Correspondence Borrelia mayonii: prying completely overlooked.8 This novel 4 Rudenko N, Golovchenko M, Vancová M, strain was reported before B mayonii, Clark K, Grubhoff er L, Oliver JH Jr. Isolation of open Pandora’s box of live Borrelia burgdorferi sensu lato spirochetes and should have been addressed in from patients with undefi ned disorders and spirochetes both the text and the phylogenetic symptoms not typical for Lyme borreliosis. Clin Microbiol Infect 2016; 22: 267, e9–e15. analyses (fi gure 4 in the Article). 5 Golovchenko M, Vancová M, Clark K, Bobbi Pritt and colleagues1 reveal Furthermore, the authors contend Oliver JH Jr, Grubhoff er L, Rudenko N. that Borrelia mayonii is a new that Wisconsin is the epicentre A divergent spirochete strain isolated from a resident of the southeastern United States member of the Borrelia burgdorferi of B mayonii; however, migratory was identifi ed by multilocus sequence typing sensu lato complex, and show songbirds play a vital part in the as Borrelia bissettii. Parasit Vectors 2016; 9: 68. that this spirochete is pathogenic epidemiology of Lyme disease vector 6 Rudenko N, Golovchenko M, Mokracek A, et al. to human beings. However, the ticks, including the blacklegged tick Detection of Borrelia bissettii in cardiac valve authors err on several key points. (Ixodes scapularis).9 Since passerine tissue of a patient with endocarditis and aortic valve stenosis (Czech Republic). J Clin Microbiol They state B burgdorferi sensu stricto migrants transport I scapularis 2008; 46: 3530–43. was previously the only cause of immatures thousands of kilometres 7 Collares-Pereira M, Couceiro S, Franca I, et al. First isolation of Borrelia lusitaniae from a Lyme borreliosis in the USA. With during bidirectional, spring and fall human patient. J Clin Microbiol 2004; the discovery of B mayonii, they migration, these avian hosts will, 42: 1316–18. take credit for describing the first undoubtedly, disperse B mayonii 8 Caporale DA, Johnson CM, Millard BJ. Presence of Borrelia burgdorferi (Spirochaetales: non-B burgdorferi sensu stricto in spirochetes much further than Spirochaetaceae) in southern Kettle Moraine patients in the USA; this assumption currently recognised. State Forest, Wisconsin, and characterization 2 of strain W97F51. J Med Entomol 2005; is not true. Girard and colleagues The authors claim that B mayonii 42: 457–72. reported B bissettii in patients in causes symptoms that distinguish it 9 Scott JD, Anderson JF, Durden LA. Widespread California and Clark and colleagues3 from other B burgdorferi sensu lato dispersal of Borrelia burgdorferi-infected ticks collected from songbirds across Canada. documented B americana and genospecies. With only six patients, J Parasitol 2012; 98: 49–59. B andersonii in human blood from however, it seems audacious to state 10 Cameron DJ, Johnson LB, Maloney EL. resi dents in the southeastern that B mayonii clinical symptoms Evidence assessments and guideline recommendations in Lyme disease: the USA. Further more, Rudenko and are distinct from patients infected clinical management of known tick bites, colleagues4 reported a B bissettii- with B burgdorferi sensu stricto. The erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther 2014; like strain in a Florida patient. In all authors laud the US Food and Drug 12: 1103–35. of these cases, patients had clinical Administration-approved Lyme symptoms commonly associated disease test kits, but some patients with Lyme borreliosis. were seronegative. Based on the Authors’ reply In their Introduction, Pritt and recom mended two-tiered algorithm We thank John Scott for his comments colleagues state that B garinii, (table 2 in the Article), patient 6 regarding our recent Article1 B afzelii, and B burgdorferi sensu was entirely negative and the other describing the identifi cation of a novel stricto are the only B burgdorferi sensu patients had inconsistent sero logical genospecies of Borrelia burgdorferi lato genospecies that cause Lyme results. Finally, the authors recom- sensu lato (Borrelia mayonii) as a new borreliosis in Europe. In fact, at least mend standard, short-term treatment cause of Lyme borreliosis among fi ve genospecies of the B burgdorferi for B mayonii, but fail to mention patients in the upper midwestern USA. sensu lato complex are pathogenic the limitations of this treatment for We agree with Scott that multiple to human beings, including B afzelii, persistent Lyme disease.10 B burgdorferi sensu lato genospecies B bavariensis, B burgdorferi sensu I declare no competing interests. can infect human beings. Our wording stricto, B garinii, and B spielmanii.5 “nearly all human infections are Additionally, B bissettii, B kurtenbachii, John D Scott caused by three B burgdorferi sensu lato [email protected] B lusitaniae, and B valaisiana have genospecies” reflects this, and does been reported in patients in Europe.5–7 Lyme Ontario, Research Division, Fergus, ON, Canada not exclude other B burgdorferi sensu The authors state that B burgdorferi 1 Pritt BS, Mead PS, Hoang Johnson DK, et al. lato genospecies. A more thorough Identifi cation of a novel pathogenic Borrelia sensu lato has never been reported species causing Lyme borreliosis with review of B burgdorferi sensu lato in peripheral blood, but actually unusually high spirochaetaemia: a descriptive genospecies was neither within the study. Lancet Infect Dis 2016; 16: 556–64. several researchers in the USA and 2 Girard YA, Fedorova N, Lane RS. Genetic focus of our Article nor possible due Europe have isolated spirochetes from diversity of Borrelia burgdorferi and detection of to the word limit. We concur that blood.4,5 B bissettii-like DNA in serum of north-coastal studies on other B burgdorferi sensu residents. J Clin Microbiol 2011; 49: 945–54. Biogeographically, the unique strain 3 Clark KL, Leydet B, Hartman S. Lyme borreliosis lato genospecies as a cause of Lyme of B burgdorferi sensu lato (W97F51) in human patients in Florida and Georgia, USA. borreliosis in North America and from southeastern Wisconsin was Int J Med Sci 2013; 10: 915–31. Europe are important. www.thelancet.com/infection Vol 16 June 2016 637 Correspondence Scott suggests that we state that competing interests. The views and conclusions in syn dromes, and severe community- B burgdorferi sensu lato has never this letter are those of the authors and do not acquired pneumonia are all diseases necessarily represent the offi cial position of the been reported from peripheral blood. Centers for Disease Control and Prevention. with evidence that favours the use To clarify, in the introduction we of steroids. Additionally, experience state “microscopic detection” of *Bobbi S Pritt, Jeannine M Petersen with another virus with haemorrhagic B burgdorferi sensu lato spirochaetes [email protected] expression, the Puumalavirus, docu- has never been reported in peripheral Mayo Clinic, Rochester, MN, USA (BSP); and Division mented an excellent outcome in a of Vector Borne Diseases, US Centers for Disease blood. This is an important distinction Control and Prevention, Fort Collins, CO, USA (JMP) few patients with multiorgan failure given that a major finding of our treated with an aggressive approach 1 Pritt BS, Mead PS, Hoang Johnson DK, et al. 5 study is that B mayonii causes Lyme Identifi cation of a novel pathogenic Borrelia that included the use of steroids. borreliosis with unusually high spiro- species causing Lyme borreliosis with As suggested by Hunt and Knott,6 unusually high spirochaetaemia: a descriptive chaetaemia. Scott questions why study. Lancet Infect Dis 2016; 16: 556–64. knowledge of a likely exposure to Borrelia species W97F51 was not steroids during the EVD acute phase included in fi gure 4. We point out that in the Sierra Leone cohort could be of Borrelia species W97F51 is included in Steroid use and clinical great interest. Apart from anecdotal the phylogenetic tree in fi gure 4A of sequelae in two cases, only a systematic collection the web appendix; this analysis shows of epidemiological and clinical data that it is distinct from B mayonii. survivors of EVD from large EVD patient cohorts Scott suggests that the geographical could provide unequivocal evidence distribution and clinical presentation John Mattia and colleagues1 on the impact of steroid use on the of B mayonii has not been fully described the clinical sequelae occurrence of clinical sequelae after defined. We agree and believe we during early Ebola viral disease Ebola virus infection. addressed this in the last paragraph (EVD) convalescence in a cohort We declare no competing interests. We received of the Article, where we highlight of 277 survivors in Sierra Leone: funding from Ricerca Corrente Italian Ministry the need to better defi ne the clinical arthralgias (76%), new ocular symp- of Health. range of illness and establish the toms (60%), and uveitis (18%) were *Emanuele Nicastri, Nicola Petrosillo, geographical distribution of infected the more common presentations. Francesco Vairo, Antonino Di Caro, human beings and ticks. With regard Ebola viral load at the time of EVD Giuseppe Ippolito to the results of serological testing, diagnosis was the independent [email protected] we note that the negative results predictor of ocular symptoms, and National Institute for Infectious Diseases (INMI), were discussed in our Article. We specifi cally uveitis. Lazzaro Spallanzani IRCCS, Via Portuense 292, expand here by clarifying that a In Rome, Italy, we successfully 00149 Rome, Italy negative result is expected early after treated two Italian patients with 1 Mattia JG, Vandy MJ, Chang JC, et al. Early clinical sequelae of Ebola virus disease illness onset when using a diagnostic EVD who had a high viral load at in Sierra Leone: a cross-sectional study. test that is dependent on detecting the time of diagnosis (5 × 10⁶ copies Lancet Infect Dis 2016; 16: 331–38. 2 Petrosillo N, Nicastri E, Lanini S, et al. the host’s production of antibodies. per μL and 5 × 10⁷ copies per μL, Ebola virus disease complicated with viral This is among the reasons why we respectively).