Ticking on Pandora's box: a prospective case-control study into 'other' tick-borne diseases

BMC Infect Dis. 2021 May 29;21(1):501. doi: 10.1186/s12879-021-06190-9.


Background: Tick-borne pathogens other than Borrelia burgdorferi sensu lato - the causative agent of Lyme borreliosis - are common in Ixodes ricinus ticks. How often these pathogens cause human disease is unknown. In addition, diagnostic tools to identify such diseases are lacking or reserved to research laboratories. To elucidate their prevalence and disease burden, the study 'Ticking on Pandora's Box' has been initiated, a collaborative effort between Amsterdam University Medical Center and the National Institute for Public Health and the Environment.

Methods: The study investigates how often the tick-borne pathogens Anaplasma phagocytophilum, Babesia species, Borrelia miyamotoi, Neoehrlichia mikurensis, spotted fever group Rickettsia species and/or tick-borne encephalitis virus cause an acute febrile illness after tick-bite. We aim to determine the impact and severity of these tick-borne diseases in the Netherlands by measuring their prevalence and describing their clinical picture and course of disease. The study is designed as a prospective case-control study. We aim to include 150 cases - individuals clinically suspected of a tick-borne disease - and 3 matched healthy control groups of 200 persons each. The controls consist respectively of a group of individuals with either a tick-bite without complaints, the general population and of healthy blood donors. During a one-year follow-up we will acquire blood, urine and skin biopsy samples and ticks at baseline, 4 and 12 weeks. Additionally, participants answer modified versions of validated questionnaires to assess self-reported symptoms, among which the SF-36, on a 3 monthly basis.

Discussion: This article describes the background and design of the study protocol of 'Ticking on Pandora's Box'. With our study we hope to provide insight into the prevalence, clinical presentation and disease burden of the tick-borne diseases anaplasmosis, babesiosis, B. miyamotoi disease, neoehrlichiosis, rickettsiosis and tick-borne encephalitis and to assist in test development as well as provide recommendations for national guidelines.

Trial registration: NL9258 (retrospectively registered at Netherlands Trial Register, trialregister.nl in in February 2021).

Keywords: Fever after tick-bite; Hard tick-borne fever; Ixodes ricinus ticks; Prospective case-control study; Study protocol; Tick-borne diseases; Tick-borne pathogens.

MeSH terms

  • Adult
  • Animals
  • Blood / microbiology
  • Blood / virology
  • Case-Control Studies
  • DNA, Bacterial
  • Fever / epidemiology
  • Fever / microbiology
  • Fever / virology
  • Follow-Up Studies
  • Humans
  • Ixodes / microbiology*
  • Middle Aged
  • Netherlands / epidemiology
  • Prevalence
  • Prospective Studies
  • Real-Time Polymerase Chain Reaction
  • Severity of Illness Index
  • Skin / microbiology
  • Skin / virology
  • Surveys and Questionnaires
  • Tick Bites / epidemiology
  • Tick Bites / microbiology
  • Tick Bites / virology
  • Tick-Borne Diseases / epidemiology*
  • Tick-Borne Diseases / microbiology*
  • Urine / microbiology
  • Urine / virology


  • DNA, Bacterial