensis
8 34 F Sjögren´s Rituximab Rickettsia spp Pain, sleep problems and (No treatment)
syndrome (>5 y) fatigue
9 48 F Psoriatic Infliximab Ca. Neoehrlichia None No change
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arthritis (>1 y) mikurensis CRP↑ CRP

10 60 F Crohn's Infliximab Ca. Neoehrlichia None Recovery of
disease (>9 y) mikurensis stiffness and fatigue
11 45 M Crohn's Infliximab Ca. Neoehrlichia None No change
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disease (>4 y) mikurensis

12 52 M Ulcerative Infliximab Ca. Neoehrlichia Bone pain, nightly sweats No change
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pancolitis (>7 y) mikurensis and sleep problems

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13 52 F Sacroiliitis Infliximab Ca. Neoehrlichia Unknown Recovery of “heavy”

HLA B27 (>2 y), mikurensis arms, rash and
fatigue
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14 59 M Psoriatic Infliximab Ca. Neoehrlichia Pain, dizziness (No treatment)

arthritis (6 mo) mikurensis headache, nightly sweats,
sleep problems and
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fatigue
Abbreviations: Ca, candidatus; CRP, C-reactive protein; HLA, human major histocompatibility complex.

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Table 4. Questionnaire-reported characteristics of non-infected and infected patients

No. of non-infected No. of infected p value**

patients (%) patients (%)
n=147* n=14

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Tick-bite current year 42 (29) 6 (43) 0.264
History of tick-bite 117 (80) 11 (79) 1.00
History of erythema 43 (29) 4 (29) 1.00
Rarely exposed to ticks 19 (13) 0 (0) 0.377
Regularly checks for ticks and/or protective 107 (73) 12 (86) 0.360
behaviour***

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*
Of 149 non-infected patients, 147 answered the questionnaire.

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**
Chi-square or Fischer’s exact tests were used.
***
Use of protective clothing and/or insect repellents.

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Figure legend

Figure. Detection of tick-borne pathogen DNA in the blood of immunosuppressed patients

during infection.

Abbreviations: Ct, cycle threshold; LOD, Limit of detection

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Figure 1

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