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# Prevalence of Lyme Disease and Relapsing Fever Borrelia spp. in Vectors, Animals, and Humans within a One Health Approach in Mediterranean Countries

Myrto Koutantou, Michel Drancourt, Emmanouil Angelakis

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Myrto Koutantou, Michel Drancourt, Emmanouil Angelakis. Prevalence of Lyme Disease and Relapsing Fever Borrelia spp. in Vectors, Animals, and Humans within a One Health Approach in Mediterranean Countries. Pathogens, 2024, 13 (6), pp.512. 10.3390/pathogens13060512. hal-04677891

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# Prevalence of Lyme Disease and Relapsing Fever *Borrelia* spp. in Vectors, Animals, and Humans within a One Health Approach in Mediterranean Countries

Myrto Koutantou¹ ID, Michel Drancourt² and Emmanouil Angelakis ¹,*

¹ Diagnostic Department and Public Health Laboratories, Hellenic Pasteur Institute, 11521 Athens, Greece

² MEPHI, Aix-Marseille University, IRD, 13005 Marseille, France

* Correspondence: e.angelakis@pasteur.gr

**Abstract:** The genus *Borrelia* has been divided into *Borreliella* spp., which can cause Lyme Disease (LD), and *Borrelia* spp., which can cause Relapsing Fever (RF). The distribution of genus *Borrelia* has broadened due to factors such as climate change, alterations in land use, and enhanced human and animal mobility. Consequently, there is an increasing necessity for a One Health strategy to identify the key components in the *Borrelia* transmission cycle by monitoring the human-animal-environment interactions. The aim of this study is to summarize all accessible data to increase our understanding and provide a comprehensive overview of *Borrelia* distribution in the Mediterranean region. Databases including PubMed, Google Scholar, and Google were searched to determine the presence of *Borreliella* and *Borrelia* spp. in vectors, animals, and humans in countries around the Mediterranean Sea. A total of 3026 were identified and screened and after exclusion of papers that did not fulfill the including criteria, 429 were used. After examination of the available literature, it was revealed that various species associated with LD and RF are prevalent in vectors, animals, and humans in Mediterranean countries and should be monitored in order to effectively manage and prevent potential infections.

**Keywords:** One Health; Lyme Disease; relapsing fever; *Borreliella*; *Borrelia*; bacteria; tick-borne; louse-borne; human-animal-environment interaction; zoonoses

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**Citation:** Koutantou, M.; Drancourt, M.; Angelakis, E. Prevalence of Lyme Disease and Relapsing Fever *Borrelia* spp. in Vectors, Animals, and Humans within a One Health Approach in Mediterranean Countries. *Pathogens* **2024**, *13*, 512. https://doi.org/10.3390/pathogens13060512

Academic Editor: Olivier A.E.
Sparagano

Received: 2 May 2024

Revised: 5 June 2024

Accepted: 10 June 2024

Published: 17 June 2024

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**Copyright:** © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
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conditions of the Creative Commons
Attribution (CC BY) license (https://
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4.0/).

## 1. Introduction

One Health approach is a holistic perspective that deals with complicated issues involving human, animal, and environmental health [1]. Such approaches have become increasingly important in recent years due to critical changes that have altered the interactions among humans, animals, and their environment [2]. Human population growth as well as their expansion into new geographical areas results in closer proximity between people and animals, facilitating the transmission of diseases among them [3,4]. Additionally, climate change and alterations in land use, along with increased movement of people, animals, and animal products through international travel and trade, further exacerbates the spread of endemic diseases [5,6].

*Borrelia* spp. are microaerophilic, slow-growing spirochetal bacteria that have been associated with human diseases [7]. Depending on the infecting species, it can cause Lyme Disease (LD) [8], also known as Lyme borreliosis, or Relapsing Fever (RF) [9].

LD is the most prevalent vector-borne disease in moderate climates of the northern hemisphere with an increasing incidence [10]. It is estimated that approximately 476,000 cases are diagnosed and treated annually in the United States [11], and over 200,000 cases per year in Europe [12].

RF can be either louse-borne (LBRF) or tick-borne (TBRF) [13] and is predominantly found in Africa, Spain, Saudi Arabia, Asia, and western United States, with epidemics still
occurring in developing countries due to poor living conditions, famine, and war [14]. Currently, LBRF is mostly observed in the Horn of Africa and among immigrants originating from endemic areas [15]. TBRF has recently been associated with travel-related disease after travelling in endemic areas [16].

*Borrelia* spp. can be transmitted by hard and soft ticks, as well as human body lice. The distribution of these arthropod vectors is closely linked to the presence of the bacteria in both animals and humans [17]. Animals serve as hosts for both ticks and bacteria, playing a crucial role in the circulation of *Borrelia* spp. [18]. Therefore, studying the distribution of ticks in relation to the surrounding environment and the prevalence of suitable hosts for ticks and *Borrelia* spp. is essential for better understanding the factors contributing to human diseases [19].

The aim of this article is to review the current data on the presence of *Borrelia* spp. in vectors, animals, and humans around the Mediterranean Sea in order to monitor their human-animal-environment interactions within a One Health approach. Such information provides insight for the better surveillance and management of *Borrelia* infections.

## 2. Methods

A review of the literature was conducted on the available publications from 1936 to February of 2024 by searching PubMed, Google Scholar, and Google. We included studies related to the presence of LD *Borrelia* spp. and RF *Borrelia* spp. in countries around the Mediterranean Sea in the vectors of transmission, the animal hosts, as well as the humans that can become infected. Search terms included "Lyme Disease", "Lyme borreliosis", "Relapsing Fever", "Borrelia", "Borrelia", "bacteria", "human-animal-environment interaction", "One Health", "humans", "animals", "ticks", "lice". Articles that were not written in English were excluded from this study (Figure 1).

**Flow diagram of study selection**

<figure><img src="image_6.png" /><figcaption>**Figure 1.** Flow diagram of study selection.</figcaption></figure>
3. Bacteriology

Species of the *Borrelia* genus are members of the Borreliaceae family of the Spirochaetales phylum and are thus characterized by the typical spirochaete (spiral) shape [20]. They are microaerophilic and host-associated since they rely on their hosts for most of their nutrients in an obligate parasitic lifestyle [21]. They possess an outer membrane around their protoplasmic cylinder analogous to that of Gram-negative bacteria, but without lipopolysaccharides [22]. They have several axial filaments attached to each pole, called endoflagella [13], between the outer membrane and the peptidoglycan layer, inside the periplasmic space, which help the bacteria move forward in a corkscrew-like motion [8]. Their genome consists of one highly conserved linear chromosome and several plasmids that can be either linear or circular and their number varies highly among strains [23]. *Borrelia* genus is divided into two genera related to human disease, *Borrelia* for the Lyme group and *Borrelia* for the Relapsing Fever group (Figure 2). Even though they belong to the same genus, they are known to have significant differences regarding their biological characteristics, their epidemiology, as well as their pathogenicity [24]. According to the phylogenetic data, although they share a genetic similarity, they are different, and they belong to independent clades under a common ancestor. For this reason, it has been proposed and recently validated [25], to include the Lyme group *Borrelia* into a new genus taxon named *Borrelia* [26].

<figure><img src="image_7.png" /><figcaption>**Figure 2.** Phylogenetic tree of the genus *Borrelia* from LD and RF groups constructed with the neighbor joining method with 1000 Bootstrap replications in MEGA 11.0 software based on the flaB gene.</figcaption></figure>
### 3.1. LD

LD is caused by the *Borreliella* genospecies. Currently, it contains twenty-six species, twenty-three validated, and three proposed (Table 1) [27,28]. It consists of bacteria 10–20 µm long, approximately 0.3 µm in diameter and the number of their endoflagella ranges from seven to twelve [24]. The species that most commonly cause human disease are *Borreliella burgdorferi*, *Borreliella afzelii*, *Borreliella garinii*, *Borreliella mayonii*, *Borreliella spielmanii*, and *Borreliella bavariensis*. *Bl. burgdorferi* is responsible for the majority of the LD cases in North America, *Bl. garinii* in Asia, and *Bl. afzelii* along with *Bl. garinii* in Europe [29,30].

<table><caption>**Table 1.** *Borreliella* spp. of the LD Group.</caption><thead><tr><th>Borreliella Species</th><th>Human Infection</th><th>Geographical Distribution</th><th>Hosts</th><th>Vectors</th><th>References</th></tr></thead><tbody><tr><td>Borreliella afzelii</td><td>Yes</td><td>Europe, Asia</td><td>Rodents</td><td>I. ricinus,<br>I. persulcatus,<br>I. pavlovsky</td><td>[31–34]</td></tr><tr><td>Borreliella americana</td><td>Unknown</td><td>North America,<br>Poland</td><td>Rodents, Birds</td><td>I. pacificus, I. minor,<br>I. ricinus</td><td>[35–37]</td></tr><tr><td>Borreliella andersonii</td><td>Unknown</td><td>USA</td><td>Cottontail rabbits</td><td>I. scapularis,<br>I. dentatus</td><td>[38–40]</td></tr><tr><td>Borreliella bavariensis</td><td>Yes</td><td>Europe, Asia</td><td>Rodents</td><td>I. ricinus, I. persulcatus</td><td>[41–43]</td></tr><tr><td>Borreliella bissettiae</td><td>Yes</td><td>USA, Europe</td><td>Rodents</td><td>I. spinipalpis, I. ricinus,<br>I. pacificus</td><td>[34,44–47]</td></tr><tr><td>Borreliella burgdorferi</td><td>Yes</td><td>America, Europe,<br>Asia</td><td>Rodents, Mammals,<br>Birds</td><td>I. scapularis,<br>I. pacificus, I. ricinus,<br>I. kaiseri</td><td>[34,48–50]</td></tr><tr><td>Borreliella californiensis</td><td>Unknown</td><td>USA, Europe</td><td>Kangaroo Rats</td><td>I. jellisoni,<br>I. spinipalpis,<br>I. pacificus, I. ricinus</td><td>[34,46,51–53]</td></tr><tr><td>Borreliella carolinensis</td><td>Unknown</td><td>USA, Europe</td><td>Rodents</td><td>I. minor, I. ricinus,<br>I. affinis</td><td>[37,54–58]</td></tr><tr><td>Borreliella chilensis</td><td>Unknown</td><td>Chile</td><td>Rodents</td><td>I. stilesi</td><td>[59]</td></tr><tr><td>Borreliella finlandensis</td><td>Unknown</td><td>Finland</td><td>Unknown</td><td>I. ricinus</td><td>[60]</td></tr><tr><td>Borreliella garinii</td><td>Yes</td><td>Europe, Asia</td><td>Rodents, Birds</td><td>I. ricinus, I. persulcatus</td><td>[34,61]</td></tr><tr><td>Candidatus Borreliella ibitipoquensis</td><td>Unknown</td><td>Brazil</td><td>Birds</td><td>I. paranaensis</td><td>[62]</td></tr><tr><td>Borreliella japonica</td><td>Unknown</td><td>Japan</td><td>Rodents</td><td>I. ovatus</td><td>[63,64]</td></tr><tr><td>Borreliella kurtenbachii</td><td>Unknown</td><td>North America</td><td>Rodents</td><td>I. scapularis</td><td>[58,65,66]</td></tr><tr><td>Borreliella lanei</td><td>Unknown</td><td>USA, Europe</td><td>Lagomorph</td><td>I. spinipalpis,<br>I. pacificus, I. ricinus</td><td>[34,44,52,53,67,68]</td></tr><tr><td>Borreliella lusitaniae</td><td>Yes</td><td>Europe, North Africa</td><td>Lizards, Rodents</td><td>I. ricinus</td><td>[69–71]</td></tr><tr><td>Borreliella maritima</td><td>Unknown</td><td>North America</td><td>Unknown</td><td>Ixodes spinipalpis</td><td>[72]</td></tr><tr><td>Borreliella mayonii</td><td>Yes</td><td>USA</td><td>Rodents</td><td>I. scapularis</td><td>[73–75]</td></tr><tr><td>Candidatus Borreliella paulista</td><td>Unknown</td><td>Brazil</td><td>Rodents</td><td>Unknown</td><td>[76]</td></tr><tr><td>Candidatus Borreliella sibirica</td><td>Unknown</td><td>Siberia</td><td>Rodents</td><td>I. apronophorus,<br>I. persulcatus,<br>I. trianguliceps</td><td>[77]</td></tr><tr><td>Borreliella sinica</td><td>Unknown</td><td>China</td><td>Rodents</td><td>I. ovatus</td><td>[78]</td></tr><tr><td>Borreliella spielmanii</td><td>Yes</td><td>Europe</td><td>Rodents</td><td>I. ricinus</td><td>[79–82]</td></tr><tr><td>Borreliella tanukii</td><td>Unknown</td><td>Japan</td><td>Unknown</td><td>I. tanuki</td><td>[83–85]</td></tr><tr><td>Borreliella turdi</td><td>Unknown</td><td>Japan, Europe</td><td>Birds</td><td>I. turdus, I. frontalis,<br>I. ricinus</td><td>[84–87]</td></tr><tr><td>Borreliella valaisiana</td><td>No</td><td>Europe, Asia</td><td>Birds</td><td>I. ricinus</td><td>[88–92]</td></tr><tr><td>Borreliella yangtzensis</td><td>Unknown</td><td>Asia</td><td>Rodents</td><td>I. granulatus</td><td>[93–97]</td></tr></tbody></table>
### 3.2. RF

RF is caused by the species of the relapsing fever complex, which consists of 22 validated and several proposed species (Table 2) [98,99]. Bacteria from the RF complex tend to have shorter bodies than the Lyme group and the number of their endoflagella ranges from 15 to 20 [98]. Depending on the vector of transmission, the species of the RF group are categorized in the soft-tick-borne relapsing fever (STBRF), the hard-tick-borne relapsing fever (HTBRF), and the louse-borne relapsing fever (LBRF) group [99]. Additionally, STBRF are further classified according to the geographical area into the Old World strains and the New World strains [100]. Another category is the avian RF which consists of *Borrelia anserina* and is transmitted by the soft tick *Argas* spp. [101].

<table><caption>**Table 2.** *Borrelia* spp. of the RF Group.</caption><thead><tr><th>Borrelia Species</th><th>Human Infection</th><th>Geographical Distribution</th><th>Hosts</th><th>Vectors</th><th>References</th></tr></thead><tbody><tr><td colspan="6">Louse-Borne Relapsing Fever</td></tr><tr><td>Borrelia recurrentis</td><td>LBRF</td><td>Virtually worldwide, currently Ethiopia, Sudan</td><td>Human</td><td>Pediculus humanus</td><td>[14,102]</td></tr><tr><td colspan="6">Old World Soft-Tick Borne Relapsing Fever</td></tr><tr><td>Candidatus Borrelia algerica</td><td>TBRF</td><td>Algeria</td><td>Human</td><td>Unknown</td><td>[103]</td></tr><tr><td>Borrelia caucasica</td><td>STBRF</td><td>Azerbaijan, Georgia, Armenia, Ukraine</td><td>Rodents, Human</td><td>O. verrucosus</td><td>[104–107]</td></tr><tr><td>Borrelia crocidurae</td><td>STBRF</td><td>Western and Northern Africa</td><td>Insectivores, Rodents, Camels, Human</td><td>O. sonrai, O. erraticus</td><td>[105,107,108]</td></tr><tr><td>Borrelia duttonii</td><td>STBRF neurological signs, neonatal infection</td><td>Central, Eastern, and Southern Africa</td><td>Human</td><td>O. moubata</td><td>[105,107,109,110]</td></tr><tr><td>Borrelia graingeri</td><td>Unknown</td><td>East Africa</td><td>Rodents</td><td>O. graingeri</td><td>[105,107,111,112]</td></tr><tr><td>Borrelia harveyi</td><td>Unknown</td><td>Kenya</td><td>Monkey</td><td>Unknown</td><td>[105,113,114]</td></tr><tr><td>Borrelia hispanica</td><td>STBRF Ocular and neurological symptoms (rare)</td><td>Iberian Peninsula and Northwestern Africa</td><td>Insectivores, Rodents, Foxes, Jackals, Dogs, Human</td><td>O. erraticus, O. marocanus, O. occidentalis</td><td>[105,107,115]</td></tr><tr><td>Candidatus Borrelia kalaharica</td><td>STBRF</td><td>Kalahari Desert (Botswana and Namibia)</td><td>Human</td><td>O. savignyi</td><td>[116]</td></tr><tr><td>Borrelia latyschewii</td><td>Unknown</td><td>Central Asia, Middle East</td><td>Unknown</td><td>O. tartakovsky</td><td>[105,114,117]</td></tr><tr><td>Borrelia merionesi</td><td>No</td><td>Morocco and Atlantic coastal areas of the Sahara Desert</td><td>Rodents</td><td>O. merionesi, O. costalis, O. erraticus</td><td>[118]</td></tr><tr><td>Borrelia microti</td><td>STBRF</td><td>Iran, Afghanistan</td><td>Human</td><td>O. erraticus</td><td>[107,119–121]</td></tr><tr><td>Borrelia persica</td><td>STBRF, neurological symptoms (rare), respiratory distress (rare)</td><td>Central Asia, Middle East, Egypt, Greece</td><td>Rodents, Carnivores, Dogs, Cats, Human</td><td>O. tholozani</td><td>[102,105,122]</td></tr><tr><td>Borrelia tillae</td><td>No</td><td>Southern Africa</td><td>Rodents</td><td>O. zumpti</td><td>[123]</td></tr></tbody></table>
<table><caption>**Table 2.** *Cont.*</caption><thead><tr><th>Borrelia Species</th><th>Human Infection</th><th>Geographical Distribution</th><th>Hosts</th><th>Vectors</th><th>References</th></tr></thead><tbody><tr><td colspan="6">New World Soft-Tick Borne Relapsing Fever</td></tr><tr><td>Borrelia brasiliensis</td><td>Unknown</td><td>Brazil</td><td>Unknown</td><td>O. brasiliensis</td><td>[124,125]</td></tr><tr><td>Borrelia coriaceae</td><td>No</td><td>USA</td><td>Rodents, Deer</td><td>O. coriaceus</td><td>[125-128]</td></tr><tr><td>Borrelia dugesii</td><td>Unknown</td><td>Mexico</td><td>Unknown</td><td>O. dugesii</td><td>[105,129]</td></tr><tr><td>Borrelia hermsii</td><td>STBRF, neurological symptoms (rare), neonatal infections (rare)</td><td>British Columbia, Western USA, France</td><td>Rodents, Deer, Dog, Human</td><td>O. hermsi</td><td>[102,105,126,128,130]</td></tr><tr><td>Borrelia johnsonii</td><td>TBRF</td><td>USA</td><td>Bats</td><td>O. talaje</td><td>[131-133]</td></tr><tr><td>Borrelia mazzottii</td><td>No</td><td>Mexico</td><td>Unknown</td><td>O. talaje</td><td>[134]</td></tr><tr><td>Borrelia parkeri</td><td>Unknown</td><td>Western USA</td><td>Horses</td><td>O. parkeri</td><td>[130,135]</td></tr><tr><td>Borrelia turicatae</td><td>STBRF, Ocular and neurological symptoms</td><td>British Columbia, USA, Mexico, Africa, Europe, Asia</td><td>Rodents, Dog, Human</td><td>O. turicata, O. maritimus, C. capensis</td><td>[102,105,136]</td></tr><tr><td>Borrelia venezualensis</td><td>STBRF</td><td>Central America and northern South America</td><td>Human</td><td>O. rudis</td><td>[105,137]</td></tr><tr><td colspan="6">Hard-Tick Borne Relapsing Fever</td></tr><tr><td>Borrelia lonestari</td><td>STARI?</td><td>USA</td><td>Rodents, Birds, Deer, Human</td><td>Amblyomma americanum (lone star tick)</td><td>[133,138-142]</td></tr><tr><td>Borrelia miyamotoi</td><td>Flu-like syndrome, HTBRF, neurological symptoms</td><td>Asia, Europe, USA</td><td>Rodents, Birds, Human</td><td>I. ricinus, I. persulcatus, I. scapularis</td><td>[143-146]</td></tr><tr><td>Candidatus Borrelia texasensis</td><td>Unknown</td><td>USA (Texas)</td><td>Unknown</td><td>Dermacentor variabilis</td><td>[147]</td></tr><tr><td>Borrelia theileri</td><td>No</td><td>Africa, Australia, North and South America</td><td>Cattle, Sheep, Goats, Camels</td><td>Rhipicephalus spp.</td><td>[105,110,148,149]</td></tr><tr><td colspan="6">Avian Relapsing Fever</td></tr><tr><td>Borrelia anserina</td><td>No</td><td>Worldwide</td><td>Birds</td><td>Argas spp.</td><td>[105,110,150-152]</td></tr></tbody></table>

## 4. One Health Approach

Global health challenges are escalating, and hence, One Health approaches emerge as a pivotal framework for addressing such complex health matters [153]. This holistic perspective acknowledges the interconnection of these domains and emphasizes the need for collaboration among medical, veterinary, environmental, and other relevant fields [154]. In recent years, the multifaceted nature of *Borrelia* infections has underlined the necessity for a comprehensive One Health approach. By integrating insights from diverse scientific areas, a One Health perspective offers synergistic efforts to address the complexities of *Borrelia* infections, enhancing the ability to protect both human and animal populations while promoting environmental sustainability (Figure 3) [155].
<figure><img src="image_8.png" /><figcaption>**Figure 3.** Interactions among humans, animals, and the environment within a One Health concept.</figcaption></figure>

**5. Lyme Disease**

**5.1. *Clinical Manifestations***

The clinical manifestations of LD can vary widely, as well as the severity and duration of the symptoms, and can affect multiple body systems [156]. The organs most frequently involved are skin, joints, nervous system, heart, and eyes [30,157]. In general, *Bl. burgdorferi* is more often associated with Lyme arthritis, *Bl. garinii* with neuroborreliosis, and *Bl. afzelii* with skin manifestations [30]. The early infection is localized, but the spirochete can spread if left untreated [158]. The most common manifestation of LD that occurs in 80–90% of the cases is a rash known as erythema migrans (EM) [159], which can have divergent characteristics [160,161]. It typically appears as an annular, erythematous rash at the site of the tick bite, which may or may not present with a central clearing [162]. It is a skin redness that appears 1–36 days (with an average of 7–14 days) after the tick bite with a tendency to expand, eventually reaching a diameter of even up to 70 cm (with a median of 10–16 cm) [163,164]. Multiple EM lesions can also occur, with a primary lesion at the site of the tick bite and secondary skin lesions caused by hematogenous dissemination [165]. Additionally, many patients also experience systemic symptoms like fatigue, fever, chills, arthralgia, myalgia, and regional lymphadenopathy [166,167]. Non-cutaneous organ involvement is also possible. Lyme neuroborreliosis occurs in approximately 12% of untreated patients who may present with cranial neuropathy (unilateral or bilateral facial nerve palsy), lymphocytic meningitis, radiculitis, or encephalitis [168–170]. Lyme arthritis is the most common late manifestation in the USA, presenting in approximately 60% of untreated patients, but only in a small percentage in Europe [8]. It usually appears months or even up to 2 years after initial infection and typically affects only one or a few large joints, especially the knee [171]. In rare but potentially fatal cases, Lyme carditis appears in 5% of untreated patients usually causing atrioventricular conduction block [172]. The development of chronic congestive cardiomyopathy has also been linked to LD [173–175].
## 5.2. Epidemiology

LD is endemic in temperate regions of the Northern Hemisphere, such as North America, Europe, and Asia [30]. The documented incidence for countries in Europe and Asia varies from negligible in the United Kingdom, Turkey, and Japan to significant in the Netherlands, Belgium, Austria, Slovenia, Lithuania, and Estonia [176,177]. Although incidents have been recorded in countries like China and Mongolia, information on the prevalence of LD in Asia is limited [178,179]. More than 90% of cases in North America are documented from only two regions of the country: the northeast and mid-Atlantic region and the north central region [180]. Both regions have grown significantly over the past 20 years and have extended up to south Canada [181,182]. LD rates are increasing worldwide [181,183] due to increased awareness [184] along with the expanding distribution of the tick vectors due to environmental factors [156,185].

### 5.2.1. Transmission Vectors Infected with *Borrelia* spp. in Countries around the Mediterranean Sea

Infectious agents causing LD are transmitted by slow-feeding hard-bodied ticks (ixodid vectors) of the *Ixodes ricinus* complex and are the only natural agents known through which humans can become infected (Figure 4) [186]. In northeastern, mid-Atlantic, and north central United States, the main vector of transmission is *Ixodes scapularis* (black-legged tick) and in the Pacific Coast states, *Ixodes pacificus* [187]. In Asia and in Eastern Europe, the main vector tick is *Ixodes persulcatus*, while in Western Europe it is *Ixodes ricinus* [8,188]. Nymphal ticks, rather than the adult ticks, are primarily responsible for transmission of the disease [189]. Spirochaetes are located mainly in the midgut of the tick before attachment and only in small numbers in the salivary glands of the ticks, however, the number in the salivary glands increases rapidly post attachment [190]. Thus, the risk of transmission increases with increased duration of tick attachment and the nymphal ticks are more likely to remain undetected for longer due to their smaller size [191]. The ticks feed on a single vertebrate host when in their larval, nymphal, and adult female phases. Adult male ticks may take sporadic small meals. When a tick, usually a larva or a nymph, feeds on an infected host, the bacteria are acquired by the tick and are subsequently transferred to its midgut [192]. The spirochetes migrate to new hosts, including humans, when the next developing stage of the tick feeds on them [193]. Nevertheless, transovarial transmission which occurs from female to offspring, is rare, resulting in a dead end for the bacteria [194]. A study concerning the human transplacental transmission has been performed, and although *Bl. burgdorferi* was not directly linked to any of the unfavorable outcomes, the frequency of adverse outcomes emphasizes the need for further studies [195].

Prevalence of the *Borrelia* complex bacteria have been identified in questing as well as feeding ticks across the Mediterranean. Nonetheless, there are no data on the following Mediterranean countries: Gibraltar, Monaco, Malta, Bosnia and Herzegovina, Montenegro, Albania, Cyprus, Syria, Lebanon, Palestine, Israel, and Libya.

### Western Mediterranean (Spain, France)

In Spain, questing *I. ricinus* ticks were tested for the presence of *Borrelia* and *Bl. garinii* was found to be the most prevalent species followed by *Bl. valaisiana*, *Bl. lusitaniae*, *Bl. afzelii*, and *Bl. burgdorferi* [196]. Additionally, *Bl. turdi* was found in *I. frontalis* ticks collected from vegetation of urban and sub-urban areas [197] as well as in *I. frontalis*, *I. ricinus*, and *Haemaphysalis punctata* ticks collected from passerine birds [87]. Moreover, *Hyalomma lusitanicum* ticks from wild ungulates revealed that they were positive for *Bl. afzelii* [198]. *Borrelia* species have also been found in non-Ixodes ticks, as reported in studies with *Haemaphysalis* spp. ticks, *Dermacentor* spp., and *Rhipicephalus bursa* from the vegetation [199,200]. Finally, *Borrelia* DNA was reported in a male *Dermacentor reticulatus* removed from a patient [201]. In France, questing *I. ricinus* ticks from peri-urban forests demonstrated the presence of *Bl. afzelii*, *Bl. burgdorferi*, and *Bl. garinii* followed by *Bl. valaisiana*, *Bl. lusitaniae*, and *Bl. spielmanii* [202]. Moreover, *Borrelia carolinensis* was reported in one questing *I. ricinus* tick
from a French forest [203]. Furthermore, ticks feeding on humans revealed the presence of *Bl. burgdorferi* in *I. ricinus*, and *Bl. garinii* in *I. ricinus* and in unidentified *Ixodes* spp. [204]. Larva ticks engorged on birds were also tested and it was found that *Borreliella* DNA was present in *I. ricinus*, *I. frontalis*, *Ixodes* spp., and *Haemaphysalis* spp. [205]. Additionally, *I. ricinus* ticks from rats and *Hyalomma marginatum* from cattle from the island of Corsica [206], as well as a questing *Dermacentor reticulatus* tick from central France were also positive for *Borreliella* DNA [207].

<figure><img src="image_9.png" /><figcaption>**Figure 4.** Transmission of Borreliella spirochetes.</figcaption></figure>

### North Central Mediterranean (Italy, Slovenia)

In Italy, questing *I. ricinus* ticks, as well as *I. ricinus* ticks feeding on wild ungulates and domestic animals, were found to be infected with *Bl. afzelii*, *Bl. burgdorferi*, *Bl. garinii*, *Bl. valaisiana*, and *Bl. lusitaniae* [208,209]. Moreover, *I. ricinus* ticks feeding on humans revealed the presence of *Borreliella* DNA with *Bl. afzelii* being the most prevalent, followed by *Bl. lusitaniae*, *Bl. garinii*, *Bl. valaisiana*, and *Bl. burgdorferi* [210]. In addition, *Bl. spielmanii* and *Bl. valaisiana* were identified in *Ixodes ventalloi* and *Ixodes acuminatus* ticks feeding on feral cats and birds from Pianosa island in the Tuscany archipelago [211], and in *Hyalomma rufipes* ticks feeding on birds from Ponza island [212]. Likewise, in Slovenia, *Bl. garinii* was the most predominant species in questing *I. ricinus* ticks, followed by *Bl. afzelii*, *Bl. valaisiana*, *Bl. burgdorferi*, and *Bl. lusitaniae* [213]. Finally, *Bl. garinii* and *Bl. valaisiana* were found on *Ixodes* spp. ticks from passerine birds feeding in Slovenia [214].

### Balkans (Croatia, Greece)

In Croatia, *I. ricinus* ticks tested positive for *Bl. afzelii*, *Bl. garinii*, *Bl. valaisiana*, *Bl. burgdorferi* [215], as well as *Bl. lusitaniae* [216]. In Greece, *Ixodes* spp. feeding on birds tested positive for *Bl. afzelii* and *Bl. garinii* [214].

### Eastern Mediterranean (Turkey)

Questing *I. ricinus* ticks from Turkey were cultivated leading to the identification of *Bl. lusitaniae*, *Bl. afzelii*, *Bl. garinii*, *Bl. burgdorferi*, and *Bl. valaisiana* [217]. Additionally, *Bl. burgdorferi* was found in *Rhipicephalus turanicus* collected from wild boar [218], as well
as in *Hyalomma marginatum*, *Hyalomma excavatum*, *Hyalomma* spp., and *Haemaphysalis parva*
ticks collected from humans [219]. *Borreliella* were also prevalent in *Rhipicephalus annulatus*,
in *Hyalomma anatolicum*, and *I. ricinus* questing or feeding on humans, pets, or other
animals [220].

Southern Mediterranean (Egypt, Tunisia, Algeria, Morocco)

Several tick species feeding on one-humped camels from Cairo, Egypt, demonstrated the presence of *Bl. afzelii* in *Hyalomma dromedarii* and *H. marginatum*, as well as *Bl. burgdorferi* in *H. dromedarii* and *Amblyomma testudinarium* [221]. Moreover, *Borreliella* were also identified in *Rhipicephalus sanguineus* from dogs and in *Hyalomma anatolicum* excavatum from cattle [222]. In Tunisia, questing *I. ricinus* ticks were positive for *Borreliella* DNA [223] and after cultivation, *Bl. lusitaniae* and *Bl. garinii* were isolated [223,224]. In Algeria, questing *I. ricinus* ticks were infected with *Bl. garinii* [225] and *I. ricinus* ticks feeding on cattle with *Bl. lusitaniae* [216]. In Morocco, questing *I. ricinus* ticks were found to be infected with *Bl. lusitaniae*, *Bl. garinii*, and *Bl. burgdorferi* [226].

In conclusion, the characterized species of the *Borreliella* complex that have been
identified among ticks throughout the Mediterranean basin are *Bl. burgdorferi*, *Bl. afzelii*,
*Bl. garinii*, *Bl. valaisiana*, *Bl. spielmanii*, *Bl. lusitaniae*, *Bl. turdi*, and *Bl. carolinensis*.
Specifically, *Bl. burgdorferi* has been identified in Spain, France, Italy, Slovenia, Croatia, Turkey,
Egypt, and Morocco, *Bl. afzelii* in Spain, France, Italy, Slovenia, Croatia, Greece, Turkey,
and Egypt, *Bl. garinii* in Spain, France, Italy, Slovenia, Croatia, Greece, Turkey, Tunisia,
Algeria, and Morocco, *Bl. valaisiana* in Spain, France, Italy, Slovenia, Croatia, and Turkey.
Additionally, *Bl. spielmanii* in France and Italy, *Bl. lusitaniae* in Spain, France, Italy, Slovenia,
Croatia, Turkey, Tunisia, Algeria, and Morocco, *Bl. turdi* in Spain and France and finally,
*Bl. carolinensis* in France (Figure 5 and Table 3).

<figure><img src="image_10.png" /><figcaption>**Figure 5.** Map of *Borreliella* spp. in vectors in countries around the Mediterranean Sea.</figcaption></figure>
<table><caption>**Table 3.** *Borreliella* spp. in vectors around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="8">Borreliella Species</th></tr><tr><th>Borreliella spp.</th><th>Bl. burgdorferi</th><th>Bl. afzelii</th><th>Bl. garinii</th><th>Bl. valaisiana</th><th>Bl. spielmanii</th><th>Bl. lusitaniae</th><th>Bl. turdi</th><th>Bl. carolinensis</th></tr></thead><tbody><tr><td>Spain</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td></tr><tr><td>France</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>Italy</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Slovenia</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Croatia</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Greece</td><td></td><td></td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Turkey</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Egypt</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Tunisia</td><td>✓</td><td></td><td></td><td>✓</td><td></td><td></td><td>✓</td><td></td><td></td></tr><tr><td>Algeria</td><td>✓</td><td></td><td></td><td>✓</td><td></td><td></td><td>✓</td><td></td><td></td></tr><tr><td>Morocco</td><td>✓</td><td>✓</td><td></td><td>✓</td><td></td><td></td><td>✓</td><td></td><td></td></tr></tbody></table>

### 5.2.2. Animal Hosts Infected with *Borreliella* spp. in Countries around the Mediterranean Sea

Reservoir hosts are important for the transmission of the bacterium, as they can become heavily infested with ticks and transmit the bacterium to them when they feed on their blood [227]. More than 100 animal species have been identified as *Borreliella* hosts, including small mammals, birds, and lizards [70,228,229]. The main hosts in North America are small mammals, such as mice, chipmunks, and squirrels, with the white-footed mice being the most common [230–232]. In Europe and Asia, the primary hosts are rodents like voles, shrews, and mice like the yellow-necked mice, especially for *Bl. afzelii* [27,192]. Birds can also become infected with *Borreliella* and serve as important hosts mainly for *Bl. garinii* as they can make long-range displacements [233]. Although deer develop antibodies when exposed to *Borreliella* via tick bites [234], they are incompetent reservoir hosts and do not transmit the infection to feeding ticks [235–237].

Infections of the *Borreliella* complex have been described in several animal species across the Mediterranean. However, there are no data on animal infections and the species involved in the following Mediterranean countries: Gibraltar, Monaco, Malta, Montenegro, Cyprus, Syria, Lebanon, Palestine, Israel, Libya, and Morocco.

#### Western Mediterranean (Spain, France)

In Spain, *Borreliella* have been identified in several host species. Wood mice tested positive for *Borreliella* and voles for *Bl. afzelii* [199]. Additionally, spleen samples from wild ungulates revealed the prevalence of *Bl. afzelii* [198]. Antibodies against *Borreliella* were identified in dogs [238], in red foxes [239], and in wolves [240]. Finally, chamois [241] and roe deer [198] were also presenting antibodies. In France, rodents have been identified as important host species of *Borreliella* [242,243]. Indeed, Siberian chipmunks were infected with *Bl. burgdorferi*, *Bl. afzelii*, *Bl. garinii* [244], and *Bl. spielmanii* [245], bank voles with *Bl. afzelii*, *Bl. burgdorferi*, and *Bl. garinii* [245] and wood mice with *Bl. afzelii* [245]. Additionally, red squirrels have also tested positive for *Bl. burgdorferi*, *Bl. afzelii*, and *Bl. garinii* [246]. Moreover, antibodies against *Borreliella* have also been identified in dogs [247], horses, and ponies [248]. Last but not least, skin biopsy specimens from deer and roe deer were DNA-positive for *Bl. burgdorferi*, *Bl. garinii* or *Bl. afzelii*, and one *Bl. burgdorferi* specimen was also positive in culture, indicating the presence of alive spirochetes in deer skin [249].

#### North Central Mediterranean (Italy, Slovenia)

In Italy, blood samples from rodents were positive for *Borreliella* DNA [250], and ear biopsies from bank voles and wood or yellow-necked mice revealed the presence of *Bl. afzelii*, *Bl. valaisiana*, or *Bl. lusitaniae* [251]. Foxes were also found to host several *Borreliella* genospecies, specifically *Bl. burgdorferi*, *Bl. afzelii*, *Bl. garinii*, *Bl. valaisiana*, *Bl. lusitaniae*,
or *Bl. bissettiae*, and one fox was co-infected with both *Bl. afzelii* and *Bl. bissettiae* [252]. Antibodies against *Borreliella* were identified in dogs from rural areas as well as from urban areas [253,254], as well as in horses [255]. Furthermore, *Bl. lusitaniae* DNA has also been identified in horses [256] and in wall lizards from southern Italy [257]. Besides the animals mentioned above, wild brown hares captured in central Italy were found to carry anti-*Borreliella* antibodies [258], and one blood sample from a wild boar was positive for *Borreliella* DNA [259]. Additionally, farm-reared pheasants were seropositive [260] and feral pigeons were positive for the presence of *Borreliella* DNA [261]. Finally, it was demonstrated that *Borreliella* DNA was found in blood samples collected from the heart of hunted red deer [262], as well as antibodies against *Borreliella* in blood samples from fallow deer from farms [263]. In Slovenia, *Borreliella* DNA was found in heart and lung biopsies from rodents including yellow-necked mice, bank voles, wood mice, Mediterranean water shrews, and a white-toothed shrew [264], and after cultivation, *Bl. afzelii* was isolated [264]. In addition, antibodies against *Borreliella* were found in deer [265] and in dogs [266].

### Balkans (Croatia, Bosnia and Herzegovina, Albania, Greece)

In Croatia, rodents from eight different collection sites were PCR-positive for *Bl. afzelii* [267] and a small seropositivity against *Borreliella* was identified in dogs [266,268,269]. Dogs were also seropositive in Bosnia and Herzegovina against *Borreliella* [266] and in Albania, for *Bl. garinii* [270]. In Greece, dogs [271,272], sheep [273], and horses [274] were also found to present antibodies against *Borreliella*.

### Eastern Mediterranean (Turkey)

In Turkey, antibodies against *Borreliella* were identified in dogs and horses [275] and against *Bl. afzelii* in mice from North Turkey [276]. Finally, sick house cats tested positive for *Borreliella* DNA [277].

### Southern Mediterranean (Egypt, Tunisia, Algeria)

In Egypt, blood samples from cattle were analyzed and *Borreliella* DNA was detected [222]. Additionally, dogs were found to have anti-*Borreliella* antibodies [278], as well as *Borreliella* DNA [279]. Moreover, *Borreliella* DNA was also identified in blood samples from healthy one-humped camels [221]. In Tunisia, *Borreliella* DNA was found in blood samples from goats, sheep, cattle, and camels [280]. Furthermore, lizards were also positive for *Bl. lusitaniae* as demonstrated by DNA identification from skin, liver, and/or kidney tissue samples, as well as by cultivation of a skin sample [281]. Finally, in Algeria, anti-*Borreliella* antibodies were found in dogs [282], as well as in horse blood samples [283].

In conclusion, the circulating *Borreliella* spp. that have been characterized from animals around the Mediterranean are *Bl. burgdorferi*, *Bl. afzelii*, *Bl. garinii*, *Bl. valaisiana*, *Bl. spielmanii*, *Bl. bissettiae*, and *Bl. lusitaniae*. Specifically, *Bl. burgdorferi* has been identified in Spain, France, Italy, Slovenia, and Egypt, *Bl. afzelii* in Spain, France, Italy, Slovenia, Croatia, and Turkey, *Bl. garinii* in France, Italy, Slovenia, and Albania, *Bl. valaisiana* in Italy, *Bl. spielmanii* in France, *Bl. bissettiae* in Italy, and *Bl. lusitaniae* in Italy and Tunisia (Figure 6 and Table 4).
<table><caption>**Table 4.** *Borrelia* spp. in animals around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="8">Borrelia Species</th></tr><tr><th>Borrelia spp.</th><th>Bl. burgdor-feri</th><th>Bl. afzelii</th><th>Bl. garinii</th><th>Bl. valaisiana</th><th>Bl. spiel-manii</th><th>Bl. bisset-tiae</th><th>Bl. lusita-niae</th></tr></thead><tbody><tr><td>Spain</td><td>Cat<br>Wolf<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td></td><td></td><td></td></tr><tr><td>France</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Squirrel</td><td></td><td></td></tr><tr><td>Italy</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td></tr><tr><td>Slovenia</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td></tr><tr><td>Croatia</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td></tr><tr><td>Bosnia and Herzegovina</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td></tr><tr><td>Albania</td><td></td><td></td><td></td><td></td><td>Cat</td><td></td><td></td><td></td></tr><tr><td>Greece</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td></td><td></td><td></td></tr><tr><td>Turkey</td><td>Cat<br>Sheep<br>Cat</td><td>Cat<br>Sheep<br>Cat</td><td>Cat<br>Sheep<br>Cat</td><td>Cat<br>Sheep<br>Cat</td><td>Cat<br>Sheep<br>Cat</td><td>Cat</td><td></td><td></td></tr><tr><td>Egypt</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep</td><td></td><td></td><td></td></tr><tr><td>Tunisia</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td><td>Cat<br>Sheep<br>Sheep<br>Sheep<br>Sheep</td></tr><tr><td>Algeria</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td><td>Cat<br>Sheep</td></tr></tbody></table>

<figure><img src="image_11.png" /></figure>

Rodents

<figure><img src="image_12.png" /></figure>

Dogs

<figure><img src="image_13.png" /></figure>

Deer

<figure><img src="image_14.png" /></figure>

Foxes/Wolves

<figure><img src="image_15.png" /></figure>

Goats/Chamois

<figure><img src="image_16.png" /></figure>

Horses

<figure><img src="image_17.png" /></figure>

Squirrels/Chipmunks

<figure><img src="image_18.png" /></figure>

Hares

<figure><img src="image_19.png" /></figure>

Birds

<figure><img src="image_20.png" /></figure>

Lizards

<figure><img src="image_21.png" /></figure>

Sheep

<figure><img src="image_22.png" /></figure>

Cats

<figure><img src="image_23.png" /></figure>

Cattle

<figure><img src="image_24.png" /></figure>

Camels

<figure><img src="image_25.png" /></figure>

Wild boar.
<figure><img src="image_26.png" /><figcaption>**Figure 6.** Map of *Borrelia* spp. in animals in countries around the Mediterranean Sea.</figcaption></figure>

### 5.2.3. *Borrelia* spp. in Humans in Countries around the Mediterranean Sea

Many *Borrelia* infections in humans are reported using molecular and/or serological assays around the Mediterranean and are associated with different genospecies of the *Borrelia* complex. However, up to date, there are no reports of human infection or very little is known on its prevalence and the species involved in the following Mediterranean countries: Gibraltar, Monaco, Malta, Montenegro, Cyprus, Syria, Lebanon, Palestine, Libya, Tunisia, Algeria, and Morocco.

#### Western Mediterranean (Spain, France)

In Spain, serum samples from the general population [284] as well as from patients bit-ten by ticks [201] were found to have antibodies against *Bl. burgdorferi* using the *Bl. burgdor-feri* B31 strain. Additionally, *Bl. garinii* was isolated from skin biopsy specimens from patients with EM [285]. In France, synovial fluids were tested for the presence of *Borrelia* DNA, revealing that the most prevalent species was *Bl. burgdorferi*, followed by *Bl. afzelii* and *Bl. garinii* [286]. Furthermore, skin samples from patients with borrelial lymphocytoma resulted in the molecular identification of *Bl. afzelii*, *Bl. burgdorferi*, and *Bl. garinii*, which was also positive in cultivation [287]. Recently, a case of LD caused by *Bl. spielmanii* was also reported manifesting as a large EM [288].

#### North Central Mediterranean (Italy, Slovenia)

Skin biopsies from patients in Italy with clinically diagnosed LD resulted in the isolation of *Bl. afzelii*, *Bl. garinii*, and *Bl. burgdorferi* [289]. Additionally, patients with early or late LD symptoms were found to be infected with *Bl. afzelii* and *Bl. garinii*. One co-infection of *Bl. garinii* with *Bl. afzelii* and another with *Bl. valaisiana* were also reported [290]. On the other hand, serum samples from blood donors in South Tyrol revealed the presence of anti-*Bl. afzelii* and anti-*Bl. bavariensis* antibodies using Western Blot analysis [291]. Several *Borrelia* species have also been responsible for human infections in Slovenia. Culture-
positive skin samples from patients with only EM as the clinical manifestation of LD indicated that the majority of the infections were due to *Bl. afzelii*, followed by *Bl. garinii* and *Bl. burgdorferi* [292]. Except from the species reported above, in Slovenia, *Bl. bavariensis* has also been isolated from humans with LD [41,293]. In addition, *Bl. spielmanii* was also isolated from skin biopsy specimens of patients with EM [294,295]. Moreover, patients with borrelial lymphocytoma were found to be infected by *Bl. afzelii*, *Bl. garinii*, or *Bl. bissettiae* [296].

### Balkans (Croatia, Bosnia and Herzegovina, Albania, Greece)

Human infections have also been reported in the Balkan region. In Croatia, antibodies against *Bl. burgdorferi* (strain B31) were found among various population groups [297]. On the other hand, molecular identification of *Bl. afzelii* DNA was reported in serum samples from patients with EM from northwest Croatia [298]. Additionally, a woman with EM was found to be infected by *Bl. garinii* [299]. In Bosnia and Herzegovina, a case of Lyme neuroborreliosis was reported in a male patient two months after a tick bite in a forest from the southern part of the country [300] and, in Albania, the Institute of Public Health reported the diagnosis of LD cases [270] without determination of the specific *Borreliella* species responsible for the disease. Finally, in Greece, serum samples from patients with suspected zoonotic infection were tested and the presence of anti-*Borreliella* antibodies was reported [301]. Positive and equivocal samples were further analyzed by Western Blot indicating *Bl. afzelii* infection [301].

### Eastern Mediterranean (Turkey, Israel)

In Turkey, LD cases have been documented [302], as well as seropositivity against *Bl. burgdorferi* from randomly selected subjects [303] and farmers and forestry workers [304]. A case of LD was also reported in Israel in 1991 [305].

### Southern Mediterranean (Egypt)

Finally, in Egypt, people with close contact to feverish cattle and dogs with loss of body weight have been found positive for *Borreliella* with serological and molecular assays [222].

To summarize, the circulating *Borreliella* spp. from the *Borreliella* complex that have been characterized from human infections around the Mediterranean Sea are *Bl. burgdorferi*, *Bl. afzelii*, *Bl. garinii*, *Bl. valaisiana*, *Bl. bavariensis*, *Bl. spielmanii*, and *Bl. bissettiae*. Specifically, *Bl. burgdorferi* has been reported in Spain, France, Italy, Slovenia, and Croatia, *Bl. afzelii* in Spain, France, Italy, Slovenia, Croatia, and Greece, *Bl. garinii* in Spain, France, Italy, Slovenia, and Croatia, *Bl. valaisiana* in Italy, *Bl. bavariensis* in Italy and Slovenia, *Bl. spielmanii* in France and Slovenia, and *Bl. bissettiae* in Slovenia (Figure 7 and Table 5, Box 1).

<table><caption>**Table 5.** *Borreliella* spp. in humans around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="8">Borreliella Species</th></tr><tr><th>Borreliella spp.</th><th>Bl. burgdorferi</th><th>Bl. afzelii</th><th>Bl. garinii</th><th>Bl. valaisiana</th><th>Bl. bavariensis</th><th>Bl. spielmanii</th><th>Bl. bissettiae</th></tr></thead><tbody><tr><td>Spain</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td></tr><tr><td>France</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td></tr><tr><td>Italy</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Slovenia</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td>✓</td><td>✓</td><td>✓</td></tr><tr><td>Croatia</td><td>✓</td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td></tr><tr><td>Albania</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Greece</td><td>✓</td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Turkey</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Israel</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Egypt</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<figure><img src="image_27.png" /><figcaption>**Figure 7.** Map of *Borrelia* spp. in humans in countries around the Mediterranean Sea.</figcaption></figure>

**Box 1.** Prevention of LD.

Spending time in tick infested areas always carries the risk of contracting LD. However, several measures can be implemented to minimize this risk. First, tick repellent should be applied to both clothing and skin before venturing outdoors. It is also important to consistently wear long-sleeved shirts and long trousers, ensuring that they remain tucked into socks throughout the entire duration spent outside. In the case of accompanying pets, acaricides should also be used. During outdoor activi-ties, it is recommended to avoid areas with dense grass and leaf litter. After outdoor activities, a thor-ough examination should be conducted on clothing, gear, and pets for the presence of ticks. Addition-ally, inspection of the human body, including the scalp, is of great importance. If any ticks are found, appropriate removal using tweezers is essential as soon as possible. Finally, modifying the surround-ings of residential areas by clearing leaf litter, placing wood chips in areas where lawns meet forests, applying acaricides, and constructing fences to prevent the entry of tick infested animals is advisable to reduce tick populations.

**6. Relapsing Fever**

**6.1. *Clinical Manifestations***

RF can be transmitted to humans through the bites of infected soft ticks, hard ticks, or body lice causing STBRF, HTBRF, and LBRF respectively. The clinical manifestations can vary, but RF hallmark is recurring episodes of high fever which can reach as high as 41 °C, spaced by afebrile periods [13]. RF patients usually experience headache, myalgia, arthralgia, and chills. Other symptoms such as fatigue, nausea and vomiting, abdominal pain and diarrhea, skin rash, neurological symptoms such as confusion and disorientation, and cardiac symptoms such as palpitations and chest pain may also occur. The severity of symptoms can vary from almost asymptomatic to lethal, depending on the species of *Borrelia* involved, the host immune response, and the stage of the infection. Untreated RF
can lead to serious complications such as meningitis, hepatitis, and multi-organ failure in all three types of RF.

### 6.1.1. TBRF

The symptoms of STBRF usually begin approximately one week after the bite of an infected tick, however the incubation period ranges from 4 to 18 days [9]. Patients typically develop an abrupt fever onset of 38.7-40 °C but can reach even up to 41 °C [99]. The first febrile episode is usually the longest and lasts for 12 h to 17 days with a median of 3 days, is frequently accompanied by nonspecific symptoms including headache, arthralgia, myalgia, and nausea, and ends with a crisis of shivering chills or rigors [306,307]. The average time between the first episode and the first relapse is 7 days and the number of recurrences of fever is up to 13 if left untreated [308]. Due to their increased neurotropism, *B. duttonii* and *B. turicatae* infections have neurological symptoms that are more severe than those of other RF pathogens, with meningitis and facial palsy among the most prevalent symptoms [102].

Untreated *B. duttonii* infections have fatality rates that range from 4 to 10%; however, if appropriate antibiotics are given right away, the death rate is less than 2% [307]. Infection during pregnancy is associated with an increased fatality rate in pregnant women, with 10-15% cases of neonatal deaths and a 43.6% perinatal lethality worldwide [309,310].

### 6.1.2. LBRF

The incubation period is 4-18 days with a median of 7 days [311]. The symptoms initiate suddenly with a fever of almost 40 °C accompanied by stiffness, often followed by headache, anorexia, nausea, vomiting, diarrhea, and generalized pain (muscle, joint, back pain) [311,312]. The length of LBRF episodes ranges from 4 to 10 days, with a median of 5 days, and it takes 5-9 days between the episodes [307,312]. In general, patients with LBRF may have 3 to 5 febrile episodes [308]. Neurological symptoms are less frequent than in TBRF [312]. Fatality rates for untreated disease range from 30 to 80% [313], however, quick administration of the proper antibiotics reduces the fatality rate to 2-5% [306,307]. Infection during pregnancy is associated with adverse outcomes in three out of four pregnancies [313].

## 6.2. Epidemiology

### 6.2.1. TBRF

TBRF has a worldwide distribution, with endemic regions in all continents except Australia and Antarctica [16,99]. Over the past few decades, there have been changes in its epidemiology due to the emergence of new TBRF species, the finding of hard tick RF vectors, the extension of the vectors' geographic range, the improvements in diagnostic techniques, and the increased awareness among healthcare professionals [143,314]. Some areas such as Europe and Japan have developed into endemic areas and in contrast, others like South America and central Africa were once thought to be more endemic than they actually are [9,307]. Additionally, with instances being recorded in people who have visited endemic regions, TBRF has also become recognized as a disease connected to travel [315].

### 6.2.2. LBRF

The epidemiology of the once-universal LBRF has radically declined during the past few decades [316]. The disappearance of this infection has been directly linked to the decline in the *Pediculus humanus humanus* lice infestation of clothing, due to improved living standards along with the use of insecticides [317]. LBRF is still endemic almost exclusively in the Horn of Africa [14], especially in Ethiopia [318,319], Somalia [320] and Eritrea [321], and it occasionally spreads to nearby countries like Sudan [308]. Remaining endemic foci of LBRF are also reported to be small parts of Asia [322] and Latin America [323]. Also, in large Mediterranean cities, homeless populations are at risk of re-emerging LBRF following reported huge lice infestation [324-326].
### 6.2.3. Transmission Vectors of *Borrelia* spp. Identified in Countries around the Mediterranean Sea

Initially, it was considered that STBRF was transmitted solely by fast-feeding soft-bodied ticks (argasid vectors) of the *Ornithodoros* genus [107], however, it is now known that *Borrelia* spp. of the RF group can be transmitted from hard-ticks [143] and human body lice too [327]. In North America, *Ornithodoros hermsii* and *Ornithodoros turicata* are the main tick species to transmit STBRF [306], along with *Ornithodoros rudis* in South America [328], *Ornithodoros erraticus* and *Ornithodoros tholozani* in Eurasia [16,329], and *Ornithodoros moubata* and *Ornithodoros sonrai* in Africa [330]. Soft tick bites are rarely noticed since they feed rapidly (15–90 min) and afterwards they return to their habitat. The STBRF-causing spirochetes enter the midgut during the blood meal of *Ornithodoros* ticks on an infected host, and in the weeks that follow, they colonize the salivary glands where they are maintained transstadially and transovarially [98]. As a result, spirochetes that colonize the salivary gland are more likely to cause an early mammalian infection, leading to rapid transmission of STBRF to the next mammalian host shortly after a bite (Figure 8) [331]. Infection can possibly occur after just 15 s of tick attachment as a tick's salivary glands are persistently infected [332]. All tick stages are obligate blood feeders and thus potential vectors of *Borrelia* transmission [306]. Infected ticks remain infectious for their entire lifespan, and they can live up to 10 years infecting several hosts [9,333]. Hard ticks that are known to cause HTBRF are *Ixodes* spp., *Amblyomma* spp., *Dermacentor* spp., and *Rhipicephalus* spp. [138,334]. The human body louse *Pediculus humanus* is the only vector of LBRF [316]. Agents of the *Borrelia* RF group are known to infect tick species throughout the Mediterranean. However, there are insufficient data about Gibraltar, Monaco, Malta, Croatia, Bosnia and Herzegovina, Montenegro, Albania, Greece, Cyprus, Syria, Lebanon, and Libya.

<figure><img src="image_28.png" /><figcaption>**Figure 8.** Transmission of RF *Borrelia* spirochetes.</figcaption></figure>

Western Mediterranean (Spain, France)

In Spain, DNA from *B. miyamotoi* was detected in questing *I. ricinus* nymph and adult ticks [196]. This presence was confirmed across various ecological regions, including coastal, plateau, and mountain areas [335]. Nymph and male *I. ricinus* ticks feeding on roe
deer were also carrying *B. miyamotoi* bacteria [336]. Additionally, on Espartar Island, a small island in the western Mediterranean Sea, *Ornithodoros maritimus* ticks from a cave occupied by small seabirds tested positive for *Borrelia* spp., showing a 99% sequence identity to *Borrelia turicatae* [337]. In France, DNA samples from free-living *I. ricinus* nymph ticks collected in the Sénart forest [338] and from the Alpes-Maritimes region [339] revealed the presence of *B. miyamotoi*. Moreover, *B. miyamotoi* was prevalent in engorged *I. ricinus* larva feeding on breeding birds [205] and in *I. ricinus* and *Haemaphysalis punctata* ticks feeding on domestic and wild animals from the island of Corsica [340]. Furthermore, *Argas vespertilionis* ticks collected from a bat-infested attic were also analyzed and a RF Group *Borrelia* sp. with a 100% sequence identity to strain CPB1 was found [341]. In addition, ticks removed from humans were also tested for the presence of RF *Borrelia* spp. and it was found that *I. ricinus* were positive [204,342].

### North Central Mediterranean (Italy, Slovenia)

Questing *I. ricinus* ticks collected by dragging from different altitudes from the mountain areas of northwestern Italy [343], and from both the western and eastern Alps [344], tested positive for *B. miyamotoi* DNA. *B. miyamotoi* was also detected in questing *I. ricinus* ticks from two regions in Slovenia, Littoral Inner Carniola, and the Coastal-Karst area [213].

### Eastern Mediterranean (Turkey, Palestine, Israel)

*B. miyamotoi* DNA was detected in adult *I. ricinus* ticks collected from the countryside of the European site of Turkey as well as from parks of the metropolitan area of Istanbul [345]. Moreover, *Hyalomma aegyptium* ticks feeding on *Testudo graeca* from four different collection sites of Turkey demonstrated the presence of RF *Borrelia* spp. [346]. Additionally, ticks collected from caves from several locations of the West Bank, Palestine, demonstrated the presence of *Borrelia persica* in *Ornithodoros tholozani* [347]. *B. persica* was also prevalent in nymph female and male *O. tholozani* ticks from different parts of Israel [348,349].

### Southern Mediterranean (Egypt, Tunisia, Algeria, Morocco)

In Egypt, *B. miyamotoi* was identified in various tick species gathered from one-humped camels in Cairo and Giza. Specifically, these species include *Hyalomma dromedarii*, *Rhipicephalus annulatus*, *Amblyomma hebraeum*, *Amblyomma lepidum*, *Amblyomma cohaerens*, and *Amblyomma variegatum* [221]. Additionally, *Borrelia* spirochetes were identified in *Ornithodoros savignyi* from a village of Giza governorate [350]. Furthermore, *R. annulatus* ticks collected from donkeys tested positive for *Borrelia theileri* [351], and *Ornithodoros erraticus* ticks collected from Nile Grass Rat burrows with *Borrelia crocidurae* [352]. In Tunisia, *Rhipicephalus sanguineus* ticks feeding on hedgehogs were infected with a RF Group *Borrelia* sp. [353] and *O. erraticus* ticks collected from rodent burrows with *B. crocidurae* [354]. Additionally, *B. hispanica* was also identified in *Ornithodoros sonrai*, *O. erraticus*, and *Ornithodoros normandi* ticks from small mammal burrows collected from nine different sites [330]. In Algeria, *B. crocidurae* was also demonstrated in *O. sonrai*, *O. erraticus*, and *O. normandi* ticks from small mammal burrows collected from 18 different sites [330]. In addition, identification of *B. hispanica* DNA was found in *O. occidentalis* ticks and *B. turicatae* in *Carios capensis* ticks from seabird nests [355]. Furthermore, *Argas persicus* ticks collected from infested hen farms were also tested and it was revealed that *Borrelia anserina* was prevalent [356]. *Hyalomma aegyptium* ticks feeding on *Testudo graeca* from seven different collection sites of north Algeria as well as from 15 collection sites of central and mostly north Morocco were found to be positive for RF *Borrelia* spp. [346]. *O. sonrai* and *O. erraticus* ticks from small mammal burrows in Morocco were also tested, revealing the presence of *B. hispanica*, *B. crocidurae*, and *Borrelia merionesi* [330,357]. Finally, *Ornithodoros marocanus* complex ticks from nine sites in Morocco were found infected with *B. hispanica* and *B. crocidurae* [358].

To sum up, the circulating *Borrelia* spp. that have been identified in vectors around the Mediterranean are *B. miyamotoi*, *B. hispanica*, *B. crocidurae*, *B. merionesi*, *B. turicatae*, *B. anserina*, *B. persica*, and *B. theileri*. *B. miyamotoi* has been reported in Spain, France, Italy,
Slovenia, Turkey, and Egypt, *B. hispanica* in Tunisia, Algeria, and Morocco, and *B. crocidurae* in Egypt, Tunisia, Algeria, and Morocco. In addition, *B. merionesi* has been found in ticks in Morocco, *B. turicatae* in Spain and Algeria, *B. anserina* in Algeria, *B. persica* in Palestine and Israel, and *B. theileri* in Egypt (Figure 9 and Table 6).

<figure><img src="image_29.png" /><figcaption>**Figure 9.** Map of *Borrelia* spp. in vectors in countries around the Mediterranean Sea.</figcaption></figure>

<table><caption>**Table 6.** *Borrelia* spp. in vectors around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="9">Borrelia Species</th></tr><tr><th>Borrelia spp.</th><th>B. miyamotoi</th><th>B. hispanica</th><th>B. crocidurae</th><th>B. merionesi</th><th>B. turicatae</th><th>B. anserina</th><th>B. persica</th><th>B. theileri</th></tr></thead><tbody><tr><td>Spain</td><td></td><td>✓</td><td></td><td></td><td></td><td>✓</td><td></td><td></td><td></td></tr><tr><td>France</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Italy</td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Slovenia</td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Turkey</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Palestine</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>✓</td><td></td></tr><tr><td>Israel</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>✓</td><td></td></tr><tr><td>Egypt</td><td></td><td>✓</td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td>✓</td></tr><tr><td>Tunisia</td><td>✓</td><td></td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Algeria</td><td>✓</td><td></td><td>✓</td><td>✓</td><td></td><td>✓</td><td>✓</td><td></td><td></td></tr><tr><td>Morocco</td><td>✓</td><td></td><td>✓</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td></tr></tbody></table>

### 6.2.4. *Borrelia* spp. in Animals in Countries around the Mediterranean Sea

The hosts of RF bacteria vary depending on the specific species. The majority of species can infect humans and small mammals, and a few species are also able to infect birds, as well as domestic or wild mammals [99]. The main hosts of *Borrelia hermsii* are small mammals such as chipmunks, squirrels, and mice [359] and of *Borrelia miyamotoi* are a wide range
of mammals, including rodents and birds [145,360]. On the other hand, *Borrelia anserina* infects exclusively birds and is not associated with human disease [152]. Humans are the primary hosts of *Borrelia recurrentis* and *Borrelia duttonii* [102,361–363]. Several animal species across the Mediterranean have been found to be infected by species of the *Borrelia* RF group. Limited data are available, though, for the following Mediterranean countries: Gibraltar, Monaco, Malta, Bosnia and Herzegovina, Montenegro, Albania, Cyprus, Syria, Lebanon, Palestine, and Libya.

### Western Mediterranean (Spain, France)

In Spain, *B. hispanica* has been identified in dogs and a street cat through positive blood smear tests and molecular analysis of 16S rRNA which revealed a 100% similarity with *B. hispanica* for all samples [364]. In France, research on the prevalence of RF spirochetes in bank voles confirmed the presence of *B. miyamotoi* [365].

### North Central Mediterranean (Italy, Slovenia)

In Italy, pigeons were discovered to have antibodies against *B. anserina*, after analysis with surface immunofluorescence assay (SIFA) and Western blotting [151]. However, in Slovenia, molecular analysis of rodent biopsy specimens indicated the presence of *B. miyamotoi* [264].

### Balkans (Croatia)

In Croatia, *B. miyamotoi* has been identified in various rodents, including common shrews, yellow-necked mice, and striped field mice [267].

### Eastern Mediterranean (Turkey, Palestine, Israel)

*B. miyamotoi* has been identified in blood samples from wild rodents from Turkey, also with the highest infection rate in Ural field mice, followed by yellow-necked mice, and bank voles [366]. In addition, in West Bank, Palestine, rodents [349] and rock hyraxes [367] were found to be infected with *B. persica*. In Israel, several species have been identified as potential hosts for RF *Borrelia* spp. Natural infection of *B. persica* in cats and dogs has been confirmed with positive blood smears and molecular assays [368], as well as with serological assays [369]. Moreover, molecular assays with blood samples from rodents and canids from all over Israel demonstrated that the species most commonly infected with *B. persica* was the social vole, followed by the red fox, the fat sand rat, the golden jackal, and the Cairo spiny mouse [349]. Additionally, besides golden jackals and red foxes, striped hyenas and European badgers also tested positive for *B. persica* DNA [370]. Finally, *B. persica* was also identified in blood and spleen samples from rock hyraxes [367].

### Southern Mediterranean (Egypt, Tunisia, Algeria, Morocco)

In Egypt, serum samples from various animals were tested for anti-*Borrelia* spp. antibodies, with the highest infection rate found in camels, followed by sheep, goats, cows, and buffaloes [350]. Furthermore, blood samples from healthy one-humped camels from Cairo and Giza indicated infections with *B. crocidurae* and *B. miyamotoi* [221]. In addition, *B. theileri* has been identified in cattle [371,372] and in sheep blood [372,373]. In Tunisia, blood samples from fat sand rats were examined microscopically and found to be infected with a *Borrelia* spp. which could not be further characterized [374]. In Algeria, blood samples from cattle were examined, revealing an infection with RF *Borrelia* species [375]. Furthermore, *B. theileri* has also been identified in blood samples from sheep and goats by molecular assays [376]. In Morocco, rodents underwent testing for the presence of *Borrelia* spp. Thick blood film analysis was conducted in blood samples and molecular assays on brain tissue samples, revealing the presence of spirochetes in both blood and brain tissue samples [330,357]. Positive samples were not further determined to species level, except from one area, where *B. merionesi* was identified [357]. *B. crocidurae* has also been reported in rodent and insectivore samples [377].
Concluding, the circulating *Borrelia* spp. that have been identified in animals across the Mediterranean are *B. miyamotoi*, *B. hispanica*, *B. persica*, *B. crocidurae*, *B. merionesi*, *B. anserina*, and *B. theileri*. *B. miyamotoi* has been reported in France, Slovenia, Croatia, Turkey, and Egypt, *B. hispanica* in Spain, *B. persica* in Palestine and Israel, *B. crocidurae* in Egypt and Morocco, *B. anserina* in Italy, *B. merionesi* in Morocco, and *B. theileri* in Egypt and Algeria (Figure 10 and Table 7).

<figure><img src="image_30.png" /><figcaption>**Figure 10.** Map of *Borrelia* spp. in animals in countries around the Mediterranean Sea.</figcaption></figure>

<table><caption>**Table 7.** *Borrelia* spp. in animals around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="8">Borrelia Species</th></tr><tr><th>Borrelia spp.</th><th>B. hispanica</th><th>B. persica</th><th>B. crocidurae</th><th>B. miyamotoi</th><th>B. anserina</th><th>B. merionesi</th><th>B. theileri</th></tr></thead><tbody><tr><td>Spain</td><td></td><td>▲</td><td>▲</td><td>▲</td><td>▲</td><td>▲</td><td>▲</td><td>▲</td></tr><tr><td>France</td><td></td><td></td><td></td><td>▲</td><td></td><td></td><td></td><td></td></tr><tr><td>Italy</td><td></td><td></td><td></td><td></td><td>▲</td><td></td><td></td><td></td></tr><tr><td>Slovenia</td><td></td><td></td><td></td><td></td><td></td><td>▲</td><td></td><td></td></tr></tbody></table>

<figure><img src="image_31.png" /></figure>

<figure><img src="image_32.png" /></figure>

<figure><img src="image_33.png" /></figure>

<figure><img src="image_34.png" /></figure>
<table><caption>**Table 7. Cont.**</caption><thead><tr><th rowspan="2">Country</th><th colspan="8">Borrelia Species</th></tr><tr><th>Borrelia spp.</th><th>B. hispanica</th><th>B. persica</th><th>B. crocidurae</th><th>B. miyamotoi</th><th>B. anserina</th><th>B. merionesi</th><th>B. theileri</th></tr></thead><tbody><tr><td>Croatia</td><td></td><td></td><td></td><td></td><td>Cat</td><td></td><td></td><td></td></tr><tr><td>Turkey</td><td></td><td></td><td></td><td></td><td>Cat</td><td></td><td></td><td></td></tr><tr><td>Palestine</td><td></td><td></td><td>Cat</td><td>Wolf</td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="3">Israel</td><td></td><td></td><td>Wolf</td><td>Wolf</td><td>Cat</td><td></td><td></td><td></td></tr><tr><td></td><td></td><td>Cat</td><td>Wolf</td><td>Wolf</td><td>Cat</td><td></td><td></td></tr><tr><td></td><td></td><td>Wolf</td><td>Wolf</td><td>Wolf</td><td>Wolf</td><td>Cat</td><td></td></tr><tr><td>Egypt</td><td></td><td>Sheep</td><td>Sheep</td><td>Sheep</td><td>Camel</td><td>Camel</td><td>Camel</td><td>Camel</td></tr><tr><td>Tunisia</td><td></td><td>Cat</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Algeria</td><td></td><td>Sheep</td><td>Sheep</td><td>Sheep</td><td>Camel</td><td>Camel</td><td>Camel</td><td>Camel</td></tr><tr><td>Morocco</td><td></td><td>Cat</td><td>Cat</td><td>Cat</td><td>Camel</td><td>Camel</td><td>Camel</td><td>Camel</td></tr></tbody></table>

<figure><img src="image_35.png" /></figure>

### 6.2.5. *Borrelia* spp. in Humans in Countries around the Mediterranean Sea

Infections due to the RF Group *Borrelia* are also present around the Mediterranean. There are no reports of human infection or very little is known on its prevalence and the species involved in the following Mediterranean countries: Gibraltar, Monaco, Malta, Slovenia, Croatia, Bosnia and Herzegovina, Montenegro, Albania, Turkey, Syria, Lebanon, Palestine, and Tunisia.

#### Western Mediterranean (Spain, France)

In Spain, RF cases have been documented in individuals within one week after exposure to ticks in mountainous regions [378] or following visits to holiday farms [314], working on a pig farm [314], or among intravenous drug users [379]. Moreover, between 1994 and 2016, numerous cases of RF were diagnosed through direct visualization of spirochetes in blood samples. Some of these samples were forwarded for identification, all of which were identified as *B. hispanica* [380]. Furthermore, from 2004 to 2015 numerous patients were diagnosed with TBRF based on microscopic analysis of blood or cerebrospinal fluid samples and had clinical data similar to those of a *B. hispanica* infection [381]. In France, *B. miyamotoi* and *B. hermsii* have been identified among patients with symptoms related to a tick bite [382]. In addition, a *B. miyamotoi* infection was confirmed by serological assays after a *B. miyamotoi*-infected tick bite [204]. Finally, *B. recurrentis* infections have been identified in homeless individuals by microimmunofluorescence [324,325] and Western Blotting [324].
## North Central Mediterranean (Italy)

In Italy, the first autochthonous case of *B. crocidurae* infection was documented in a 51-year-old woman from Macedonia who was living in Italy from 15 years old and was diagnosed with meningitis due to *B. crocidurae* as shown by PCR from CSF specimen after a ten-day history of headache, vertical diplopia, and low-grade fever [383].

## Balkans (Greece)

Following a two-week camping excursion on the Greek island of Tilos, during which he explored several caves, a traveler from Belgium reported experiencing recurrent febrile episodes. Upon admission to the hospital, spirochetes were detected on his blood smear, and molecular assays to identify the responsible *Borrelia* sp. confirmed a *B. persica* infection [384].

## Eastern Mediterranean (Cyprus, Israel)

In Cyprus, a number of cases involving RF among civilians and military personnel, all of whom had somehow spent time in caves or near tick habitats, have been documented over the past century, and in some cases spirochetes were also observed in the blood smears of these individuals as well [385,386]. Also, a case of RF contracted in Cyprus and imported in the United Kingdom was published regarding a soldier who had spent three weeks on exercise in Cyprus and spent the night inside a cave where he observed ticks on his feet when he woke up [387]. In Israel, several cases of RF have been reported during the past years. Outbreaks in 2009 and 2010 have been reported among soldiers during cave entry and prolonged close contact with the ground in the context of a military exercise [388]. Additional cases have been documented, including those diagnosed by a hematological laboratory [389], neonatal cases [390] with severe Jarisch-Herxheimer reaction [391], cases who received placebos in a double-blind trial for post-exposure treatment to prevent TBRF [392], and cases confirmed by molecular assays for *B. persica* infection [348,393]. *B. persica* was also identified in spirochetemic patients from Israel as well as in patients with similar clinical manifestations, but with negative blood smears [394], and in a TBRF patient with adult respiratory distress syndrome (ARDS) [395].

## Southern Mediterranean (Egypt, Libya, Algeria, Morocco)

A case of RF in a patient with nephritis and subarachnoid hemorrhage, confirmed by blood film, was reported in Egypt after spending the night on the ground before the onset of the symptoms [396]. Additionally, humans have been found to carry antibodies against *Borrelia* spp. antigen [350]. In Libya, cases of RF with confirmed diagnosis by blood film, have been reported in one case of a young Palestinian driver who had not been anywhere else other than Benghazi for at least one month before the onset of his symptoms, an Italian P.O.W. whose specific route before the illness onset is unknown, but he came from Western Cyrenaica, an Indian pioneer who had spent his time wholly in Cyrenaica and in Benghazi, and a British lance-corporal who spent two nights in Tobruk and otherwise was totally in Benghazi [397]. In Algeria, *Borrelia* spp. DNA has been identified in feverish patients from Oran, and one sample was indicative of a new *Borrelia* spp. called *Candidatus Borrelia algerica* [103]. Finally, in Morocco, cases of RF have been confirmed in patients with unexplained fever by positive blood film [357], as well as by molecular assays demonstrating *B. hispanica* infections [398,399].

To sum up, the circulating *Borrelia* spp. that have been reported to cause human infections in countries around the Mediterranean Sea are *B. hispanica*, *B. persica*, *B. crocidurae*, *B. miyamotoi*, *B. hermsii*, *Candidatus B. algerica*, and *B. recurrentis*. *B. hispanica* has been reported in Spain and Morocco, *B. persica* in Greece and Israel, *B. crocidurae* in Italy, *B. miyamotoi* in France, *B. hermsii* in France, *Candidatus B. algerica* in Algeria, and *B. recurrentis* in France (Figure 11 and Table 8, Box 2).
<figure><img src="image_36.png" /><figcaption>**Figure 11.** Map of *Borrelia* spp. in humans in countries around the Mediterranean Sea.</figcaption></figure>

<table><caption>**Table 8.** *Borrelia* spp. in humans around the Mediterranean Sea.</caption><thead><tr><th rowspan="2">Country</th><th colspan="7">Borrelia Species</th></tr><tr><th>Borrelia spp.</th><th>B. hispanica</th><th>B. persica</th><th>B. crocidurae</th><th>B. miyamotoi</th><th>B. hermsii</th><th>Candidatus B. algerica</th><th>B. recurrentis</th></tr></thead><tbody><tr><td>Spain</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>France</td><td></td><td></td><td></td><td></td><td>✓</td><td>✓</td><td></td><td>✓</td></tr><tr><td>Italy</td><td></td><td></td><td></td><td>✓</td><td></td><td></td><td></td><td></td></tr><tr><td>Greece</td><td></td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Cyprus</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Palestine</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Israel</td><td>✓</td><td></td><td>✓</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Egypt</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Libya</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Algeria</td><td></td><td></td><td></td><td></td><td></td><td></td><td>✓</td><td></td></tr><tr><td>Morocco</td><td>✓</td><td>✓</td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
**Box 2.** Prevention of RF.

Preventing TBRF relies on minimizing exposure to soft ticks. This can be achieved by avoiding habitats where soft ticks are prevalent, such as caves, animal burrows, huts, and cabins. Furthermore, it is recom-mended to use tick repellents on clothing and skin, along with wearing long-sleeved shirts and trousers tucked into socks when engaging in outdoor activities. On the other hand, preventing LBRF primarily de-pends on maintaining personal and clothing hygiene to prevent infestation by body lice.

### 6.2.6. Imported Human Cases of RF in Mediterranean Countries

Cases of RF are not only contracted in Mediterranean countries but can also be transferred there due to travelling or immigration in other countries, especially from central Africa and Asia. In France, several cases of *B. crocidurae* infection have been identified, most of which were in immigrants from Somalia [400–403] passing through Mauritania [315] or immigrants from Mali [315]. Additionally, a case of *B. hispanica* was identified after travel in Morocco and Spain [315] and another of *B. persica* after a trip to Uzbekistan and Tajikistan [404]. In Italy, the vast majority of imported RF cases are due to *B. recurrentis* in immigrants from the Horn of Africa, e.g., Somalia, Eritrea, and Ethiopia [15,405,406]. The immigration route usually includes more or less prolonged stays in Sudan and Libya [326,407,408], and in some cases the immigration route includes Kenya and South Sudan, before crossing Sudan and Libya [409,410]. However, a case of *B. recurrentis* has also been reported in an immigrant from Mali, who passed by Algeria and Libya before arriving to Italy [411]. Also, a *B. crocidurae* infection was identified in Italy after travel to Senegal [412]. Finally, *B. recurrentis* infection has been demonstrated in Israel in Ethiopian Pilgrims [413] and in Libya and Italy in immigrants from Somalia with Germany as their final destination, who were passing through Libya and Italy as intermediate stations [14] (Table 9).

<table><caption>**Table 9.** Imported RF cases in Mediterranean countries.</caption><thead><tr><th>Country of Manifestation</th><th>Country of Origin/Immigration Route</th><th>Borrelia Species</th><th>References</th></tr></thead><tbody><tr><td rowspan="5">France</td><td>Senegal</td><td>B. crocidurae</td><td>[400–403]</td></tr><tr><td>Senegal and Mauritania</td><td>B. crocidurae</td><td>[315]</td></tr><tr><td>Mali</td><td>B. crocidurae</td><td>[315]</td></tr><tr><td>Morocco and Spain</td><td>B. hispanica</td><td>[315]</td></tr><tr><td>Uzbekistan and Tajikistan</td><td>B. persica</td><td>[404]</td></tr><tr><td rowspan="8">Italy</td><td>Eritrea/Somalia/Ethiopia and Libya</td><td>B. recurrentis</td><td>[15]</td></tr><tr><td>Somalia and Libya</td><td>B. recurrentis</td><td>[326,408]</td></tr><tr><td>Somalia, Kenya, South Sudan, Sudan, and Libya</td><td>B. recurrentis</td><td>[409]</td></tr><tr><td>Somalia/Sudan and Libya</td><td>B. recurrentis</td><td>[407]</td></tr><tr><td>East Africa</td><td>B. recurrentis</td><td>[405]</td></tr><tr><td>Mali, Algeria, and Libya</td><td>B. recurrentis</td><td>[411]</td></tr><tr><td>Somalia, Kenya, Uganda, Sudan, and Libya</td><td>B. recurrentis</td><td>[410]</td></tr><tr><td>Somalia</td><td>B. recurrentis</td><td>[406]</td></tr><tr><td>Senegal</td><td>B. crocidurae</td><td>[412]</td></tr><tr><td>Israel</td><td>Ethiopia</td><td>B. recurrentis</td><td>[413]</td></tr><tr><td>Libya and Italy as intermediate destinations</td><td>Somalia, Ethiopia, Kenya, South Sudan, and Sudan</td><td>B. recurrentis</td><td>[14]</td></tr></tbody></table>
## 7. Conclusions

In order to successfully monitor and limit the spread of *Borrelia* infections, it is vital that the medical, veterinary, and environmental sectors collaborate. For this reason, we provide insight for every country around the Mediterranean Sea with available information regarding the prevalence of all *Borrelia* spp. that have been implicated in tick, animal, and human infection. In summary, LD agents were mostly found in the European part of the Mediterranean. Several *Borrelia* spp. were identified in hard ticks and in numerous animals, such as rodents, wild ungulates, farm animals, and pets. RF agents were identified all around the Mediterranean in both soft ticks as well as hard ticks. Many animal species were reported to be infected with RF agents, such as rodents, pets, and farm animals. In conclusion, infections caused by *Borrelia* spp. are still a serious issue that afflict thousands of people every year and hence demand our undivided attention.

**Supplementary Materials:** The tables with all the references of the *Borrelia* spp. in humans, animals and vectors can be downloaded at https://www.mdpi.com/article/10.3390/pathogens13060512/s1, Table S1: Lyme Group *Borreliella* spp. in humans [41,201,222,265,270,284–305,382,414–517]; Table S2: Lyme Group *Borreliella* spp. in animals [198,199,221,222,238–283,365,373,447,496,502,518–538]; Table S3: Lyme Group *Borreliella* spp. in ticks [61,87,196–226,233,244,250,251,257,259,279,281,285,291,295,335,336,338–340,342,343,346,365,447,473,495,501,502,525,535,539–641]; Table S4: Relapsing Fever Group *Borrelia* spp. in humans [103,204,314,324,325,347,348,350,357,378–399,642–651]; Table S5: Relapsing Fever Group *Borrelia* spp. in animals [151,221,264,267,330,349,350,357,364–377,652,653]; Table S6: Relapsing Fever Group *Borrelia* spp. in ticks [196,204,205,213,221,330,335–349,351–358,365,447,540,551,559,562,563,566,568,570,575,576,582,643,653–655].

**Author Contributions:** Data curation, M.K.; writing—original draft preparation, M.K.; review and editing, M.D.; supervision, E.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Data Availability Statement:** The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

**Conflicts of Interest:** The authors declare no conflicts of interest.

## References

1. Calistri, P.; Iannetti, S.; Danzetta, M.L.; Narcisi, V.; Cito, F.; Sabatino, D.D.; Bruno, R.; Sauro, F.; Atzeni, M.; Carvelli, A.; et al. The components of 'One World—One Health' approach. *Transbound. Emerg. Dis.* **2013**, *60* (Suppl. 2), 4–13. [CrossRef] [PubMed]

2. Mackenzie, J.S.; Jeggo, M. The One Health Approach-Why Is It So Important? *Trop. Med. Infect. Dis.* **2019**, *4*, 88. [CrossRef] [PubMed]

3. Rabinowitz, P.M.; Kock, R.; Kachani, M.; Kunkel, R.; Thomas, J.; Gilbert, J.; Wallace, R.; Blackmore, C.; Wong, D.; Karesh, W.; et al. Toward proof of concept of a one health approach to disease prediction and control. *Emerg. Infect. Dis.* **2013**, *19*, e1302650. [CrossRef] [PubMed]

4. Karesh, W.B.; Dobson, A.; Lloyd-Smith, J.O.; Lubroth, J.; Dixon, M.A.; Bennett, M.; Aldrich, S.; Harrington, T.; Formenty, P.; Loh, E.H.; et al. Ecology of zoonoses: Natural and unnatural histories. *Lancet* **2012**, *380*, 1936–1945. [CrossRef] [PubMed]

5. Jones, K.E.; Patel, N.G.; Levy, M.A.; Storeygard, A.; Balk, D.; Gittleman, J.L.; Daszak, P. Global trends in emerging infectious diseases. *Nature* **2008**, *451*, 990–993. [CrossRef] [PubMed]

6. Jones, B.A.; Grace, D.; Kock, R.; Alonso, S.; Rushton, J.; Said, M.Y.; McKeever, D.; Mutua, F.; Young, J.; McDermott, J.; et al. Zoonosis emergence linked to agricultural intensification and environmental change. *Proc. Natl. Acad. Sci. USA* **2013**, *110*, 8399–8404. [CrossRef] [PubMed]

7. Oppler, Z.J.; O’Keeffe, K.R.; McCoy, K.D.; Brisson, D. Evolutionary Genetics of Borrelia. *Curr. Issues Mol. Biol.* **2021**, *42*, 97–112. [CrossRef] [PubMed]

8. Steere, A.C.; Strle, F.; Wormser, G.P.; Hu, L.T.; Branda, J.A.; Hovius, J.W.; Li, X.; Mead, P.S. Lyme borreliosis. *Nat. Rev. Dis. Primers* **2016**, *2*, 16090. [CrossRef]

9. Jakab, A.; Kahlig, P.; Kuenzli, E.; Neumayr, A. Tick borne relapsing fever—A systematic review and analysis of the literature. *PLoS Negl. Trop. Dis.* **2022**, *16*, e0010212. [CrossRef]

10. Olafsdottir, B.; Askling, H.H. Increasing spread of borreliosis in Europe. *New Microbes New Infect.* **2022**, *48*, 101022. [CrossRef]

11. Kugeler, K.J.; Schwartz, A.M.; Delorey, M.J.; Mead, P.S.; Hinckley, A.F. Estimating the Frequency of Lyme Disease Diagnoses, United States, 2010–2018. *Emerg. Infect. Dis.* **2021**, *27*, 616–619. [CrossRef]
12. Marques, A.R.; Strle, F.; Wormser, G.P. Comparison of Lyme Disease in the United States and Europe. *Emerg. Infect. Dis.* **2021**, *27*, 2017–2024. [CrossRef] [PubMed]

13. Felsenfeld, O. *BORRELIA: Strains, Vectors, Human and Animal Borreliosis*; CABI Digital Library: Wallingford, UK, 1971.

14. Hoch, M.; Wieser, A.; Loscher, T.; Margos, G.; Purner, F.; Zuhl, J.; Seilmaier, M.; Balzer, L.; Guggemos, W.; Rack-Hoch, A.; et al. Louse-borne relapsing fever (*Borrelia recurrentis*) diagnosed in 15 refugees from northeast Africa: Epidemiology and preventive control measures, Bavaria, Germany, July to October 2015. *Eurosurveillance* **2015**, *20*, 30046. [CrossRef] [PubMed]

15. Antinori, S.; Mediannikov, O.; Corbellino, M.; Raoult, D. Louse-borne relapsing fever among East African refugees in Europe. *Travel. Med. Infect. Dis.* **2016**, *14*, 110–114. [CrossRef]

16. Rebaudet, S.; Parola, P. Epidemiology of relapsing fever borreliosis in Europe. *FEMS Immunol. Med. Microbiol. 2006*, *48*, 11–15. [CrossRef] [PubMed]

17. Kurokawa, C.; Lynn, G.E.; Pedra, J.H.F.; Pal, U.; Narasimhan, S.; Fikrig, E. Interactions between Borrelia burgdorferi and ticks. *Nat. Rev. Microbiol.* **2020**, *18*, 587–600. [CrossRef]

18. Helble, J.D.; McCarthy, J.E.; Hu, L.T. Interactions between Borrelia burgdorferi and its hosts across the enzootic cycle. *Parasite Immunol.* **2021**, *43*, e12816. [CrossRef]

19. Couret, J.; Schofield, S.; Narasimhan, S. The environment, the tick, and the pathogen—It is an ensemble. *Front. Cell. Infect. Microbiol.* **2022**, *12*, 1049646. [CrossRef]

20. Gupta, R.S.; Mahmood, S.; Adeolu, M. A phylogenomic and molecular signature based approach for characterization of the phylum Spirochaetes and its major clades: Proposal for a taxonomic revision of the phylum. *Front. Microbiol.* **2013**, *4*, 217. [CrossRef]

21. Tilly, K.; Rosa, P.A.; Stewart, P.E. Biology of infection with Borrelia burgdorferi. *Infect. Dis. Clin. N. Am.* **2008**, *22*, 217–234. [CrossRef]

22. Hyde, J.A. Borrelia burgdorferi Keeps Moving and Carries on: A Review of Borrelial Dissemination and Invasion. *Front. Immunol.* **2017**, *8*, 114. [CrossRef] [PubMed]

23. Schwartz, I.; Margos, G.; Casjens, S.R.; Qiu, W.G.; Eggers, C.H. Multipartite Genome of Lyme Disease Borrelia: Structure, Variation and Prophages. *Curr. Issues Mol. Biol.* **2021**, *42*, 409–454. [CrossRef] [PubMed]

24. Trevisan, G.; Cinco, M.; Trevisini, S.; di Meo, N.; Chersi, K.; Ruscio, M.; Forgione, P.; Bonin, S. Borreliae Part 1: Borrelia Lyme Group and Echidna-Reptile Group. *Biology* **2021**, *10*, 1036. [CrossRef] [PubMed]

25. Arahal, D.R.; Bull, C.T.; Busse, H.J.; Christensen, H.; Chuvochina, M.; Dedysh, S.N.; Fournier, P.E.; Konstantinidis, K.T.; Parker, C.T.; Rossello-Mora, R.; et al. Judicial Opinions 123–127. *Int. J. Syst. Evol. Microbiol.* **2022**, *72*, 005708. [CrossRef] [PubMed]

26. Adeolu, M.; Gupta, R.S. A phylogenomic and molecular marker based proposal for the division of the genus Borrelia into two genera: The emended genus Borrelia containing only the members of the relapsing fever Borrelia, and the genus Borrelia sensu lato complex. *Antonie Leeuwenhoek* **2014**, *105*, 1049–1072. [CrossRef] [PubMed]

27. Steinbrink, A.; Brugger, K.; Margos, G.; Kraiczy, P.; Klimpel, S. The evolving story of Borrelia burgdorferi sensu lato transmission in Europe. *Parasitol. Res.* **2022**, *121*, 781–803. [CrossRef] [PubMed]

28. Wolcott, K.A.; Margos, G.; Fingerle, V.; Becker, N.S. Host association of Borrelia burgdorferi sensu lato: A review. *Ticks Tick-Borne Dis.* **2021**, *12*, 101766. [CrossRef]

29. Branda, J.A.; Steere, A.C. Laboratory Diagnosis of Lyme Borreliosis. *Clin. Microbiol. Rev.* **2021**, *34*, e00018-19. [CrossRef]

30. Stanek, G.; Wormser, G.P.; Gray, J.; Strle, F. Lyme borreliosis. *Lancet* **2012**, *379*, 461–473. [CrossRef]

31. Canica, M.M.; Nato, F.; du Merle, L.; Mazie, J.C.; Baranton, G.; Postic, D. Monoclonal antibodies for identification of Borrelia afzelii sp. nov. associated with late cutaneous manifestations of Lyme borreliosis. *Scand. J. Infect. Dis.* **1993**, *25*, 441–448. [CrossRef]

32. Nakao, M.; Miyamoto, K.; Fukunaga, M.; Hashimoto, Y.; Takahashi, H. Comparative studies on Borrelia afzelii isolated from a patient of Lyme disease, Ixodes persulcatus ticks, and Apodemus speciosus rodents in Japan. *Microbiol. Immunol.* **1994**, *38*, 413–420. [CrossRef]

33. Korenberg, E.I.; Nefedova, V.V.; Romanenko, V.N.; Gorelova, N.B. The tick Ixodes pavlovskyi as a host of spirochetes pathogenic for humans and its possible role in the epizootiology and epidemiology of borrelioses. *Vector Borne Zoonotic Dis.* **2010**, *10*, 453–458. [CrossRef] [PubMed]

34. Wodecka, B.; Michalik, J.; Grochowalska, R. Red Foxes (*Vulpes vulpes*) Are Exposed to High Diversity of *Borrelia burgdorferi* Sensu Lato Species Infecting Fox-Derived Ixodes Ticks in West-Central Poland. *Pathogens* **2022**, *11*, 696. [CrossRef]

35. Rudenko, N.; Golovchenko, M.; Lin, T.; Gao, L.; Grubhoffer, L.; Oliver, J.H., Jr. Delineation of a new species of the Borrelia burgdorferi Sensu Lato Complex, Borrelia americana sp. nov. *J. Clin. Microbiol.* **2009**, *47*, 3875–3880. [CrossRef]

36. Scott, J.D.; Foley, J.E. Detection of Borrelia americana in the Avian Coastal Tick, Ixodes auritulus (Acari: Ixodidae), Collected from a Bird Captured in Canada. *Open J. Anim. Sci.* **2016**, *6*, 207–216. [CrossRef]

37. Dunaj, J.; Drewnowska, J.; Moniuszko-Malinowska, A.; Swiecicka, I.; Pancewicz, S. First metagenomic report of Borrelia americana and Borrelia carolinensis in Poland—A preliminary study. *Ann. Agric. Environ. Med.* **2021**, *28*, 49–55. [CrossRef]

38. Anderson, J.F.; Magnarelli, L.A.; McAninch, J.B. New Borrelia burgdorferi antigenic variant isolated from Ixodes dammini from upstate New York. *J. Clin. Microbiol.* **1988**, *26*, 2209–2212. [CrossRef] [PubMed]
39. Marconi, R.T.; Liveris, D.; Schwartz, I. Identification of novel insertion elements, restriction fragment length polymorphism patterns, and discontinuous 23S rRNA in Lyme disease spirochetes: Phylogenetic analyses of rRNA genes and their intergenic spacers in Borrelia japonica sp. nov. and genomic group 21038 (*Borrelia andersonii* sp. nov.) isolates. *J. Clin. Microbiol.* **1995**, *33*, 2427–2434. [CrossRef] [PubMed]

40. Hamer, S.A.; Hickling, G.J.; Keith, R.; Sidge, J.L.; Walker, E.D.; Tsao, J.I. Associations of passerine birds, rabbits, and ticks with Borrelia miyamotoi and Borrelia andersonii in Michigan, U.S.A. *Parasit Vectors* **2012**, *5*, 231. [CrossRef] [PubMed]

41. Margos, G.; Vollmer, S.A.; Cornet, M.; Garnier, M.; Fingerle, V.; Wilske, B.; Bormane, A.; Vitorino, L.; Collares-Pereira, M.; Drancourt, M.; et al. A new Borrelia species defined by multilocus sequence analysis of housekeeping genes. *Appl. Environ. Microbiol.* **2009**, *75*, 5410–5416. [CrossRef]

42. Margos, G.; Wilske, B.; Sing, A.; Hizo-Teufel, C.; Cao, W.C.; Chu, C.; Scholz, H.; Straubinger, R.K.; Fingerle, V. Borrelia bavariensis sp. nov. is widely distributed in Europe and Asia. *Int. J. Syst. Evol. Microbiol.* **2013**, *63*, 4284–4288. [CrossRef] [PubMed]

43. Margos, G.; Fingerle, V.; Reynolds, S. Borrelia bavariensis: Vector Switch, Niche Invasion, and Geographical Spread of a Tick-Borne Bacterial Parasite. *Front. Ecol. Evol.* **2019**, *7*, 401. [CrossRef]

44. Postic, D.; Ras, N.M.; Lane, R.S.; Henderson, M.; Baranton, G. Expanded diversity among Californian borrelia isolates and description of Borrelia bissettii sp. nov. (formerly Borrelia group DN127). *J. Clin. Microbiol.* **1998**, *36*, 3497–3504. [CrossRef] [PubMed]

45. Schneider, B.S.; Zeidner, N.S.; Burkot, T.R.; Maupin, G.O.; Piesman, J. Borrelia isolates in Northern Colorado identified as Borrelia bissettii. *J. Clin. Microbiol.* **2000**, *38*, 3103–3105. [CrossRef] [PubMed]

46. Margos, G.; Lane, R.S.; Fedorova, N.; Koloczek, J.; Piesman, J.; Hojgaard, A.; Sing, A.; Fingerle, V. Borrelia bissettiae sp. nov. and Borrelia californiensis sp. nov. prevail in diverse enzootic transmission cycles. *Int. J. Syst. Evol. Microbiol.* **2016**, *66*, 1447–1452. [CrossRef] [PubMed]

47. Fedorova, N.; Kleinjan, J.E.; James, D.; Hui, L.T.; Peeters, H.; Lane, R.S. Remarkable diversity of tick or mammalian-associated Borreliae in the metropolitan San Francisco Bay Area, California. *Ticks Tick-Borne Dis.* **2014**, *5*, 951–961. [CrossRef] [PubMed]

48. Burgdorfer, W.; Barbour, A.G.; Hayes, S.F.; Benach, J.L.; Grunwaldt, E.; Davis, J.P. Lyme disease-a tick-borne spirochetosis? *Science* **1982**, *216*, 1317–1319. [CrossRef]

49. Johnson, R.C.; Schmid, G.P.; Hyde, F.W.; Steigerwalt, A.G.; Brenner, D.J. Borrelia burgdorferi sp. nov.: Etiologic Agent of Lyme Disease. *Int. J. Syst. Bacteriol.* **1984**, *34*, 496–497. [CrossRef]

50. Kim, C.M.; Park, S.Y.; Kim, D.M.; Park, J.W.; Chung, J.K. First report of Borrelia burgdorferi sensu stricto detection in a commune genospecies in Apodemus agrarius in Gwangju, South Korea. *Sci. Rep.* **2021**, *11*, 18199. [CrossRef]

51. Postic, D.; Garnier, M.; Baranton, G. Multilocus sequence analysis of atypical Borrelia burgdorferi sensu lato isolates—Description of *Borrelia californiensis* sp. nov., and genomospecies 1 and 2. *Int. J. Med. Microbiol. IJMM* **2007**, *297*, 263–271. [CrossRef]

52. Wodecka, B.; Kolomiiets, V. Genetic Diversity of Borreliaceae Species Detected in Natural Populations ofIxodes ricinus Ticks in Northern Poland. *Life* **2023**, *13*, 972. [CrossRef] [PubMed]

53. Michalik, J.; Wodecka, B.; Liberska, J.; Dabert, M.; Postawa, T.; Piksa, K.; Stanczak, J. Diversity of Borrelia burgdorferi sensu lato species in Ixodes ticks (Acari: Ixodidae) associated with cave-dwelling bats from Poland and Romania. *Ticks Tick-Borne Dis.* **2020**, *11*, 101300. [CrossRef] [PubMed]

54. Rudenko, N.; Golovchenko, M.; Grubhoffer, L.; Oliver, J.H., Jr. *Borrelia carolinensis* sp. nov., a new (14th) member of the Borrelia burgdorferi Sensu Lato complex from the southeastern region of the United States. *J. Clin. Microbiol.* **2009**, *47*, 134–141. [CrossRef] [PubMed]

55. Foley, J.; Ott-Conn, C.; Worth, J.; Poulsen, A.; Clifford, D. An Ixodes minor and Borrelia carolinensis enzootic cycle involving a critically endangered Mojave Desert rodent. *Ecol. Evol.* **2014**, *4*, 576–581. [CrossRef] [PubMed]

56. Springer, A.; Raulf, M.K.; Fingerle, V.; Strube, C. Borrelia prevalence and species distribution in ticks removed from humans in Germany, 2013–2017. *Ticks Tick-Borne Dis.* **2020**, *11*, 101363. [CrossRef] [PubMed]

57. Rudenko, N.; Golovchenko, M.; Grubhoffer, L.; Oliver, J.H. Borrelia carolinensis sp. nov., a novel species of the Borrelia burgdorferi sensu lato complex isolated from rodents and a tick from the south-eastern USA. *Int. J. Syst. Evol. Microbiol.* **2011**, *61*, 381–383. [CrossRef] [PubMed]

58. Osikowicz, L.M.; Rizzo, M.R.; Hojgaard, A.; Maes, S.E.; Eisen, R.J. Detection of Borrelia burgdorferi sensu lato species in host-seeking Ixodes species ticks in the United States. *Ticks Tick-Borne Dis.* **2024**, *15*, 102270. [CrossRef] [PubMed]

59. Ivanova, L.B.; Tomova, A.; Gonzalez-Acuna, D.; Murua, R.; Moreno, C.X.; Hernandez, C.; Cabello, J.; Cabello, C.; Daniels, T.J.; Godfrey, H.P.; et al. Borrelia chilensis, a new member of the *Borrelia burgdorferi* sensu lato complex that extends the range of this genospecies in the Southern Hemisphere. *Environ. Microbiol.* **2014**, *16*, 1069–1080. [CrossRef]

60. Casjens, S.R.; Fraser-Liggett, C.M.; Mongodin, E.F.; Qiu, W.G.; Dunn, J.J.; Luft, B.J.; Schutzer, S.E. Whole genome sequence of an unusual Borrelia burgdorferi sensu lato isolate. *J. Bacteriol.* **2011**, *193*, 1489–1490. [CrossRef]

61. Baranton, G.; Postic, D.; Saint Girons, I.; Boerlin, P.; Piffaretti, J.C.; Assous, M.; Grimont, P.A. Delineation of Borrelia burgdorferi sensu stricto, Borrelia garinii sp. nov., and group VS461 associated with Lyme borreliosis. *Int. J. Syst. Bacteriol.* **1992**, *42*, 378–383. [CrossRef]

62. Munoz-Leal, S.; Ramirez, D.G.; Luz, H.R.; Faccini, J.L.H.; Labruna, M.B. "Candidatus Borrelia ibitipoquensis", a Borrelia valaisiana-Related Genospecies Characterized from Ixodes paranaensis in Brazil. *Microb. Ecol.* **2020**, *80*, 682–689. [CrossRef] [PubMed]
63. Kawabata, H.; Masuzawa, T.; Yanagihara, Y. Genomic analysis of Borrelia japonica sp. nov. isolated from Ixodes ovatus in Japan. *Microbiol. Immunol.* **1993**, *37*, 843–848. [CrossRef] [PubMed]

64. Masuzawa, T.; Suzuki, H.; Kawabata, H.; Ishiguro, F.; Takada, N.; Yano, Y.; Yanagihara, Y. Identification of spirochetes isolated from wild rodents in Japan as Borrelia japonica. *J. Clin. Microbiol.* **1995**, *33*, 1392–1394. [CrossRef] [PubMed]

65. Margos, G.; Hojgaard, A.; Lane, R.S.; Cornet, M.; Fingerle, V.; Rudenko, N.; Ogden, N.; Aanensen, D.M.; Fish, D.; Piesman, J. Multilocus sequence analysis of Borrelia bissettii strains from North America reveals a new Borrelia species, Borrelia kurtenbachii. *Ticks Tick-Borne Dis.* **2010**, *1*, 151–158. [CrossRef] [PubMed]

66. Margos, G.; Piesman, J.; Lane, R.S.; Ogden, N.H.; Sing, A.; Straubinger, R.K.; Fingerle, V. Borrelia kurtenbachii sp. nov., a widely distributed member of the Borrelia burgdorferi sensu lato species complex in North America. *Int. J. Syst. Evol. Microbiol.* **2014**, *64*, 128–130. [CrossRef] [PubMed]

67. Lane, R.S.; Quistad, G.B. Borreliacidal factor in the blood of the western fence lizard (Sceloporus occidentalis). *J. Parasitol.* **1998**, *84*, 29–34. [CrossRef] [PubMed]

68. Margos, G.; Fedorova, N.; Kleinjan, J.E.; Hartberger, C.; Schwan, T.G.; Sing, A.; Fingerle, V. Borrelia lanei sp. nov. extends the diversity of Borrelia species in California. *Int. J. Syst. Evol. Microbiol.* **2017**, *67*, 3872–3876. [CrossRef] [PubMed]

69. Le Fleche, A.; Postic, D.; Girardet, K.; Peter, O.; Baranton, G. Characterization of Borrelia lusitaniae sp. nov. by 16S ribosomal DNA sequence analysis. *Int. J. Syst. Bacteriol.* **1997**, *47*, 921–925. [CrossRef] [PubMed]

70. Richter, D.; Matuschka, F.R. Perpetuation of the Lyme disease spirochete Borrelia lusitaniae by lizards. *Appl. Environ. Microbiol.* **2006**, *72*, 4627–4632. [CrossRef]

71. de Carvalho, I.L.; Zeidner, N.; Ullmann, A.; Hojgaard, A.; Amaro, F.; Ze-Ze, L.; Alves, M.J.; de Sousa, R.; Piesman, J.; Nuncio, M.S. Molecular characterization of a new isolate of *Borrelia lusitaniae* derived from *Apodemus sylvaticus* in Portugal. *Vector Borne Zoonotic Dis.* **2010**, *10*, 531–534. [CrossRef]

72. Margos, G.; Fedorova, N.; Becker, N.S.; Kleinjan, J.E.; Marosevic, D.; Krebs, S.; Hui, L.; Fingerle, V.; Lane, R.S. Borrelia maritima sp. nov., a novel species of the Borrelia burgdorferi sensu lato complex, occupying a basal position to North American species. *Int. J. Syst. Evol. Microbiol.* **2020**, *70*, 849–856. [CrossRef] [PubMed]

73. Johnson, T.L.; Graham, C.B.; Hojgaard, A.; Breuner, N.E.; Maes, S.E.; Boegler, K.A.; Replogle, A.J.; Kingry, L.C.; Petersen, J.M.; Eisen, L.; et al. Isolation of the Lyme Disease Spirochete Borrelia mayonii From Naturally Infected Rodents in Minnesota. *J. Med. Entomol.* **2017**, *54*, 1088–1092. [CrossRef] [PubMed]

74. Pritt, B.S.; Mead, P.S.; Johnson, D.K.H.; Neitzel, D.F.; Respicio-Kingry, L.B.; Davis, J.P.; Schiffman, E.; Sloan, L.M.; Schriefer, M.E.; Replogle, A.J.; et al. Identification of a novel pathogenic Borrelia species causing Lyme borreliosis with unusually high spirochaetaemia: A descriptive study. *Lancet Infect. Dis.* **2016**, *16*, 556–564. [CrossRef] [PubMed]

75. Siy, P.N.; Larson, R.T.; Zembsch, T.E.; Lee, X.; Paskewitz, S.M. High Prevalence of Borrelia mayonii (Spirochaetales: Spirochaetaceae) in Field-Caught Tamias striatus (Rodentia: Sciuridae) From Northern Wisconsin. *J. Med. Entomol.* **2021**, *58*, 2504–2507. [CrossRef] [PubMed]

76. Weck, B.C.; Serpa, M.C.A.; Labruna, M.B.; Munoz-Leal, S. A Novel Genospecies of Borrelia burgdorferi Sensu Lato Associated with Cricetid Rodents in Brazil. *Microorganisms* **2022**, *10*, 204. [CrossRef] [PubMed]

77. Sabitova, Y.; Rar, V.; Tikunov, A.; Yakimenko, V.; Korallo-Vinarskaya, N.; Livanova, N.; Tikunova, N. Detection and genetic characterization of a putative novel Borrelia genospecies in Ixodes apronophorus / Ixodes persulcatus / Ixodes trianguliceps sympatric areas in Western Siberia. *Ticks Tick-Borne Dis.* **2023**, *14*, 102075. [CrossRef] [PubMed]

78. Masuzawa, T.; Takada, N.; Kudeken, M.; Fukui, T.; Yano, Y.; Ishiguro, F.; Kawamura, Y.; Imai, Y.; Ezaki, T. Borrelia sinica sp. nov., a lyme disease-related Borrelia species isolated in China. *Int. J. Syst. Evol. Microbiol.* **2001**, *51*, 1817–1824. [CrossRef] [PubMed]

79. Wang, G.; van Dam, A.P.; Dankert, J. Phenotypic and genetic characterization of a novel Borrelia burgdorferi sensu lato isolate from a patient with lyme borreliosis. *J. Clin. Microbiol.* **1999**, *37*, 3025–3028. [CrossRef] [PubMed]

80. Richter, D.; Schlee, D.B.; Allgower, R.; Matuschka, F.R. Relationships of a novel Lyme disease spirochete, Borrelia spielmani sp. nov., with its hosts in Central Europe. *Appl. Environ. Microbiol.* **2004**, *70*, 6414–6419. [CrossRef]

81. Foldvari, G.; Farkas, R.; Lakos, A. Borrelia spielmanii erythema migrans, Hungary. *Emerg. Infect. Dis.* **2005**, *11*, 1794–1795. [CrossRef]

82. Richter, D.; Postic, D.; Sertour, N.; Livey, I.; Matuschka, F.R.; Baranton, G. Delineation of Borrelia burgdorferi sensu lato species by multilocus sequence analysis and confirmation of the delineation of Borrelia spielmanii sp. nov. *Int. J. Syst. Evol. Microbiol.* **2006**, *56*, 873–881. [CrossRef] [PubMed]

83. Hiraoka, H.; Shimada, Y.; Sakata, Y.; Watanabe, M.; Itamoto, K.; Okuda, M.; Masuzawa, T.; Inokuma, H. Detection of Borrelia garinii, Borrelia tanukii and Borrelia sp. closely related to Borrelia valaisiana in Ixodes ticks removed from dogs and cats in Japan. *Vet. Parasitol.* **2007**, *144*, 188–192. [CrossRef] [PubMed]

84. Norte, A.C.; Araujo, P.M.; da Silva, L.P.; Tenreiro, P.Q.; Ramos, J.A.; Nuncio, M.S.; Ze-Ze, L.; de Carvalho, I.L. Characterization Through Multilocus Sequence Analysis of Borrelia turdi Isolates from Portugal. *Microb. Ecol.* **2016**, *72*, 831–839. [CrossRef] [PubMed]

85. Fukunaga, M.; Hamase, A.; Okada, K.; Nakao, M. Borrelia tanukii sp. nov. and Borrelia turdae sp. nov. found from ixodid ticks in Japan: Rapid species identification by 16S rRNA gene-targeted PCR analysis. *Microbiol. Immunol.* **1996**, *40*, 877–881. [CrossRef] [PubMed]
86. Fukunaga, M.; Hamase, A.; Okada, K.; Inoue, H.; Tsuruta, Y.; Miyamoto, K.; Nakao, M. Characterization of spirochetes isolated from ticks (Ixodes tanuki, Ixodes turdus, and Ixodes columnae) and comparison of the sequences with those of Borrelia burgdorferi sensu lato strains. *Appl. Environ. Microbiol.* **1996**, *62*, 2338–2344. [CrossRef] [PubMed]

87. Palomar, A.M.; Portillo, A.; Santibanez, P.; Mazuelas, D.; Roncero, L.; Gutierrez, O.; Oteo, J.A. Presence of Borrelia turdi and Borrelia valaisiana (Spirochaetales: Spirochaetaceae) in Ticks Removed From Birds in the North of Spain, 2009–2011. *J. Med. Entomol.* **2017**, *54*, 243–246. [CrossRef] [PubMed]

88. Masuzawa, T.; Pan, M.J.; Kadosaka, T.; Kudeken, M.; Takada, N.; Yano, Y.; Imai, Y.; Yanagihara, Y. Characterization and identification of Borrelia isolates as Borrelia valaisiana in Taiwan and Kinmen Islands. *Microbiol. Immunol.* **2000**, *44*, 1003–1009. [CrossRef] [PubMed]

89. Hanincova, K.; Taragelova, V.; Koci, J.; Schafer, S.M.; Hails, R.; Ullmann, A.J.; Piesman, J.; Labuda, M.; Kurtenbach, K. Association of Borrelia garinii and B. valaisiana with songbirds in Slovakia. *Appl. Environ. Microbiol.* **2003**, *69*, 2825–2830. [CrossRef] [PubMed]

90. Stanek, G.; Reiter, M. The expanding Lyme Borrelia complex—Clinical significance of genomic species? *Clin. Microbiol. Infect.* **2011**, *17*, 487–493. [CrossRef]

91. Wang, G.; van Dam, A.P.; Le Fleche, A.; Postic, D.; Peter, O.; Baranton, G.; de Boer, R.; Spanjaard, L.; Dankert, J. Genetic and phenotypic analysis of Borrelia valaisiana sp. nov. (Borrelia genomic groups VS116 and M19). *Int. J. Syst. Bacteriol.* **1997**, *47*, 926–932. [CrossRef]

92. Margos, G.; Sing, A.; Fingerle, V. Published data do not support the notion that Borrelia valaisiana is human pathogenic. *Infection* **2017**, *45*, 567–569. [CrossRef]

93. Yun, S.M.; Lee, W.G.; Ryou, J.; Yang, S.C.; Park, S.W.; Roh, J.Y.; Lee, Y.J.; Park, C.; Han, M.G. Severe fever with thrombocytopenia syndrome virus in ticks collected from humans, South Korea, 2013. *Emerg. Infect. Dis.* **2014**, *20*, 1358–1361. [CrossRef] [PubMed]

94. Tanskul, P.; Stark, H.E.; Inlao, I. A checklist of ticks of Thailand (Acari: Metastigmata: Ixodoidea). *J. Med. Entomol.* **1983**, *20*, 330–341. [CrossRef]

95. Lau, A.C.C.; Qiu, Y.; Moustafa, M.A.M.; Nakao, R.; Shimozuru, M.; Onuma, M.; Mohd-Azlan, J.; Tsubota, T. Detection of Borrelia burgdorferi Sensu Lato and Relapsing Fever Borrelia in Feeding Ixodes Ticks and Rodents in Sarawak, Malaysia: New Geographical Records of *Borrelia yangtzensis* and *Borrelia miyamotoi*. *Pathogens* **2020**, *9*, 8460. [CrossRef]

96. Margos, G.; Chu, C.Y.; Takano, A.; Jiang, B.G.; Liu, W.; Kurtenbach, K.; Masuzawa, T.; Fingerle, V.; Cao, W.C.; Kawabata, H. *Borrelia yangtzensis* sp. nov., a rodent-associated species in Asia, is related to Borrelia valaisiana. *Int. J. Syst. Evol. Microbiol.* **2015**, *65*, 3836–3840. [CrossRef]

97. Chu, C.Y.; Liu, W.; Jiang, B.G.; Wang, D.M.; Jiang, W.J.; Zhao, Q.M.; Zhang, P.H.; Wang, Z.X.; Tang, G.P.; Yang, H.; et al. Novel genospecies of *Borrelia burgdorferi* sensu lato from rodents and ticks in southwestern China. *J. Clin. Microbiol.* **2008**, *46*, 3130–3133. [CrossRef] [PubMed]

98. Trevisan, G.; Cinco, M.; Trevisini, S.; di Meo, N.; Ruscio, M.; Forgione, P.; Bonin, S. Borreliae Part 2: Borrelia Relapsing Fever Group and Unclassified Borrelia. *Biology* **2021**, *10*, 1117. [CrossRef]

99. Talagrand-Reboul, E.; Boyer, P.H.; Bergstrom, S.; Vial, L.; Boulanger, N. Relapsing Fevers: Neglected Tick-Borne Diseases. *Front. Cell Infect. Microbiol.* **2018**, *8*, 98. [CrossRef] [PubMed]

100. Lopez, J.; Hovius, J.W.; Bergstrom, S. Pathogenesis of Relapsing Fever. *Curr. Issues Mol. Biol.* **2021**, *42*, 519–550. [CrossRef]

101. Zahid, H.; Alouffi, A.; Almutairi, M.M.; Ateeq, M.; Tanaka, T.; Chang, S.C.; Chen, C.C.; Ali, A. Argas persicus and Carios vespertilionis Ticks Infesting Ducks, Domestic Fowls and Bats in Pakistan: First Report on Molecular Survey and Phylogenetic Position of Borrelia anserina. *Vet. Sci.* **2023**, *10*, 628. [CrossRef]

102. Cadavid, D.; Barbour, A.G. Neuroborreliosis during relapsing fever: Review of the clinical manifestations, pathology, and treatment of infections in humans and experimental animals. *Clin. Infect. Dis.* **1998**, *26*, 151–164. [CrossRef]

103. Fotso Fotso, A.; Angelakis, E.; Mouffok, N.; Drancourt, M.; Raoult, D. Blood-Borne Candidatus Borrelia algerica in a Patient with Prolonged Fever in Oran, Algeria. *Am. J. Trop. Med. Hyg.* **2015**, *93*, 1070–1073. [CrossRef] [PubMed]

104. Kandelaki; Maruashvili, G.M. On the tick borne relapsing fever. *Meditsinskaya Parazitol. Parazit. Bolezn.* **1945**, *14*, 24–27.

105. Skerman, V.B.D.; McGowan, V.; Sneath, P.H.A. Approved Lists of Bacterial Names. *Int. J. Syst. Bacteriol.* **1980**, *30*, 225–420. [CrossRef]

106. Filatov, S.; Krishnavajhala, A.; Armstrong, B.A.; Kneubehl, A.R.; Nieto, N.C.; Perez De Leon, A.A.; Lopez, J.E. Isolation and Molecular Characterization of Tick-Borne Relapsing Fever Borrelia Infecting Ornithodoros (Pavlovskyella) verrucosus Ticks Collected in Ukraine. *J. Infect. Dis.* **2020**, *221*, 804–811. [CrossRef] [PubMed]

107. Felsenfeld, O. Borreliae, Human Relapsing Fever, and Parasite-Vector-Host Relationships. *Bacteriol. Rev.* **1965**, *29*, 46–74. [CrossRef] [PubMed]

108. Leger, A. Spirochaete of the Shrew (Crocidura stampflii, Jentink.). *Bull. Société Pathol. Exot.* **1917**, *10*, 280–281.

109. Novy, F.G.; Knapp, R.E. Studies on Spirillum Obermeierii and Related Organisms. *J. Infect. Dis.* **1906**, *3*, 291–393. [CrossRef]

110. Bergey, D.H.; Harrison, F.C.; Breed, R.S.; Hammer, B.W.; Huntoon, F.M. (Eds) *Bergey's Manual of Determinative Bacteriology*; Lippincott Williams & Wilkins: Philadelphia, PA, USA, 1925.

111. Heisch, R.B. On a spirochaete isolated from ornithodoros graingeri. *Parasitology* **1953**, *43*, 133–135. [CrossRef]

112. Parola, P.; Raoult, D. Ticks and tickborne bacterial diseases in humans: An emerging infectious threat. *Clin. Infect. Dis.* **2001**, *32*, 897–928. [CrossRef]

113. Garnham, P.C. A new blood spirochaete in the grivet monkey; Ceropithecus aethiops. *East. Afr. Med. J.* **1947**, *24*, 47–51.
114. Davis, G.E. The spirochetes. *Annu. Rev. Microbiol.* **1948**, *2*, 305–334. [CrossRef] [PubMed]

115. de Buen, S. Note préliminaire sur l'épidémiologie de la fièvre récurrente espagnole. *Ann. Parasitol. Hum. Comparée* **1926**, *4*, 185-192. [CrossRef]

116. Fingerle, V.; Pritsch, M.; Wachtler, M.; Margos, G.; Ruske, S.; Jung, J.; Loscher, T.; Wendtner, C.; Wieser, A. "Candidatus *Borrelia kalaharica*" Detected from a Febrile Traveller Returning to Germany from Vacation in Southern Africa. *PLoS Negl. Trop. Dis.* **2016**, *10*, e0004559. [CrossRef] [PubMed]

117. Sofiev, M. Spirochaeta latyshewi n. sp. of the Recurrens Group. *Med. Parasitol. Mosc.* **1941**, *10*, 267-271.

118. Hougen, K.H. Electron microscopy of Borrelia merionesi and Borrelia recurrentis. *Acta Pathol. Microbiol. Scand. B Microbiol. Immunol.* **1974**, *82*, 799-809. [CrossRef]

119. Rafyi, A. Spirochaeta microti n. sp., parasite du campagnol (*Microtus* sp.) en Iran. *Bull. Soc. Pathol. Exot. Fil.* **1947**, *40*, 149-151.

120. Naddaf, S.R.; Ghazinezhad, B.; Bahramali, G.; Cutler, S.J. Phylogenetic analysis of the spirochete Borrelia microti, a potential agent of relapsing fever in Iran. *J. Clin. Microbiol.* **2012**, *50*, 2873-2876. [CrossRef] [PubMed]

121. Masoumi Asl, H.; Goya, M.M.; Vatandoost, H.; Zahraei, S.M.; Mafi, M.; Asmar, M.; Piazak, N.; Aghighi, Z. The epidemiology of tick-borne relapsing fever in Iran during 1997-2006. *Travel Med. Infect. Dis.* **2009**, *7*, 160-164. [CrossRef] [PubMed]

122. Dschunkowsky, E. Das Rückfallfieber in Persien. *Dtsch. Med. Wochenschr.* **1913**, *39*, 419-420. [CrossRef]

123. Zumpt, F.; Organ, D. Strains of spirochaetes isolated from Ornithodoros zumpti Heisch & Guggisberg, and from wild rats in the Cape Province. A preliminary note. *S. Afr. J. Lab. Clin. Med.* **1961**, *7*, 31-35.

124. Davis, G.E. Observations on the biology of the argasid tick, Ornithodoros brasiliensis Aragao, 1923; with the recovery of a spirochete, Borrelia brasiliensis, n. sp. *J. Parasitol.* **1952**, *38*, 473-476. [CrossRef] [PubMed]

125. Lopez, J.E.; Krishnavahjala, A.; Garcia, M.N.; Bermudez, S. Tick-Borne Relapsing Fever Spirochetes in the Americas. *Vet. Sci.* **2016**, *3*, 16. [CrossRef]

126. Nieto, N.C.; Teglas, M.B.; Stewart, K.M.; Wasley, T.; Wolff, P.L. Detection of relapsing fever spirochetes (*Borrelia hermsii* and *Borrelia coriaceae*) in free-ranging mule deer (*Odocoileus hemionus*) from Nevada, United States. *Vector Borne Zoonotic Dis.* **2012**, *12*, 99-105. [CrossRef] [PubMed]

127. Russell, C.; Johnson, R.C.; Burgdorfer, W.; Lane, R.S.; Barbour, A.G.; Hayes, S.F.; Hyde, F.W. *Borrelia coriaceae* sp. nov.: Putative Agent of Epizootic Bovine Abortion. *Int. J. Syst. Bacteriol.* **1987**, *37*, 72-74. [CrossRef]

128. Nieto, N.C.; Teglas, M.B. Relapsing fever group Borrelia in Southern California rodents. *J. Med. Entomol.* **2014**, *51*, 1029-1034. [CrossRef] [PubMed]

129. Mazzotti, L. A New Spirochaete of Relapsing Fever occurring in Mexico. *Rev. Inst. Salubr. Enferm. Trop.* **1949**, *10*, 277-281.

130. Davis, G.E. Species unity or plurality of the relapsing fever spiroehetes. *Publ. Amer. Assoc. Adv. Sci.* **1942**, *18*, 41-47.

131. Kingry, L.C.; Anacker, M.; Pritt, B.; Bjork, J.; Respicio-Kingry, L.; Liu, G.; Sheldon, S.; Boxrud, D.; Strain, A.; Oatman, S.; et al. Surveillance for and Discovery of Borrelia Species in US Patients Suspected of Tickborne Illness. *Clin. Infect. Dis.* **2018**, *66*, 1864-1871. [CrossRef]

132. Schwan, T.G.; Raffel, S.J.; Schrumpf, M.E.; Gill, J.S.; Piesman, J. Characterization of a novel relapsing fever spirochete in the midgut, coxal fluid, and salivary glands of the bat tick *Carios kelleyi*. *Vector Borne Zoonotic Dis.* **2009**, *9*, 643-647. [CrossRef]

133. Tang, T.; Zhu, Y.; Zhang, Y.Y.; Chen, J.J.; Tian, J.B.; Xu, Q.; Jiang, B.G.; Wang, G.L.; Golding, N.; Mehlman, M.L.; et al. The global distribution and the risk prediction of relapsing fever group Borrelia: A data review with modelling analysis. *Lancet Microbe* **2024**, *5*, e442-e451. [CrossRef]

134. Davis, G.E. A relapsing fever spirochete, *Borrelia mazzottii* (sp. nov.) from Mexico. *Am. J. Hyg.* **1956**, *63*, 13-17. [CrossRef]

135. Walker, R.L.; Read, D.H.; Hayes, D.C.; Nordhausen, R.W. Equine abortion associated with the Borrelia parkeri-B. turicatae tick-borne relapsing fever spirochete group. *J. Clin. Microbiol.* **2002**, *40*, 1558-1562. [CrossRef] [PubMed]

136. Brumpt, E. Étude du *Spirochaeta turicatae*, n. sp. agent de la fièvre récurrente sporadique des Etats-Unis transmis par Ornithodorus turicata. *Comptes Rendus Séances Société Biol.* **1933**, *113*, 1369-1372.

137. Brumpt, E. *Les Parasites des Invertébrés Hématophages*; Lavier, A., Ed.; Vigot Frères: Paris, France, 1921; Volume 207.

138. Barbour, A.G.; Maupin, G.O.; Teltow, G.J.; Carter, C.J.; Piesman, J. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: Possible agent of a Lyme disease-like illness. *J. Infect. Dis.* **1996**, *173*, 403-409. [CrossRef] [PubMed]

139. Castellaw, A.H.; Chenney, E.F.; Varela-Stokes, A.S. Tick-borne disease agents in various wildlife from Mississippi. *Vector Borne Zoonotic Dis.* **2011**, *11*, 439-442. [CrossRef] [PubMed]

140. Jordan, B.E.; Onks, K.R.; Hamilton, S.W.; Hayslette, S.E.; Wright, S.M. Detection of Borrelia burgdorferi and Borrelia lonestari in birds in Tennessee. *J. Med. Entomol.* **2009**, *46*, 131-138. [CrossRef] [PubMed]

141. Vazquez Guillamet, L.J.; Marx, G.E.; Benjamin, W.; Pappas, P.; Lieberman, N.A.P.; Bachiashvili, K.; Leal, S.; Lieberman, J.A. Relapsing Fever Caused by Borrelia lonestari after Tick Bite in Alabama, USA. *Emerg. Infect. Dis.* **2023**, *29*, 441-444. [CrossRef]

142. Abdelmaseih, R.; Ashraf, B.; Abdelmasih, R.; Dunn, S.; Nasser, H. Southern Tick-Associated Rash Illness: Florida's Lyme Disease Variant. *Cureus* **2021**, *13*, e15306. [CrossRef] [PubMed]

143. Fukunaga, M.; Takahashi, Y.; Tsuruta, Y.; Matsushita, O.; Ralph, D.; McClelland, M.; Nakao, M. Genetic and phenotypic analysis of Borrelia miyamotoi sp. nov., isolated from the ixodid tick *Ixodes persulcatus*, the vector for Lyme disease in Japan. *Int. J. Syst. Bacteriol.* **1995**, *45*, 804-810. [CrossRef] [PubMed]
144. Platonov, A.E.; Karan, L.S.; Kolyasnikova, N.M.; Makhneva, N.A.; Toporkova, M.G.; Maleev, V.V.; Fish, D.; Krause, P.J. Humans infected with relapsing fever spirochete Borrelia miyamotoi, Russia. *Emerg. Infect. Dis.* **2011**, *17*, 1816–1823. [CrossRef]

145. Wagemakers, A.; Jahfari, S.; de Wever, B.; Spanjaard, L.; Starink, M.V.; de Vries, H.J.C.; Sprong, H.; Hovius, J.W. Borrelia miyamotoi in vectors and hosts in The Netherlands. *Ticks Tick-Borne Dis.* **2017**, *8*, 370–374. [CrossRef]

146. Gugliotta, J.L.; Goethert, H.K.; Berardi, V.P.; Telford, S.R., 3rd. Meningoencephalitis from Borrelia miyamotoi in an immunocompromised patient. *N. Engl. J. Med.* **2013**, *368*, 240–245. [CrossRef] [PubMed]

147. Lin, T.; Gao, L.; Seyfang, A.; Oliver, J.H. 'Candidatus Borrelia texasensis', from the American dog tick Dermacentor variabilis. *Int. J. Syst. Evol. Microbiol.* **2005**, *55*, 685–693. [CrossRef] [PubMed]

148. Laveran, A. Sur la spirillose des bovidés. CR Acad. Sci. Paris **1903**, 136, 939-941.

149. Theiler, A. Transmission and inoculability of Spirillum Theileri (Laveran). Proc. R. Soc. Lond. B. **1905**, 76, 504–506. [CrossRef]

150. Sakharoff, M.N. Spirochaeta anserina et la septicémie des oies. *Ann. Inst. Pasteur.* **1891**, *5*, 564–566.

151. Fabbi, M.; Sambri, V.; Marangoni, A.; Magnino, S.; Solari Basano, F.; Cevenini, R.; Genchi, C. Borrelia in pigeons: No serological evidence of Borrelia burgdorferi infection. *Zentralbl. Vet. B* **1995**, *42*, 503–507. [CrossRef] [PubMed]

152. Hovind-Hougen, K. A morphological characterization of Borrelia anserina. *Microbiology (Reading)* **1995**, *141 Pt 1*, 79–83. [CrossRef] [PubMed]

153. Horefti, E. The Importance of the One Health Concept in Combating Zoonoses. *Pathogens* **2023**, *12*, 977. [CrossRef] [PubMed]

154. Dye, C. One Health as a catalyst for sustainable development. *Nat. Microbiol.* **2022**, *7*, 467–468. [CrossRef]

155. One Health High-Level Expert, P.; Adisasmito, W.B.; Almuhairi, S.; Behravesh, C.B.; Bilivogui, P.; Bukachi, S.A.; Casas, N.; Cediel Becerra, N.; Charron, D.F.; Chaudhary, A.; et al. One Health: A new definition for a sustainable and healthy future. *PLoS Pathog.* **2022**, *18*, e1010537. [CrossRef]

156. Radolf, J.D.; Strle, K.; Lemieux, J.E.; Strle, F. Lyme Disease in Humans. *Curr. Issues Mol. Biol.* **2021**, *42*, 333–384. [CrossRef]

157. Stanek, G.; Strle, F. Lyme borreliosis. Lancet **2003**, 362, 1639–1647. [CrossRef]

158. Steere, A.C. Lyme disease. *N. Engl. J. Med.* **1989**, *321*, 586–596. [CrossRef] [PubMed]

159. Kullberg, B.J.; Vrijmoeth, H.D.; van de Schoor, F.; Hovius, J.W. Lyme borreliosis: Diagnosis and management. *BMJ* **2020**, *369*, m1041. [CrossRef]

160. Huppertz, H.I.; Bohme, M.; Standaert, S.M.; Karch, H.; Plotkin, S.A. Incidence of Lyme borreliosis in the Würzburg region of Germany. *Eur. J. Clin. Microbiol. Infect. Dis. Off. Publ. Eur. Soc. Clin. Microbiol.* **1999**, *18*, 697–703. [CrossRef] [PubMed]

161. Steere, A.C.; Sikand, V.K. The presenting manifestations of Lyme disease and the outcomes of treatment. *N. Engl. J. Med.* **2003**, *348*, 2472–2474. [CrossRef] [PubMed]

162. Sanchez, J.L. Clinical Manifestations and Treatment of Lyme Disease. Clin. Lab. Med. **2015**, *35*, 765–778. [CrossRef]

163. Nadelman, R.B. Erythema migrans. *Infect. Dis. Clin. N. Am.* **2015**, *29*, 211–239. [CrossRef]

164. Smith, R.P.; Schoen, R.T.; Rahn, D.W.; Sikand, V.K.; Nowakowski, J.; Parenti, D.L.; Holman, M.S.; Persing, D.H.; Steere, A.C. Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans. *Ann. Intern. Med.* **2002**, *136*, 421–428. [CrossRef]

165. Wormser, G.P.; McKenna, D.; Carlin, J.; Nadelman, R.B.; Cavaliere, L.F.; Holmgren, D.; Byrne, D.W.; Nowakowski, J. Brief communication: Hematogenous dissemination in early Lyme disease. *Ann. Intern. Med.* **2005**, *142*, 751–755. [CrossRef] [PubMed]

166. Nadelman, R.B.; Nowakowski, J.; Forseter, G.; Goldberg, N.S.; Bittker, S.; Cooper, D.; Aguero-Rosenfeld, M.; Wormser, G.P. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. *Am. J. Med.* **1996**, *100*, 502–508. [CrossRef] [PubMed]

167. Steere, A.C.; Bartenhagen, N.H.; Craft, J.E.; Hutchinson, G.J.; Newman, J.H.; Rahn, D.W.; Sigal, L.H.; Spieler, P.N.; Stenn, K.S.; Malawista, S.E. The early clinical manifestations of Lyme disease. *Ann. Intern. Med.* **1983**, *99*, 76–82. [CrossRef] [PubMed]

168. Wormser, G.P.; Dattwyler, R.J.; Shapiro, E.D.; Halperin, J.J.; Steere, A.C.; Klempner, M.S.; Krause, P.J.; Bakken, J.S.; Strle, F.; Stanek, G.; et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America. *Clin. Infect. Dis.* **2006**, *43*, 1089–1134. [CrossRef] [PubMed]

169. Koedel, U.; Fingerle, V.; Pfister, H.W. Lyme neuroborreliosis-epidemiology, diagnosis and management. *Nat. Rev. Neurol.* **2015**, *11*, 446–456. [CrossRef] [PubMed]

170. Knudtzen, F.C.; Eikeland, R.; Bremell, D.; Quist-Paulsen, E.; Johansen, I.S.; Solheim, A.M.; Skarphedinsson, S. Lyme neuroborreliosis with encephalitis; a systematic literature review and a Scandinavian cohort study. *Clin. Microbiol. Infect. Off. Publ. Eur. Soc. Clin. Microbiol. Infect. Dis.* **2022**, *28*, 649–656. [CrossRef] [PubMed]

171. Lochhead, R.B.; Strle, K.; Arvikar, S.L.; Weis, J.J.; Steere, A.C. Lyme arthritis: Linking infection, inflammation and autoimmunity. *Nat. Rev. Rheumatol.* **2021**, *17*, 449–461. [CrossRef] [PubMed]

172. Forrester, J.D.; Meiman, J.; Mullins, J.; Nelson, R.; Ertel, S.H.; Carter, M.; Brown, C.M.; Lijewski, V.; Schiffman, E.; Neitzel, D.; et al. Notes from the field: Update on Lyme carditis, groups at high risk, and frequency of associated sudden cardiac death—United States. MMWR Morb. Mortal. Wkly. Rep. **2014**, *63*, 982–983. [PubMed]

173. Stanek, G.; Klein, J.; Bittner, R.; Glogar, D. Isolation of Borrelia burgdorferi from the myocardium of a patient with longstanding cardiomyopathy. *N. Engl. J. Med.* **1990**, *322*, 249–252. [CrossRef]

174. Bobe, J.R.; Jutras, B.L.; Horn, E.J.; Embers, M.E.; Bailey, A.; Moritz, R.L.; Zhang, Y.; Soloski, M.J.; Ostfeld, R.S.; Marconi, R.T.; et al. Recent Progress in Lyme Disease and Remaining Challenges. *Front. Med.* **2021**, *8*, 666554. [CrossRef]
175. Motamed, M.; Liblik, K.; Miranda-Arboleda, A.F.; Wamboldt, R.; Wang, C.N.; Cingolani, O.; Rebman, A.W.; Novak, C.B.; Aucott, J.N.; Farina, J.M.; et al. Disseminated Lyme disease and dilated cardiomyopathy: A systematic review. *Trends Cardiovasc. Med.* **2023**, *33*, 531–536. [CrossRef] [PubMed]

176. Hubalek, Z. Epidemiology of lyme borreliosis. *Curr. Probl. Dermatol.* **2009**, *37*, 31–50. [CrossRef] [PubMed]

177. Sykes, R.A.; Makiello, P. An estimate of Lyme borreliosis incidence in Western Europedagger. *J. Public Health* **2017**, *39*, 74–81. [CrossRef] [PubMed]

178. Ai, C.X.; Zhang, W.F.; Zhao, J.H. Sero-epidemiology of Lyme disease in an endemic area in China. *Microbiol. Immunol.* **1994**, *38*, 505–509. [CrossRef] [PubMed]

179. von Fricken, M.E.; Rolomjav, L.; Illar, M.; Altantogtokh, D.; Hogan, K.M.; Uyanga, B.; Ganbold, D.; Tsogbadrakh, N. Geographic Range of Lyme Borreliosis in Mongolia. *Vector Borne Zoonotic Dis.* **2019**, *19*, 658–661. [CrossRef] [PubMed]

180. Schwartz, A.M.; Hinckley, A.F.; Mead, P.S.; Hook, S.A.; Kugeler, K.J. Surveillance for Lyme Disease—United States, 2008–2015. *MMWR Surveill. Summ.* **2017**, *66*, 1–12. [CrossRef] [PubMed]

181. Kugeler, K.J.; Farley, G.M.; Forrester, J.D.; Mead, P.S. Geographic Distribution and Expansion of Human Lyme Disease, United States. *Emerg. Infect. Dis.* **2015**, *21*, 1455–1457. [CrossRef] [PubMed]

182. Gasmi, S.; Ogden, N.H.; Ripoche, M.; Leighton, P.A.; Lindsay, R.L.; Nelder, M.P.; Rees, E.; Bouchard, C.; Vrbova, L.; Rusk, R.; et al. Detection of municipalities at-risk of Lyme disease using passive surveillance of Ixodes scapularis as an early signal: A province-specific indicator in Canada. *PLoS ONE* **2019**, *14*, e0212637. [CrossRef] [PubMed]

183. Medlock, J.M.; Hansford, K.M.; Bormane, A.; Derdakova, M.; Estrada-Pena, A.; George, J.C.; Golovljova, I.; Jaenson, T.G.; Jensen, J.K.; Jensen, P.M.; et al. Driving forces for changes in geographical distribution of Ixodes ricinus ticks in Europe. *Parasit Vectors* **2013**, *6*, 1–11. [CrossRef] [PubMed]

184. Smith, R.; Takkinen, J. Lyme borreliosis: Europe-wide coordinated surveillance and action needed? *Wkly. Releases* **2006**, *11*, 2977. [CrossRef]

185. Semenza, J.C.; Suk, J.E. Vector-borne diseases and climate change: A European perspective. *FEMS Microbiol. Lett.* **2018**, *365*, fnx244. [CrossRef]

186. Piesman, J.; Gern, L. Lyme borreliosis in Europe and North America. *Parasitology* **2004**, *129*, S191–S220. [CrossRef]

187. Maggi, R.G.; Reichelt, S.; Toliver, M.; Engber, B. Borrelia species in Ixodes affinis and Ixodes scapularis ticks collected from the coastal plain of North Carolina. *Ticks Tick-Borne Dis.* **2010**, *1*, 168–171. [CrossRef] [PubMed]

188. Stark, J.H.; Li, X.; Zhang, J.C.; Burn, L.; Valluri, S.R.; Liang, J.; Pan, K.; Fletcher, M.A.; Simon, R.; Jodar, L.; et al. Systematic Review and Meta-analysis of Lyme Disease Data and Seropositivity for Borrelia burgdorferi, China, 2005–2020. *Emerg. Infect. Dis.* **2022**, *28*, 2389–2397. [CrossRef]

189. Eisen, L.; Eisen, R.J. Critical Evaluation of the Linkage Between Tick-Based Risk Measures and the Occurrence of Lyme Disease Cases. *J. Med. Entomol.* **2016**, *53*, 1050–1062. [CrossRef] [PubMed]

190. Piesman, J.; Schneider, B.S.; Zeidner, N.S. Use of quantitative PCR to measure density of Borrelia burgdorferi in the midgut and salivary glands of feeding tick vectors. *J. Clin. Microbiol.* **2001**, *39*, 4145–4148. [CrossRef]

191. des Vignes, F.; Piesman, J.; Heffernan, R.; Schulze, T.L.; Stafford, K.C., 3rd; Fish, D. Effect of tick removal on transmission of Borrelia burgdorferi and Ehrlichia phagocytophila by Ixodes scapularis nymphs. *J. Infect. Dis.* **2001**, *183*, 773–778. [CrossRef] [PubMed]

192. Mannelli, A.; Bertolotti, L.; Gern, L.; Gray, J. Ecology of Borrelia burgdorferi sensu lato in Europe: Transmission dynamics in multi-host systems, influence of molecular processes and effects of climate change. *FEMS Microbiol. Rev.* **2012**, *36*, 837–861. [CrossRef]

193. Stanek, G.; Strle, F. Lyme borreliosis-from tick bite to diagnosis and treatment. *FEMS Microbiol. Rev.* **2018**, *42*, 233–258. [CrossRef]

194. Rollend, L.; Fish, D.; Childs, J.E. Transovarial transmission of Borrelia spirochetes by Ixodes scapularis: A summary of the literature and recent observations. *Ticks Tick-Borne Dis.* **2013**, *4*, 46–51. [CrossRef]

195. Markowitz, L.E.; Steere, A.C.; Benach, J.L.; Slade, J.D.; Broome, C.V. Lyme disease during pregnancy. *JAMA* **1986**, *255*, 3394–3396. [CrossRef] [PubMed]

196. Diaz, P.; Arnal, J.L.; Remesar, S.; Perez-Creo, A.; Venzal, J.M.; Vazquez-Lopez, M.E.; Prieto, A.; Fernandez, G.; Lopez, C.M.; Panadero, R.; et al. Molecular identification of Borrelia spirochetes in questing Ixodes ricinus from northwestern Spain. *Parasit Vectors* **2017**, *10*, 615. [CrossRef] [PubMed]

197. Remesar, S.; Matute, R.; Diaz, P.; Martinez-Calabuig, N.; Prieto, A.; Diaz-Cao, J.M.; Lopez-Lorenzo, G.; Fernandez, G.; Lopez, C.; Panadero, R.; et al. Tick-borne pathogens in ticks from urban and suburban areas of north-western Spain: Importance of Ixodes frontalis harbouring zoonotic pathogens. *Med. Vet. Entomol.* **2023**, *37*, 499–510. [CrossRef] [PubMed]

198. Diaz-Cao, J.M.; Adaszek, L.; Dziegiel, B.; Paniagua, J.; Caballero-Gomez, J.; Winiarczyk, S.; Winiarczyk, D.; Cano-Terriza, D.; Garcia-Bocanegra, I. Prevalence of selected tick-borne pathogens in wild ungulates and ticks in southern Spain. *Transbound. Emerg. Dis.* **2022**, *69*, 1084–1094. [CrossRef] [PubMed]

199. Espi, A.; Del Cerro, A.; Somoano, A.; Garcia, V.; Prieto, J.M.; Barandika, J.F.; Garcia-Perez, A.L. Borrelia burgdorferi sensu lato prevalence and diversity in ticks and small mammals in a Lyme borreliosis endemic Nature Reserve in North-Western Spain. Incidence in surrounding human populations. *Enferm. Infect. Microbiol. Clin.* **2017**, *35*, 563–568. [CrossRef] [PubMed]
200. Del Cerro, A.; Oleaga, A.; Somoano, A.; Barandika, J.F.; Garcia-Perez, A.L.; Espi, A. Molecular identification of tick-borne pathogens (*Rickettsia* spp., *Anaplasma phagocytophilum*, *Borrelia burgdorferi* sensu lato, *Coxiella burnetii* and piroplasms) in questing and feeding hard ticks from North-Western Spain. *Ticks Tick-Borne Dis.* **2022**, *13*, 101961. [CrossRef] [PubMed]

201. Lledo, L.; Gegundez, M.I.; Gimenez-Pardo, C.; Alamo, R.; Fernandez-Soto, P.; Nuncio, M.S.; Saz, J.V. A seventeen-year epidemiological surveillance study of Borrelia burgdorferi infections in two provinces of northern Spain. *Int. J. Environ. Res. Public Health* **2014**, *11*, 1661–1672. [CrossRef] [PubMed]

202. Marchant, A.; Le Coupanec, A.; Joly, C.; Perthame, E.; Sertour, N.; Garnier, M.; Godard, V.; Ferquel, E.; Choumet, V. Infection of Ixodes ricinus by Borrelia burgdorferi sensu lato in peri-urban forests of France. *PLoS ONE* **2017**, *12*, e0183543. [CrossRef]

203. Cotte, V.; Bonnet, S.; Cote, M.; Vayssier-Taussat, M. Prevalence of five pathogenic agents in questing Ixodes ricinus ticks from western France. *Vector Borne Zoonotic Dis.* **2010**, *10*, 723–730. [CrossRef]

204. Aubry, C.; Socolovschi, C.; Raoult, D.; Parola, P. Bacterial agents in 248 ticks removed from people from 2002 to 2013. *Ticks Tick-Borne Dis.* **2016**, *7*, 475–481. [CrossRef]

205. Rataud, A.; Galon, C.; Bournez, L.; Henry, P.Y.; Marsot, M.; Moutailler, S. Diversity of Tick-Borne Pathogens in Tick Larvae Feeding on Breeding Birds in France. *Pathogens* **2022**, *11*, 946. [CrossRef] [PubMed]

206. Cicculi, V.; Capai, L.; Quilichini, Y.; Masse, S.; Fernandez-Alvarez, A.; Minodier, L.; Bompard, P.; Charrel, R.; Falchi, A. Molecular investigation of tick-borne pathogens in ixodid ticks infesting domestic animals (cattle and sheep) and small rodents (black rats) of Corsica, France. *Ticks Tick-Borne Dis.* **2019**, *10*, 606–613. [CrossRef] [PubMed]

207. Bonnet, S.; de la Fuente, J.; Nicollet, P.; Liu, X.; Madani, N.; Blanchard, B.; Maingourd, C.; Alongi, A.; Torina, A.; Fernandez de Mera, I.G.; et al. Prevalence of tick-borne pathogens in adult Dermacentor spp. ticks from nine collection sites in France. *Vector Borne Zoonotic Dis.* **2013**, *13*, 226–236. [CrossRef] [PubMed]

208. Pistone, D.; Pajoro, M.; Novakova, E.; Vicari, N.; Gaiardelli, C.; Vigano, R.; Luzzago, C.; Montagna, M.; Lanfranchi, P. Ticks and bacterial tick-borne pathogens in Piemonte region, Northwest Italy. *Exp. Appl. Acarol.* **2017**, *73*, 477–491. [CrossRef] [PubMed]

209. Ragagli, C.; Mannelli, A.; Ambrogi, C.; Bisanzio, D.; Ceballos, L.A.; Grego, E.; Martello, E.; Selmi, M.; Tomassone, L. Presence of host-seeking Ixodes ricinus and their infection with Borrelia burgdorferi sensu lato in the Northern Apennines, Italy. *Exp. Appl. Acarol.* **2016**, *69*, 167–178. [CrossRef] [PubMed]

210. Audino, T.; Pautasso, A.; Bellavia, V.; Carta, V.; Ferrari, A.; Verna, F.; Grattarola, C.; Iulini, B.; Pintore, M.D.; Bardelli, M.; et al. Ticks infesting humans and associated pathogens: A cross-sectional study in a 3-year period (2017–2019) in northwest Italy. *Parasit Vectors* **2021**, *14*, 136. [CrossRef]

211. Tomassone, L.; Grego, E.; Auricchio, D.; Iori, A.; Giannini, F.; Rambozzi, L. Lyme borreliosis spirochetes and spotted fever group rickettsiae in ixodid ticks from Pianosa island, Tuscany Archipelago, Italy. *Vector Borne Zoonotic Dis.* **2013**, *13*, 84–91. [CrossRef]

212. Rollins, R.E.; Schaper, S.; Kahlhofer, C.; Frangoulidis, D.; Strauss, A.F.T.; Cardinale, M.; Springer, A.; Strube, C.; Bakkes, D.K.; Becker, N.S.; et al. Ticks (Acari: Ixodidae) on birds migrating to the island of Ponza, Italy, and the tick-borne pathogens they carry. *Ticks Tick-Borne Dis.* **2021**, *12*, 101590. [CrossRef]

213. Susnjar, J.; Cerar Kisek, T.; Strasek Smrdel, K.; Ruzic-Sabljic, E.; Adam, K.; Ivovic, V. Detection, identification and genotyping of Borrelia spp. in ticks of Coastal-Karst and Littoral-Inner Carniola regions in Slovenia. *Folia Parasitol.* **2023**, *70*, 007. [CrossRef]

214. Norte, A.C.; Margos, G.; Becker, N.S.; Albino Ramos, J.; Nuncio, M.S.; Fingerle, V.; Araujo, P.M.; Adamik, P.; Alivizatos, H.; Barba, E.; et al. Host dispersal shapes the population structure of a tick-borne bacterial pathogen. *Mol. Ecol.* **2020**, *29*, 485–501. [CrossRef]

215. Rijpkema, S.; Golubic, D.; Molkenboer, M.; Verbeek-De Kruif, N.; Schellekens, J. Identification of four genomic groups of Borrelia burgdorferi sensu lato in Ixodes ricinus ticks collected in a Lyme borreliosis endemic region of northern Croatia. *Exp. Appl. Acarol.* **1996**, *20*, 23–30. [CrossRef] [PubMed]

216. Norte, A.C.; Boyer, P.H.; Castillo-Ramirez, S.; Chvostac, M.; Brahami, M.O.; Rollins, R.E.; Woudenberg, T.; Didyk, Y.M.; Derdakova, M.; Nuncio, M.S.; et al. The Population Structure of Borrelia lusitaniae Is Reflected by a Population Division of Its Ixodes Vector. *Microorganisms* **2021**, *9*, 933. [CrossRef] [PubMed]

217. Guner, E.S.; Hashimoto, N.; Takada, N.; Kaneda, K.; Imai, Y.; Masuzawa, T. First isolation and characterization of Borrelia burgdorferi sensu lato strains from Ixodes ricinus ticks in Turkey. *J. Med. Microbiol.* **2003**, *52*, 807–813. [CrossRef] [PubMed]

218. Orkun, O.; Cakmak, A. Molecular identification of tick-borne bacteria in wild animals and their ticks in Central Anatolia, Turkey. *Comp. Immunol. Microbiol. Infect. Dis.* **2019**, *63*, 58–65. [CrossRef] [PubMed]

219. Orkun, O.; Karaer, Z.; Cakmak, A.; Nalbantoglu, S. Identification of tick-borne pathogens in ticks feeding on humans in Turkey. *PLoS Negl. Trop. Dis.* **2014**, *8*, e3067. [CrossRef] [PubMed]

220. Polat, E.; Altinkum, S.M.; Bagdatli, Y.; Baykara, O. The tick fauna in Istanbul, Turkey, from 2013 to 2017 and identification of their pathogens by multiplex PCR: An epidemiological study. *Exp. Appl. Acarol.* **2021**, *84*, 825–834. [CrossRef] [PubMed]

221. Ashour, R.; Hamza, D.; Kadry, M.; Sabry, M.A. The Surveillance of Borrelia Species in Camelus dromedarius and Associated Ticks: The First Detection of Borrelia miyamotoi in Egypt. *Vet. Sci.* **2023**, *10*, 141. [CrossRef] [PubMed]

222. Elhelw, R.A.; El-Enbaawy, M.I.; Samir, A. Lyme borreliosis: A neglected zoonosis in Egypt. *Acta Trop.* **2014**, *140*, 188–192. [CrossRef] [PubMed]

223. Younsi, H.; Postic, D.; Baranton, G.; Bouattour, A. High prevalence of *Borrelia lusitaniae* in Ixodes ricinus ticks in Tunisia. *Eur. J. Epidemiol.* **2001**, *17*, 53–56. [CrossRef]

224. Younsi, H.; Sarih, M.; Jouda, F.; Godfroid, E.; Gern, L.; Bouattour, A.; Baranton, G.; Postic, D. Characterization of Borrelia lusitaniae isolates collected in Tunisia and Morocco. *J. Clin. Microbiol.* **2005**, *43*, 1587–1593. [CrossRef]
225. Benredjem, W.; Leulmi, H.; Bitam, I.; Raoult, D.; Parola, P. Borrelia garinii and Rickettsia monacensis inIxodes ricinus ticks, Algeria. *Emerg. Infect. Dis.* **2014**, *20*, 1776-1777. [CrossRef] [PubMed]

226. Sarih, M.; Jouda, F.; Gern, L.; Postic, D. First isolation of Borrelia burgdorferi sensu lato fromIxodes ricinus ticks in Morocco. *Vector Borne Zoonotic Dis.* **2003**, *3*, 133-139. [CrossRef] [PubMed]

227. LoGiudice, K.; Ostfeld, R.S.; Schmidt, K.A.; Keesing, F. The ecology of infectious disease: Effects of host diversity and community composition on Lyme disease risk. *Proc. Natl. Acad. Sci. USA* **2003**, *100*, 567-571. [CrossRef] [PubMed]

228. Gern, L.; Estrada-Pena, A.; Frandsen, F.; Gray, J.S.; Jaenson, T.G.; Jongejan, F.; Kahl, O.; Korenberg, E.; Mehl, R.; Nuttall, P.A. European reservoir hosts of Borrelia burgdorferi sensu lato. *Zentralbl Bakteriol.* **1998**, *287*, 196-204. [CrossRef] [PubMed]

229. Margos, G.; Vollmer, S.A.; Ogden, N.H.; Fish, D. Population genetics, taxonomy, phylogeny and evolution of Borrelia burgdorferi sensu lato. *Infect. Genet. Evol.* **2011**, *11*, 1545-1563. [CrossRef] [PubMed]

230. Craine, N.G.; Nuttall, P.A.; Marriott, A.C.; Randolph, S.E. Role of grey squirrels and pheasants in the transmission of *Borrelia burgdorferi* sensu lato, the Lyme disease spirochaete, in the U.K. *Folia Parasitol.* **1997**, *44*, 155-160.

231. Slajchert, T.; Kitron, U.D.; Jones, C.J.; Mannelli, A. Role of the eastern chipmunk (*Tamias striatus*) in the epizootiology of Lyme borreliosis in northwestern Illinois, USA. *J. Wildl. Dis.* **1997**, *33*, 40-46. [CrossRef] [PubMed]

232. Donahue, J.G.; Piesman, J.; Spielman, A. Reservoir competence of white-footed mice for Lyme disease spirochetes. *Am. J. Trop. Med. Hyg.* **1987**, *36*, 92-96. [CrossRef] [PubMed]

233. Saint Girons, I.; Gern, L.; Gray, J.S.; Guy, E.C.; Korenberg, E.; Nuttall, P.A.; Rijpkema, S.G.; Schonberg, A.; Stanek, G.; Postic, D. Identification of Borrelia burgdorferi sensu lato species in Europe. *Zentralbl Bakteriol.* **1998**, *287*, 190-195. [CrossRef]

234. Skarphedinsson, S.; Jensen, P.M.; Kristiansen, K. Survey of tickborne infections in Denmark. *Emerg. Infect. Dis.* **2005**, *11*, 1055-1061. [CrossRef]

235. Jaenson, T.G.; Talleklint, L. Incompetence of roe deer as reservoirs of the Lyme borreliosis spirochete. *J. Med. Entomol.* **1992**, *29*, 813-817. [CrossRef] [PubMed]

236. Roome, A.; Hill, L.; Al-Feghali, V.; Murnock, C.G.; Goodsell, J.A.; Spathis, R.; Garruto, R.M. Impact of white-tailed deer on the spread of Borrelia burgdorferi. *Med. Vet. Entomol.* **2017**, *31*, 1-5. [CrossRef] [PubMed]

237. Rand, P.W.; Lubelczyk, C.; Lavigne, G.R.; Elias, S.; Holman, M.S.; Lacombe, E.H.; Smith, R.P., Jr. Deer density and the abundance of Ixodes scapularis (Acari: Ixodidae). *J. Med. Entomol.* **2003**, *40*, 179-184. [CrossRef] [PubMed]

238. Delgado, S.; Carmenes, P. Seroepidemiological survey for Borrelia burgdorferi (Lyme disease) in dogs from northwestern of Spain. *Eur. J. Epidemiol.* **1995**, *11*, 321-324. [CrossRef] [PubMed]

239. Lledo, L.; Serrano, J.L.; Isabel Gegundez, M.; Gimenez-Pardo, C.; Saz, J.V. Antibodies to Rickettsia spp. and Borrelia burgdorferi in Spanish Wild Red Foxes (*Vulpes vulpes*). *J. Wildl. Dis.* **2016**, *52*, 122-125. [CrossRef] [PubMed]

240. Sobrino, R.; Gortazar, C. Seroprevalence of antibodies to Borrelia burgdorferi in wild canids in Spain. *Vet. Rec.* **2008**, *162*, 248-249. [CrossRef] [PubMed]

241. Ortuno, A.; Castella, J.; Marco, I.; Ruiz, M.; Lavin, S. Prevalence of antibodies to Borrelia burgdorferi sensu lato in southern chamois (Rupicapra pyrenaica) in Spain. *J. Vet. Med. B Infect. Dis. Vet. Public. Health* **2003**, *50*, 253-254. [CrossRef] [PubMed]

242. Marsot, M.; Chapuis, J.L.; Gasqui, P.; Dozieres, A.; Masseglia, S.; Pisanu, B.; Ferquel, E.; Vourc'h, G. Introduced Siberian chipmunks (*Tamias sibiricus* barberi) contribute more to lyme borreliosis risk than native reservoir rodents. *PLoS ONE* **2013**, *8*, e55377. [CrossRef]

243. Vourc'h, G.; Marmet, J.; Chassagne, M.; Bord, S.; Chapuis, J.L. Borrelia burgdorferi Sensu Lato in Siberian chipmunks (*Tamias sibiricus*) introduced in suburban forests in France. *Vector Borne Zoonotic Dis.* **2007**, *7*, 637-641. [CrossRef]

244. Marsot, M.; Sigaud, M.; Chapuis, J.L.; Ferquel, E.; Cornet, M.; Vourc'h, G. Introduced Siberian chipmunks (*Tamias sibiricus* barberi) harbor more-diverse Borrelia burgdorferi sensu lato genospecies than native bank voles (*Myodes glareolus*). *Appl. Environ. Microbiol.* **2011**, *77*, 5716-5721. [CrossRef]

245. Jacquot, M.; Bisseux, M.; Abrial, D.; Marsot, M.; Ferquel, E.; Chapuis, J.L.; Vourc'h, G.; Bailly, X. High-throughput sequence typing reveals genetic differentiation and host specialization among populations of the Borrelia burgdorferi species complex that infect rodents. *PLoS ONE* **2014**, *9*, e88581. [CrossRef] [PubMed]

246. Pisanu, B.; Chapuis, J.L.; Dozieres, A.; Basset, F.; Poux, V.; Vourc'h, G. High prevalence of Borrelia burgdorferi s.l. in the European red squirrel Sciurus vulgaris in France. *Ticks Tick-Borne Dis.* **2014**, *5*, 1-6. [CrossRef] [PubMed]

247. Pantchev, N.; Schaper, R.; Limousin, S.; Norden, N.; Weise, M.; Lorentzen, L. Occurrence of Dirofilaria immitis and tick-borne infections caused by Anaplasma phagocytophilum, Borrelia burgdorferi sensu lato and Ehrlichia canis in domestic dogs in France: Results of a countrywide serologic survey. *Parasitol. Res.* **2009**, *105* (Suppl. 1), S101-S114. [CrossRef] [PubMed]

248. Maurizi, L.; Marie, J.L.; Aoun, O.; Courtin, C.; Gorsane, S.; Chal, D.; Davoust, B. Seroprevalence survey of equine Lyme borreliosis in France and in sub-Saharan Africa. *Vector Borne Zoonotic Dis.* **2010**, *10*, 535-537. [CrossRef] [PubMed]

249. Pichon, B.; Gilot, B.; Perez-Eid, C. Detection of spirochaetes of Borrelia burgdorferi complexe in the skin of cervids by PCR and culture. *Eur. J. Epidemiol.* **2000**, *16*, 869-873. [CrossRef] [PubMed]

250. Pascucci, I.; Di Domenico, M.; Dall'Acqua, F.; Sozio, G.; Camma, C. Detection of Lyme Disease and Q Fever Agents in Wild Rodents in Central Italy. *Vector Borne Zoonotic Dis.* **2015**, *15*, 404-411. [CrossRef] [PubMed]

251. Martello, E.; Mannelli, A.; Grego, E.; Ceballos, L.A.; Ragagli, C.; Stella, M.C.; Tomassone, L. Borrelia burgdorferi sensu lato and spotted fever group rickettsiae in small rodents and attached ticks in the Northern Apennines, Italy. *Ticks Tick-Borne Dis.* **2019**, *10*, 862-867. [CrossRef] [PubMed]
252. Sgroi, G.; Iatta, R.; Veneziano, V.; Bezerra-Santos, M.A.; Lesiczka, P.; Hrazdilova, K.; Annoscia, G.; D'Alessio, N.; Golovchenko, M.; Rudenko, N.; et al. Molecular survey on tick-borne pathogens and Leishmania infantum in red foxes (*Vulpes vulpes*) from southern Italy. *Ticks Tick-Borne Dis.* **2021**, *12*, 101669. [CrossRef] [PubMed]

253. Ebani, V.V.; Bertelloni, F.; Torracca, B.; Cerri, D. Serological survey of Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, and Ehrlichia canis infections in rural and urban dogs in Central Italy. *Ann. Agric. Environ. Med.* **2014**, *21*, 671–675. [CrossRef]

254. Piantedosi, D.; Neola, B.; D'Alessio, N.; Di Prisco, F.; Santoro, M.; Pacifico, L.; Sgroi, G.; Auletta, L.; Buch, J.; Chandrashekar, R.; et al. Seroprevalence and risk factors associated with Ehrlichia canis, Anaplasma spp., Borrelia burgdorferi sensu lato, and D. immitis in hunting dogs from southern Italy. *Parasitol. Res.* **2017**, *116*, 2651–2660. [CrossRef]

255. Ebani, V.V.; Bertelloni, F.; Pinzauti, P.; Cerri, D. Seroprevalence of Leptospira spp. and Borrelia burgdorferi sensu lato in Italian horses. *Ann. Agric. Environ. Med.* **2012**, *19*, 237–240. [PubMed]

256. Veronesi, F.; Laus, F.; Passamonti, F.; Tesei, B.; Piergili Fioretti, D.; Genchi, C. Occurrence of Borrelia lusitaniae infection in horses. *Vet. Microbiol.* **2012**, *160*, 535–538. [CrossRef] [PubMed]

257. Mendoza-Roldan, J.A.; Colella, V.; Lia, R.P.; Nguyen, V.L.; Barros-Battesti, D.M.; Iatta, R.; Dantas-Torres, F.; Otranto, D. *Borrelia burgdorferi* (sensu lato) in ectoparasites and reptiles in southern Italy. *Parasit Vectors* **2019**, *12*, 35. [CrossRef] [PubMed]

258. Ebani, V.V.; Poli, A.; Rocchigiani, G.; Bertelloni, F.; Nardoni, S.; Papini, R.A.; Mancianti, F. Serological survey on some pathogens in wild brown hares (*Lepus europaeus*) in Central Italy. *Asian Pac. J. Trop. Med.* **2016**, *9*, 465–469. [CrossRef] [PubMed]

259. Grassi, L.; Drigo, M.; Zelena, H.; Pasotto, D.; Cassini, R.; Mondin, A.; Franzo, G.; Tucciarone, C.M.; Ossola, M.; Vidorin, E.; et al. Wild ungulates as sentinels of flaviviruses and tick-borne zoonotic pathogen circulation: An Italian perspective. *BMC Vet. Res.* **2023**, *19*, 155. [CrossRef] [PubMed]

260. Ebani, V.V.; Bertelloni, F.; Mani, P. Serological evidence of exposure to zoonotic tick-borne bacteria in pheasants (*Phasianus colchicus*). *Ann. Agric. Environ. Med.* **2017**, *24*, 82–85. [CrossRef] [PubMed]

261. Ebani, V.V.; Bertelloni, F.; Mani, P. Molecular survey on zoonotic tick-borne bacteria and chlamydiae in feral pigeons (Columba livia domestica). *Asian Pac. J. Trop. Med.* **2016**, *9*, 324–327. [CrossRef] [PubMed]

262. Ebani, V.V.; Rocchigiani, G.; Bertelloni, F.; Nardoni, S.; Leoni, A.; Nicoloso, S.; Mancianti, F. Molecular survey on the presence of zoonotic arthropod-borne pathogens in wild red deer (*Cervus elaphus*). *Comp. Immunol. Microbiol. Infect. Dis.* **2016**, *47*, 77–80. [CrossRef]

263. Cuteri, V.; Diverio, S.; Carnieletto, P.; Turilli, C.; Valente, C. Serological survey for antibodies against selected infectious agents among fallow deer (*Dama dama*) in central Italy. *Zentralbl. Vet. B* **1999**, *46*, 545–549. [CrossRef]

264. Cerar, T.; Korva, M.; Avsic-Zupanc, T.; Ruzic-Sabljic, E. Detection, identification and genotyping of Borrellia spp. in rodents in Slovenia by PCR and culture. *BMC Vet. Res.* **2015**, *11*, 188. [CrossRef]

265. Strle, F. Lyme borreliosis in Slovenia. *Zentralbl. Bakteriol.* **1999**, *289*, 643–652. [CrossRef] [PubMed]

266. Miro, G.; Wright, I.; Michael, H.; Burton, W.; Hegarty, E.; Rodon, J.; Buch, J.; Pantchev, N.; von Samson-Himmelstjerna, G. Seropositivity of main vector-borne pathogens in dogs across Europe. *Parasit Vectors* **2022**, *15*, 189. [CrossRef] [PubMed]

267. Tadin, A.; Tokarz, R.; Markotic, A.; Margaletic, J.; Turk, N.; Habus, J.; Svoboda, P.; Vucelja, M.; Desai, A.; Jain, K.; et al. Molecular Survey of Zoonotic Agents in Rodents and Other Small Mammals in Croatia. *Am. J. Trop. Med. Hyg.* **2016**, *94*, 466–473. [CrossRef] [PubMed]

268. Mrljak, V.; Kules, J.; Mihaljevic, Z.; Torti, M.; Gotic, J.; Crnogaj, M.; Zivicnjak, T.; Mayer, I.; Smit, I.; Bhide, M.; et al. Prevalence and Geographic Distribution of Vector-Borne Pathogens in Apparently Healthy Dogs in Croatia. *Vector Borne Zoonotic Dis.* **2017**, *17*, 398–408. [CrossRef] [PubMed]

269. Jurkovic, D.; Beck, A.; Huber, D.; Mihaljevic, Z.; Polkinghorne, A.; Martinkovic, F.; Lukacevic, D.; Pilat, M.; Brezak, R.; Bosnic, S.; et al. Seroprevalence of vector-borne pathogens in dogs from Croatia. *Parasitol. Res.* **2019**, *118*, 347–352. [CrossRef]

270. Myrseli, T.; Schönberg, A.; Simaku, A.; Como, N.; Pipero, P.; Bërxholi, K.; Bino, S.; Kraja, D. The current situation of Lyme borreliosis and the first seroepidemiology survey in dogs in Albania. *Albanian Med. J.* **2018**, *2*, 19–23.

271. Angelou, A.; Gelasakis, A.I.; Verde, N.; Pantchev, N.; Schaper, R.; Chandrashekar, R.; Papadopoulos, E. Prevalence and risk factors for selected canine vector-borne diseases in Greece. *Parasit Vectors* **2019**, *12*, 283. [CrossRef]

272. Athanasiou, L.V.; Kontos, V.I.; Kritsepi Konstantinou, M.; Polizopoulou, Z.S.; Rousou, X.A.; Christodoulopoulos, G. Cross-Sectional Serosurvey and Factors Associated with Exposure of Dogs to Vector-Borne Pathogens in Greece. *Vector Borne Zoonotic Dis.* **2019**, *19*, 923–928. [CrossRef]

273. Athanasiou, L.V.; Spanou, V.M.; Katsogiannou, E.G.; Katsoulos, P.D. Hematological Features in Sheep with IgG and IgM Antibodies against Borrelia burgdorferi sensu lato. *Pathogens* **2021**, *10*, 164. [CrossRef]

274. Athanasiou, L.V.; Katsogiannou, E.G.; Tyrnenopoulou, P.; Gougoulis, D.; Apostolidis, K.N.; Papadakis, S.M.; Kokkinaki, K.C.G.; Papatsiros, V.G.; Tsokana, C.N. Evidence of Horse Exposure to Anaplasma phagocytophilum, Borrelia burgdorferi, and Leishmania infantum in Greece through the Detection of IgG Antibodies in Serum and in an Alternative Diagnostic Sample-The Saliva. *Biomolecules* **2023**, *13*, 1374. [CrossRef]

275. Bhide, M.; Yilmaz, Z.; Golcu, E.; Torun, S.; Mikula, I. Seroprevalence of anti-Borrelia burgdorferi antibodies in dogs and horses in Turkey. *Ann. Agric. Environ. Med.* **2008**, *15*, 85–90. [PubMed]

276. Guner, E.S.; Watanabe, M.; Kadosaka, T.; Polat, E.; Gargili, A.; Gulanber, A.; Ohashi, N.; Kaneda, K.; Imai, Y.; Masuzawa, T. Seroepidemiology of Borrelia burgdorferi sensu lato and Anaplasma phagocytophilum in wild mice captured in northern Turkey. *Epidemiol. Infect.* **2005**, *133*, 331–336. [CrossRef] [PubMed]
277. Muz, M.N.; Erat, S.; Mumcuoglu, K.Y. Protozoan and Microbial Pathogens of House Cats in the Province of Tekirdag in Western Turkey. *Pathogens* **2021**, *10*, 1114. [CrossRef] [PubMed]

278. Selim, A.; Alanazi, A.D.; Sazmand, A.; Otranto, D. Seroprevalence and associated risk factors for vector-borne pathogens in dogs from Egypt. *Parasit Vectors* **2021**, *14*, 175. [CrossRef] [PubMed]

279. Elhelw, R.; Elhariri, M.; Hamza, D.; Abuowarda, M.; Ismael, E.; Farag, H. Evidence of the presence of Borrelia burgdorferi in dogs and associated ticks in Egypt. *BMC Vet. Res.* **2021**, *17*, 49. [CrossRef] [PubMed]

280. Ben Said, M.; Belkahia, H.; Alberti, A.; Abdi, K.; Zhioua, M.; Daaloul-Jedidi, M.; Messadi, L. First molecular evidence of [i]Borrelia burgdorferi[i] sensu lato in goats, sheep, cattle and camels in Tunisia. *Ann. Agric. Environ. Med.* **2016**, *23*, 442–447. [CrossRef] [PubMed]

281. Dsouli, N.; Younsi-Kabachii, H.; Postic, D.; Nouira, S.; Gern, L.; Bouattour, A. Reservoir role of lizard Psammodromus algirus in transmission cycle of Borrelia burgdorferi sensu lato (Spirochaetaceae) in Tunisia. *J. Med. Entomol.* **2006**, *43*, 737–742. [CrossRef] [PubMed]

282. Azzag, N.; Petit, E.; Gandoin, C.; Bouillin, C.; Ghalmi, F.; Haddad, N.; Boulouis, H.J. Prevalence of select vector-borne pathogens in stray and client-owned dogs from Algiers. *Comp. Immunol. Microbiol. Infect. Dis.* **2015**, *38*, 1–7. [CrossRef] [PubMed]

283. Laamari, A.; Azzag, N.; Tennah, S.; Derdour, S.Y.; China, B.; Bouabdallah, R.; Ghalmi, F. Seroprevalence of Antibodies Against Anaplasma Phagocytophilum and Borrelia Burgdorferi in Horses (*Equus caballus*) from Northern Algeria. *J. Vet. Res.* **2020**, *64*, 413–419. [CrossRef]

284. Lledo, L.; Gegundez, M.I.; Saz, J.V.; Beltran, M. Screening of the prevalence of antibodies to Borrelia burgdorferi in Madrid province, Spain. *Eur. J. Epidemiol.* **2004**, *19*, 471–472. [CrossRef]

285. Escudero, R.; Barral, M.; Perez, A.; Vitutia, M.M.; Garcia-Perez, A.L.; Jimenez, S.; Sellek, R.E.; Anda, P. Molecular and pathogenic characterization of Borrelia burgdorferi sensu lato isolates from Spain. *J. Clin. Microbiol.* **2000**, *38*, 4026–4033. [CrossRef]

286. Grillon, A.; Scherlinger, M.; Boyer, P.H.; De Martino, S.; Perdriger, A.; Blasquez, A.; Wipff, J.; Korganow, A.S.; Bonnard, C.; Cantagrel, A.; et al. Characteristics and clinical outcomes after treatment of a national cohort of PCR-positive Lyme arthritis. *Semin. Arthritis Rheum.* **2019**, *48*, 1105–1112. [CrossRef] [PubMed]

287. Lenormand, C.; Jaulhac, B.; De Martino, S.; Barthel, C.; Lipsker, D. Species of Borrelia burgdorferi complex that cause borrelial lymphocytoma in France. *Br. J. Dermatol.* **2009**, *161*, 174–176. [CrossRef]

288. Del Giudice, P.; Freychet, F.; Kopec, L.; Fenollar, F.; Eldin, C.; Velin, M.; Hubiche, T.; Raoult, D.; Mediannikov, O. Erythema Migrans Caused by Borrelia spielmanii, France. *Emerg. Infect. Dis.* **2023**, *29*, 2366–2369. [CrossRef]

289. Ciceroni, L.; Ciarrochi, S.; Ciervo, A.; Mondarini, V.; Guzzo, F.; Caruso, G.; Murgia, R.; Cinco, M. Isolation and characterization of Borrelia burgdorferi sensu lato strains in an area of Italy where Lyme borreliosis is endemic. *J. Clin. Microbiol.* **2001**, *39*, 2254–2260. [CrossRef] [PubMed]

290. Santino, I.; Berlutti, F.; Pantanella, F.; Sessa, R.; del Piano, M. Detection of Borrelia burgdorferi sensu lato DNA by PCR in serum of patients with clinical symptoms of Lyme borreliosis. *FEMS Microbiol. Lett.* **2008**, *283*, 30–35. [CrossRef] [PubMed]

291. Sonnleitner, S.T.; Margos, G.; Wex, F.; Simeoni, J.; Zelger, R.; Schmutzhard, E.; Lass-Florl, C.; Walder, G. Human seroprevalence against Borrelia burgdorferi sensu lato in two comparable regions of the eastern Alps is not correlated to vector infection rates. *Ticks Tick-Borne Dis.* **2015**, *6*, 221–227. [CrossRef]

292. Strle, F.; Lusa, L.; Ruzic-Sabljic, E.; Maraspin, V.; Lotric Furlan, S.; Cimperman, J.; Ogrinc, K.; Rojko, T.; Videcnik Zorman, J.; Stupica, D. Clinical characteristics associated with Borrelia burgdorferi sensu lato skin culture results in patients with erythema migrans. *PLoS ONE* **2013**, *8*, e82132. [CrossRef]

293. Gatzmann, F.; Metzler, D.; Krebs, S.; Blum, H.; Sing, A.; Takano, A.; Kawabata, H.; Fingerle, V.; Margos, G.; Becker, N.S. NGS population genetics analyses reveal divergent evolution of a Lyme Borreliosis agent in Europe and Asia. *Ticks Tick-Borne Dis.* **2015**, *6*, 344–351. [CrossRef]

294. Maraspin, V.; Ruzic-Sabljic, E.; Strle, F. Lyme borreliosis and Borrelia spielmanii. *Emerg. Infect. Dis.* **2006**, *12*, 1177. [CrossRef]

295. Ruzic-Sabljic, E.; Zore, A.; Strle, F. Characterization of Borrelia burgdorferi sensu lato isolates by pulsed-field gel electrophoresis after MluI restriction of genomic DNA. *Res. Microbiol.* **2008**, *159*, 441–448. [CrossRef] [PubMed]

296. Maraspin, V.; Nahtigal Klevisar, M.; Ruzic-Sabljic, E.; Lusa, L.; Strle, F. Borrelial Lymphocytoma in Adult Patients. *Clin. Infect. Dis.* **2016**, *63*, 914–921. [CrossRef] [PubMed]

297. Burek, V.; Misic-Mayerus, L.; Maretic, T. Antibodies to Borrelia burgdorferi in various population groups in Croatia. *Scand. J. Infect. Dis.* **1992**, *24*, 683–684. [CrossRef] [PubMed]

298. Situm, M.; Grahovac, B.; Markovic, S.; Lipozencic, J.; Poje, G.; Dobric, I.; Marinovic, B.; Bolanca-Bumber, S.; Misic-Majerus, L. Detection and genotyping of Borrelia burgdorferi sensu lato by polymerase chain reaction. *Croat. Med. J.* **2000**, *41*, 47–53. [PubMed]

299. Mulic, R.; Antonijevic, S.; Klismanic, Z.; Ropac, D.; Lucev, O. Epidemiological characteristics and clinical manifestations of Lyme borreliosis in Croatia. *Mil. Med.* **2006**, *171*, 1105–1109. [CrossRef] [PubMed]

300. Arapovic, J.; Skocibusic, S.; Grgic, S.; Nikolic, J. The first evidence of lyme neuroborreliosis in southern bosnia and herzegovina. *Case Rep. Infect. Dis.* **2014**, *2014*, 231969. [CrossRef] [PubMed]

301. Karageorgou, I.; Koutantou, M.; Papadogiannaki, I.; Voulgari-Kokota, A.; Makka, S.; Angelakis, E. Serological evidence of possible Borrelia afzelii lyme disease in Greece. *New Microbes New Infect.* **2022**, *46*, 100978. [CrossRef] [PubMed]
302. Onal, U.; Aytac Erdem, H.; Uyan Onal, A.; Resat Sipahi, O. Systematic review of Lyme disease in Turkey. *Trop. Dr. 2019*, *49*, 165–170. [CrossRef] [PubMed]

303. Gazi, H.; Ozkutuk, N.; Ecemis, O.; Atasoylu, G.; Koroglu, G.; Kurutepe, S.; Horasan, G.D. Seroprevalence of West Nile virus, Crimean-Congo hemorrhagic fever virus, Francisella tularensis and Borrelia burgdorferi in rural population of Manisa, western Turkey. *J. Vector Borne Dis.* **2016**, *53*, 112–117. [CrossRef]

304. Kaya, A.D.; Parlak, A.H.; Ozturk, C.E.; Behcet, M. Seroprevalence of Borrelia burgdorferi infection among forestry workers and farmers in Duzce, north-western Turkey. *New Microbiol.* **2008**, *31*, 203–209.

305. Abraham, Z.; Feuerman, E.J.; Rozenbaum, M.; Gluck, Z. Lyme disease in Israel. *J. Am. Acad. Dermatol.* **1991**, *25*, 729. [CrossRef] [PubMed]

306. Dworkin, M.S.; Schwan, T.G.; Anderson, D.E., Jr.; Borchardt, S.M. Tick-borne relapsing fever. *Infect. Dis. Clin. N. Am.* **2008**, *22*, 449–468, viii. [CrossRef] [PubMed]

307. Faccini-Martinez, A.A.; Silva-Ramos, C.R.; Santodomingo, A.M.; Ramirez-Hernandez, A.; Costa, F.B.; Labruna, M.B.; Munoz-Leal, S. Historical overview and update on relapsing fever group Borrelia in Latin America. *Parasit Vectors* **2022**, *15*, 196. [CrossRef] [PubMed]

308. Cutler, S.J. Relapsing Fever Borreliae: A Global Review. *Clin. Lab. Med.* **2015**, *35*, 847–865. [CrossRef] [PubMed]

309. Larsson, C.; Andersson, M.; Guo, B.P.; Nordstrand, A.; Hagerstrand, I.; Carlsson, S.; Bergstrom, S. Complications of pregnancy and transplacental transmission of relapsing-fever borreliosis. *J. Infect. Dis.* **2006**, *194*, 1367–1374. [CrossRef] [PubMed]

310. Melkert, P.W. Relapsing fever in pregnancy: Analysis of high-risk factors. *Br. J. Obstet. Gynaecol.* **1988**, *95*, 1070–1072. [CrossRef] [PubMed]

311. Bryceson, A.D.; Parry, E.H.; Perine, P.L.; Warrell, D.A.; Vukotich, D.; Leithead, C.S. Louse-borne relapsing fever. *Q. J. Med.* **1970**, *39*, 129–170. [PubMed]

312. Warrell, D.A. Louse-borne relapsing fever (Borrelia recurrentis infection). *Epidemiol. Infect.* **2019**, *147*, e106. [CrossRef]

313. Kahlig, P.; Neumayr, A.; Paris, D.H. Louse-borne relapsing fever-A systematic review and analysis of the literature: Part 2-Mortality, Jarisch-Herxheimer reaction, impact on pregnancy. *PLoS Negl. Trop. Dis.* **2021**, *15*, e0008656. [CrossRef]

314. Anda, P.; Sanchez-Yebra, W.; del Mar Vitutia, M.; Perez Pastrana, E.; Rodriguez, I.; Miller, N.S.; Backenson, P.B.; Benach, J.L. A new Borrelia species isolated from patients with relapsing fever in Spain. *Lancet* **1996**, *348*, 162–165. [CrossRef]

315. Wyplosz, B.; Mihaila-Amrouche, L.; Baixench, M.T.; Bigel, M.L.; Berardi-Grassias, L.; Fontaine, C.; Hornstein, M.; Izri, A.; Baranton, G.; Postic, D. Imported tickborne relapsing fever, France. *Emerg. Infect. Dis.* **2005**, *11*, 1801–1803. [CrossRef] [PubMed]

316. Kahlig, P.; Paris, D.H.; Neumayr, A. Louse-borne relapsing fever-A systematic review and analysis of the literature: Part 1-Epidemiology and diagnostic aspects. *PLoS Negl. Trop. Dis.* **2021**, *15*, e0008564. [CrossRef] [PubMed]

317. Ramos, J.M.; Malmierca, E.; Reyes, F.; Tesfamariam, A. Results of a 10-year survey of louse-borne relapsing fever in southern Ethiopia: A decline in endemicity. *Ann. Trop. Med. Parasitol.* **2008**, *102*, 467–469. [CrossRef] [PubMed]

318. Ramos, J.M.; Malmierca, E.; Reyes, F.; Wolde, W.; Galata, A.; Tesfamariam, A.; Gorgolas, M. Characteristics of louse-borne relapsing fever in Ethiopian children and adults. *Ann. Trop. Med. Parasitol.* **2004**, *98*, 191–196. [CrossRef] [PubMed]

319. Nordmann, T.; Feldt, T.; Bosselmann, M.; Tufa, T.B.; Lemma, G.; Holtfreter, M.; Haussinger, D. Outbreak of Louse-Borne Relapsing Fever among Urban Dwellers in Arsi Zone, Central Ethiopia, from July to November 2016. *Am. J. Trop. Med. Hyg.* **2018**, *98*, 1599–1602. [CrossRef] [PubMed]

320. Darcis, G.; Hayette, M.P.; Bontems, S.; Sauvage, A.S.; Meuris, C.; Van Esbroeck, M.; Leonard, P. Louse-borne relapsing fever in a refugee from Somalia arriving in Belgium. *J. Travel Med.* **2016**, *23*, taw009. [CrossRef] [PubMed]

321. Osthoff, M.; Schibli, A.; Fadini, D.; Lardelli, P.; Goldenberger, D. Louse-borne relapsing fever—Report of four cases in Switzerland, June-December 2015. *BMC Infect Dis* **2016**, *16*, 210. [CrossRef] [PubMed]

322. Naddaf, S.R.; Ghazinezhad, B.; Kazemirad, E.; Cutler, S.J. Relapsing fever causative agent in Southern Iran is a closely related species to East African borreliae. *Ticks Tick-Borne Dis.* **2017**, *8*, 882–886. [CrossRef] [PubMed]

323. Raoult, D.; Birtles, R.J.; Montoya, M.; Perez, E.; Tissot-Dupont, H.; Roux, V.; Guerra, H. Survey of three bacterial louse-associated diseases among rural Andean communities in Peru: Prevalence of epidemic typhus, trench fever, and relapsing fever. *Clin. Infect. Dis.* **1999**, *29*, 434–436. [CrossRef]

324. Brouqui, P.; Stein, A.; Dupont, H.T.; Gallian, P.; Badiaga, S.; Rolain, J.M.; Mege, J.L.; La Scola, B.; Berbis, P.; Raoult, D. Ectoparasitism and vector-borne diseases in 930 homeless people from Marseilles. *Medicine* **2005**, *84*, 61–68. [CrossRef]

325. Ly, T.D.A.; Louni, M.; Hoang, V.T.; Dao, T.L.; Badiaga, S.; Brouqui, P.; Tissot-Dupont, H.; Raoult, D.; Fournier, P.E.; Gautret, P. Epidemiological serosurvey of vector-borne and zoonotic pathogens among homeless people living in shelters in Marseille: Cross-sectional one-day surveys (2005–2015). *Eur. J. Clin. Microbiol. Infect. Dis.* **2020**, *39*, 1663–1672. [CrossRef] [PubMed]

326. Ciervo, A.; Mancini, F.; di Bernardo, F.; Giammanco, A.; Vitale, G.; Dones, P.; Fasciana, T.; Quartaro, P.; Mazzola, G.; Rezza, G. Louseborne Relapsing Fever in Young Migrants, Sicily, Italy, July–September 2015. *Emerg. Infect. Dis.* **2016**, *22*, 152–153. [CrossRef]

327. Cutler, S.J.; Moss, J.; Fukunaga, M.; Wright, D.J.; Fekade, D.; Warrell, D. Borrelia recurrentis characterization and comparison with relapsing-fever, Lyme-associated, and other Borrelia spp. *Int. J. Syst. Bacteriol.* **1997**, *47*, 958–968. [CrossRef]

328. Munoz-Leal, S.; Faccini-Martinez, A.A.; Costa, F.B.; Marcili, A.; Mesquita, E.; Marques, E.P., Jr.; Labruna, M.B. Isolation and molecular characterization of a relapsing fever Borrelia recovered from Ornithodoros rudis in Brazil. *Ticks Tick-Borne Dis.* **2018**, *9*, 864–871. [CrossRef] [PubMed]
329. Assous, M.V.; Wilamowski, A. Relapsing fever borreliosis in Eurasia--forgotten, but certainly not gone! *Clin. Microbiol. Infect. Off.* Publ. Eur. Soc. Clin. Microbiol. Infect. Dis. **2009**, *15*, 407–414. [CrossRef]

330. Trape, J.F.; Diatta, G.; Arnathau, C.; Bitam, I.; Sarih, M.; Belgyti, D.; Bouattour, A.; Elguero, E.; Vial, L.; Mane, Y.; et al. The epidemiology and geographic distribution of relapsing fever borreliosis in West and North Africa, with a review of the Ornithodoros erraticus complex (Acari: Ixodida). *PLoS ONE* **2013**, *8*, e78473. [CrossRef] [PubMed]

331. Schwan, T.G.; Hinnebusch, B.J. Bloodstream- versus tick-associated variants of a relapsing fever bacterium. *Science* **1998**, *280*, 1938–1940. [CrossRef] [PubMed]

332. Boyle, W.K.; Wilder, H.K.; Lawrence, A.M.; Lopez, J.E. Transmission dynamics of Borrelia turicatae from the arthropod vector. *PLoS Negl. Trop. Dis.* **2014**, *8*, e2767. [CrossRef]

333. Johnson, T.L.; Landguth, E.L.; Stone, E.F. Modeling Relapsing Disease Dynamics in a Host-Vector Community. *PLoS Negl. Trop. Dis.* **2016**, *10*, e0004428. [CrossRef]

334. Barbour, A.G. Phylogeny of a relapsing fever Borrelia species transmitted by the hard tick Ixodes scapularis. *Infect. Genet. Evol.* **2014**, *27*, 551–558. [CrossRef]

335. Remesar, S.; Diaz, P.; Venzal, J.M.; Prieto, A.; Estrada-Pena, A.; Lopez, C.M.; Panadero, R.; Fernandez, G.; Diez-Banos, P.; Morrondo, P. Longitudinal Study of Infection with Borrelia spp. in Questing Ticks from North-Western Spain. *Vector Borne Zoonotic Dis.* **2019**, *19*, 785–792. [CrossRef]

336. Diaz, P.; Remesar, S.; Venzal, J.M.; Vazquez-Lopez, M.E.; Fernandez, G.; Lopez, C.; Diez-Banos, P.; Morrondo, P.; Panadero, R. Occurrence of Borrelia and Borrelia species in Ixodes ricinus collected from roe deer in northwestern Spain. *Med. Vet. Entomol.* **2019**, *33*, 427–430. [CrossRef] [PubMed]

337. Sanz-Aguilar, A.; Payo-Payo, A.; Rotger, A.; Yousfi, L.; Moutailler, S.; Beck, C.; Dumarest, M.; Igual, J.M.; Miranda, M.A.; Vinas Torres, M.; et al. Infestation of small seabirds by Ornithodoros maritimus ticks: Effects on chick body condition, reproduction and associated infectious agents. *Ticks Tick-Borne Dis.* **2020**, *11*, 101281. [CrossRef] [PubMed]

338. Lejal, E.; Marsot, M.; Chalvet-Monfray, K.; Cosson, J.F.; Moutailler, S.; Vayssier-Taussat, M.; Pollet, T. A three-years assessment of Ixodes ricinus-borne pathogens in a French peri-urban forest. *Parasit Vectors* **2019**, *12*, 551. [CrossRef] [PubMed]

339. Sevestre, J.; Diarra, A.Z.; Oumarou, H.A.; Durant, J.; Delaunay, P.; Parola, P. Detection of emerging tick-borne disease agents in the Alpes-Maritimes region, southeastern France. *Ticks Tick-Borne Dis.* **2021**, *12*, 101800. [CrossRef]

340. Grech-Angelini, S.; Stachurski, F.; Vayssier-Taussat, M.; Devillers, E.; Casabianca, F.; Lancelot, R.; Uilenberg, G.; Moutailler, S. Tick-borne pathogens in ticks (Acari: Ixodidae) collected from various domestic and wild hosts in Corsica (France), a Mediterranean island environment. *Transbound. Emerg. Dis.* **2020**, *67*, 745–757. [CrossRef] [PubMed]

341. Socolovschi, C.; Kernif, T.; Raoult, D.; Parola, P. Borrelia, Rickettsia, and Ehrlichia species in bat ticks, France, 2010. *Emerg. Infect. Dis.* **2012**, *18*, 1966–1975. [CrossRef]

342. Jumpertz, M.; Sevestre, J.; Luciani, L.; Houhamdi, L.; Fournier, P.E.; Parola, P. Bacterial Agents Detected in 418 Ticks Removed from Humans during 2014–2021, France. *Emerg. Infect. Dis.* **2023**, *29*, 701–710. [CrossRef]

343. Garcia-Vozmediano, A.; Krawczyk, A.I.; Sprong, H.; Rossi, L.; Ramassa, E.; Tomassone, L. Ticks climb the mountains: Ixodid tick infestation and infection by tick-borne pathogens in the Western Alps. *Ticks Tick-Borne Dis.* **2020**, *11*, 101489. [CrossRef]

344. Ravagnan, S.; Tomassone, L.; Montarsi, F.; Krawczyk, A.I.; Mastrorilli, E.; Sprong, H.; Milani, A.; Rossi, L.; Capelli, G. First detection of Borrelia miyamotoi in Ixodes ricinus ticks from northern Italy. *Parasit Vectors* **2018**, *11*, 130. [CrossRef]

345. Sakakibara, K.; Sen, E.; Sato, K.; Kawabata, H.; Ohashi, N.; Masuzawa, T. Detection and Characterization of the Emerging Relapsing Fever Pathogen, Borrelia miyamotoi, from the Ixodes ricinus Tick in the Rural Trakya (Thrace) Region of Northwestern Turkey. *Vector Borne Zoonotic Dis.* **2016**, *16*, 797–799. [CrossRef] [PubMed]

346. Norte, A.C.; Harris, D.J.; Silveira, D.; Nunes, C.S.; Nuncio, M.S.; Martinez, E.G.; Gimenez, A.; de Sousa, R.; Lopes de Carvalho, I.; Perera, A. Diversity of microorganisms in Hyalomma aegyptium collected from spur-thighed tortoise (*Testudo graeca*) in North Africa and Anatolia. *Transbound. Emerg. Dis.* **2022**, *69*, 1951–1962. [CrossRef] [PubMed]

347. Safdie, G.; Farrah, I.Y.; Yahia, R.; Marva, E.; Wilamowski, A.; Sawalha, S.S.; Wald, N.; Schmiedel, J.; Moter, A.; Gobel, U.B.; et al. Molecular characterization of Borrelia persica, the agent of tick borne relapsing fever in Israel and the Palestinian Authority. *PLoS ONE* **2010**, *5*, e14105. [CrossRef] [PubMed]

348. Assous, M.V.; Wilamowski, A.; Bercovier, H.; Marva, E. Molecular characterization of tickborne relapsing fever Borrelia, Israel. *Emerg. Infect. Dis.* **2006**, *12*, 1740–1743. [CrossRef] [PubMed]

349. Kleinerman, G.; Eshed, T.; Nachum-Biala, Y.; King, R.; Baneth, G. Transmission of the Human Relapsing Fever Spirochete Borrelia persica by the Argasid Tick Ornithodoros tholozani Involves Blood Meals from Wildlife Animal Reservoirs and Mainly Transstadial Transfer. *Appl. Environ. Microbiol.* **2021**, *87*, e03117-20. [CrossRef] [PubMed]

350. Helmy, N. Seasonal abundance of Ornithodoros (O.) savignyi and prevalence of infection with Borrelia spirochetes in Egypt. *J. Egypt. Soc. Parasitol.* **2000**, *30*, 607–619. [PubMed]

351. Abdullah, H.; Aboelsoued, D.; Farag, T.K.; Abdel-Shafy, S.; Abdel Megeed, K.N.; Parola, P.; Raoult, D.; Mediannikov, O. Molecular characterization of some equine vector-borne diseases and associated arthropods in Egypt. *Acta Trop.* **2022**, *227*, 106274. [CrossRef] [PubMed]

352. Khalil, G.M.; Helmy, N.; Hoogstraal, H.; el-Said, A. Seasonal dynamics of Ornithodoros (Pavlovskyella) erraticus (Acari: Ixodoidea: Argasidae) and the spirochete Borrelia crocidurae in Egypt. *J. Med. Entomol.* **1984**, *21*, 536–539. [CrossRef] [PubMed]
353. Balti, G.; Galon, C.; Derghal, M.; Souguir, H.; Guerbouj, S.; Rhim, A.; Chemkhi, J.; Guizani, I.; Bouattour, A.; Moutailler, S.; et al. Atelerrix algirus, the North African Hedgehog: Suitable Wild Host for Infected Ticks and Fleas and Reservoir of Vector-Borne Pathogens in Tunisia. *Pathogens* **2021**, *10*, 953. [CrossRef]

354. Bouattour, A.; Garnier, M.; M'Ghirbi, Y.; Sarih, M.; Gern, L.; Ferquel, E.; Postic, D.; Cornet, M. Borrelia crocidurae infection of Ornithodoros erraticus (Lucas, 1849) ticks in Tunisia. *Vector Borne Zoonotic Dis.* **2010**, *10*, 825–830. [CrossRef]

355. Lafri, I.; El Hamzaoui, B.; Bitam, I.; Leulmi, H.; Lalout, R.; Mediannikov, O.; Chergui, M.; Karakellah, M.; Raoult, D.; Parola, P. Detection of relapsing fever Borrelia spp., Bartonella spp. and Anaplasmataceae bacteria in argasid ticks in Algeria. *PLoS Negl. Trop. Dis.* **2017**, *11*, e0006064. [CrossRef] [PubMed]

356. Ouchene, N.; Nebbak, A.; Ouchene-Khelifi, N.A.; Dahmani, A.; Zeroual, F.; Khelef, D.; Bitam, I.; Benakhla, A.; Parola, P. Molecular detection of avian spirochete Borrelia anserina in Argas persicus ticks in Algeria. *Comp. Immunol. Microbiol. Infect. Dis.* **2020**, *68*, 101408. [CrossRef] [PubMed]

357. Diatta, G.; Souidi, Y.; Granjon, L.; Arnathau, C.; Durand, P.; Chauvancy, G.; Mane, Y.; Sarih, M.; Belghyti, D.; Renaud, F.; et al. Epidemiology of tick-borne borreliosis in Morocco. *PLoS Negl. Trop. Dis.* **2012**, *6*, e1810. [CrossRef] [PubMed]

358. Souidi, Y.; Boudebouch, N.; Ezikouri, S.; Belghyti, D.; Trape, J.F.; Sarih, M. Borrelia crocidurae in Ornithodoros ticks from northwestern Morocco: A range extension in relation to climatic change? *J. Vector Ecol.* **2014**, *39*, 316–320. [CrossRef] [PubMed]

359. Johnson, T.L.; Fischer, R.J.; Raffel, S.J.; Schwan, T.G. Host associations and genomic diversity of Borrelia hermsii in an endemic focus of tick-borne relapsing fever in western North America. *Parasit Vectors* **2016**, *9*, 575. [CrossRef] [PubMed]

360. Han, S.; Hickling, G.J.; Tsao, J.I. High Prevalence of Borrelia miyamotoi among Adult Blacklegged Ticks from White-Tailed Deer. *Emerg. Infect. Dis.* **2016**, *22*, 316–318. [CrossRef] [PubMed]

361. Larsson, C.; Lundqvist, J.; van Rooijen, N.; Bergstrom, S. A novel animal model of Borrelia recurrentis louse-borne relapsing fever borreliosis using immunodeficient mice. *PLoS Negl. Trop. Dis.* **2009**, *3*, e522. [CrossRef] [PubMed]

362. McCall, P.J.; Hume, J.C.; Motshegwa, K.; Pignatelli, P.; Talbert, A.; Kisinza, W. Does tick-borne relapsing fever have an animal reservoir in East Africa? *Vector Borne Zoonotic Dis.* **2007**, *7*, 659–666. [CrossRef]

363. Meri, T.; Cutler, S.J.; Blom, A.M.; Meri, S.; Jokiranta, T.S. Relapsing fever spirochetes Borrelia recurrentis and B. duttonii acquire complement regulators C4b-binding protein and factor H. *Infect. Immun.* **2006**, *74*, 4157–4163. [CrossRef]

364. Margos, G.; Pantchev, N.; Globokar, M.; Lopez, J.; Rodon, J.; Hernandez, L.; Herold, H.; Salas, N.; Civit, A.; Fingerle, V. First Cases of Natural Infections with Borrelia hispanica in Two Dogs and a Cat from Europe. *Microorganisms* **2020**, *8*, 1251. [CrossRef]

365. Cosson, J.F.; Michelet, L.; Chotte, J.; Le Naour, E.; Cote, M.; Devillers, E.; Poulle, M.L.; Huet, D.; Galan, M.; Geller, J.; et al. Genetic characterization of the human relapsing fever spirochete Borrelia miyamotoi in vectors and animal reservoirs of Lyme disease spirochetes in France. *Parasit Vectors* **2014**, *7*, 233. [CrossRef] [PubMed]

366. Celebi, B.; Yeni, D.K.; Yilmaz, Y.; Matur, F.; Babur, C.; Oktem, M.A.; Sozen, M.; Karatas, A.; Raoult, D.; Mediannikov, O.; et al. Borrelia miyamotoi in wild rodents from four different regions of Turkey. *Ticks Tick-Borne Dis.* **2023**, *14*, 102143. [CrossRef] [PubMed]

367. Kleinerman, G.; King, R.; Nachum-Biala, Y.; Baneth, G. Borrelia persica infection in rock hyraxes. *Ticks Tick-Borne Dis.* **2018**, *9*, 382–388. [CrossRef] [PubMed]

368. Baneth, G.; Nachum-Biala, Y.; Halperin, T.; Hershko, Y.; Kleinerman, G.; Anug, Y.; Abdeen, Z.; Lavy, E.; Aroch, I.; Straubinger, R.K. Borrelia persica infection in dogs and cats: Clinical manifestations, clinicopathological findings and genetic characterization. *Parasit Vectors* **2016**, *9*, 244. [CrossRef] [PubMed]

369. Baneth, G.; Dvorkin, A.; Ben-Shitrit, B.; Kleinerman, G.; Salant, H.; Straubinger, R.K.; Nachum-Biala, Y. Infection and seroprevalence of Borrelia persica in domestic cats and dogs in Israel. *Parasit Vectors* **2022**, *15*, 102. [CrossRef] [PubMed]

370. Shwartz, D.; Nachum-Biala, Y.; Oren, S.; Aharoni, K.; Edery, N.; Moss, L.; King, R.; Lapid, R.; Straubinger, R.K.; Baneth, G. Borrelia persica infection in wild carnivores in Israel: Molecular characterization and new potential reservoirs. *Parasit Vectors* **2023**, *16*, 337. [CrossRef] [PubMed]

371. Abdullah, H.; Elbayoumy, M.K.; Allam, A.M.; Ashry, H.M.; Abdel-Shafy, S. Molecular epidemiology of certain vector-borne bacterial microorganisms in domestic animals and their ectoparasites in Egypt. *Trop. Anim. Health Prod.* **2021**, *53*, 484. [CrossRef] [PubMed]

372. Abdullah, H.; Amanzougaghene, N.; Dahmana, H.; Louni, M.; Raoult, D.; Mediannikov, O. Multiple vector-borne pathogens of domestic animals in Egypt. *PLoS Negl. Trop. Dis.* **2021**, *15*, e0009767. [CrossRef] [PubMed]

373. El-Alfy, E.S.; Abbas, I.; Baghdadi, H.B.; El-Sayed, S.A.E.; Ji, S.; Rizk, M.A. Molecular Epidemiology and Species Diversity of Tick-Borne Pathogens of Animals in Egypt: A Systematic Review and Meta-Analysis. *Pathogens* **2022**, *11*, 912. [CrossRef]

374. Fichet-Calvet, E.; Jomaa, I.; Ben Ismail, R.; Ashford, R.W. Patterns of infection of haemoparasites in the fat sand rat, Psammomys obesus, in Tunisia, and effect on the host. *Ann. Trop. Med. Parasitol.* **2000**, *94*, 55–68. [CrossRef]

375. Sadeddine, R.; Diarra, A.Z.; Laroche, M.; Mediannikov, O.; Righi, S.; Benakhla, A.; Dahmana, H.; Raoult, D.; Parola, P. Molecular identification of protozoal and bacterial organisms in domestic animals and their infesting ticks from north-eastern Algeria. *Ticks Tick-Borne Dis.* **2020**, *11*, 101330. [CrossRef] [PubMed]

376. Aouadi, A.; Leulmi, H.; Boucheikhchoukh, M.; Benakhla, A.; Raoult, D.; Parola, P. Molecular evidence of tick-borne hemoprotozoan-parasites (*Theileria ovis* and *Babesia ovis*) and bacteria in ticks and blood from small ruminants in Northern Algeria. *Comp. Immunol. Microbiol. Infect. Dis.* **2017**, *50*, 34–39. [CrossRef] [PubMed]
377. Diatta, G.; Duplantier, J.M.; Granjon, L.; Ba, K.; Chauvancy, G.; Ndiaye, M.; Trape, J.F. Borrelia infection in small mammals in West Africa and its relationship with tick occurrence inside burrows. *Acta Trop.* **2015**, *152*, 131–140. [CrossRef] [PubMed]

378. Castilla-Guerra, L.; Alvarez-Suero, J.; Del Carmen Fernandez-Moreno, M.; Fontana, E.R. Tick-borne relapsing fever: Conjunctival haemorrhages. *BMJ Case Rep.* **2009**, *2009*, bcr0620080114. [CrossRef] [PubMed]

379. Lopez-Cortes, L.; Lozano de Leon, F.; Gomez-Mateos, J.M.; Sanchez-Porto, A.; Obrador, C. Tick-borne relapsing fever in intravenous drug abusers. *J. Infect. Dis.* **1989**, *159*, 804. [CrossRef] [PubMed]

380. Dominguez, M.C.; Vergara, S.; Gomez, M.C.; Roldan, M.E. Epidemiology of Tick-Borne Relapsing Fever in Endemic Area, Spain. *Emerg. Infect. Dis.* **2020**, *26*, 849–856. [CrossRef] [PubMed]

381. Castilla-Guerra, L.; Marin-Martin, J.; Colmenero-Camacho, M.A. Tick-Borne Relapsing Fever, Southern Spain, 2004–2015. *Emerg. Infect. Dis.* **2016**, *22*, 2217–2219. [PubMed]

382. Lacout, A.; Mas, M.; Pajaud, J.; Perronne, V.; Lequette, Y.; Franck, M.; Perronne, C. Real time micro-organisms PCR in 104 patients with polymorphic signs and symptoms that may be related to a tick bite. *Eur. J. Microbiol. Immunol.* **2021**, *11*, 62–75. [CrossRef] [PubMed]

383. Malincarne, L.; Schiaroli, E.; Ciervo, A.; Scaglione, V.; Paciaroni, M.; Mancini, F.; Paglia, M.G.; Cardaci, S.; Pasticci, M.B.; Francisci, D.; et al. Meningitis with cranial polyneuritis and cavernous sinus thrombosis by *Borrelia crocidurae*: First autochthonous case in Europe. *Int. J. Infect. Dis.* **2019**, *82*, 30–32. [CrossRef]

384. Billiet, A.; Vanderschueren, S.; Lagrou, K.; Pilate, T.; Fournier, P.E.; Luciani, L.; Henckaerts, L. Tick borne relapsing fever after travelling to a Greek island. *J. Travel. Med.* **2022**, *29*, taab073. [CrossRef]

385. Gambles, R.M.; Coghill, N.F. Relapsing fever in Cyprus. *Ann. Trop. Med. Parasitol.* **1948**, *42*, 288–303. [CrossRef] [PubMed]

386. Wood, R.C.; Dixon, K.C. Tick-borne Relapsing Fever. *Br. Med. J.* **1945**, *2*, 526–528. [CrossRef] [PubMed]

387. Simon, J.W. Tick borne relapsing fever imported into the United Kingdom. *J. R. Army Med. Corps* **1985**, *131*, 65–67. [CrossRef] [PubMed]

388. Moran-Gilad, J.; Levine, H.; Schwartz, E.; Bartal, C.; Huerta-Hartal, M.; Schwaber, M.J.; Ostfeld, I. Postexposure prophylaxis of tick-borne relapsing fever: Lessons learned from recent outbreaks in Israel. *Vector Borne Zoonotic Dis.* **2013**, *13*, 791–797. [CrossRef] [PubMed]

389. Fuchs, I.; Tarabin, S.; Kafka, M. Relapsing Fever: Diagnosis Thanks to a Vigilant Hematology Laboratory. *Vector Borne Zoonotic Dis.* **2015**, *15*, 446–448. [CrossRef] [PubMed]

390. Yagupsky, P.; Moses, S. Neonatal Borrelia species infection (relapsing fever). *Am. J. Dis. Child.* **1985**, *139*, 74–76. [CrossRef] [PubMed]

391. Koton, Y.; Bisharat, N. Tick-Borne Relapsing Fever with Severe Jarisch-Herxheimer Reaction. *Isr. Med. Assoc. J.* **2018**, *20*, 62–63.

392. Hasin, T.; Davidovitch, N.; Cohen, R.; Dagan, T.; Romem, A.; Orr, N.; Klement, E.; Lubezky, N.; Kayouf, R.; Sela, T.; et al. Postexposure treatment with doxycycline for the prevention of tick-borne relapsing fever. *N. Engl. J. Med.* **2006**, *355*, 148–155. [CrossRef] [PubMed]

393. Hashavya, S.; Gross, I.; Gross, M.; Hurvitz, N.; Weiser, G.; Temper, V.; Megged, O. Tickborne Relapsing Fever, Jerusalem, Israel, 2004–2018. *Emerg. Infect. Dis.* **2020**, *26*, 2420–2423. [CrossRef]

394. Halperin, T.; Orr, N.; Cohen, R.; Hasin, T.; Davidovitch, N.; Klement, E.; Kayouf, R.; Baneth, G.; Cohen, D.; Yavzori, M. Detection of relapsing fever in human blood samples from Israel using PCR targeting the glycerophosphodiester phosphodiesterase (GlpQ) gene. *Acta Trop.* **2006**, *98*, 189–195. [CrossRef]

395. Yossepowitch, O.; Gottesman, T.; Schwartz-Harari, O.; Soroksky, A.; Dan, M. Aseptic meningitis and adult respiratory distress syndrome caused by Borrelia persica. *Infection* **2012**, *40*, 695–697. [CrossRef] [PubMed]

396. Dewar, H.A.; Walmsley, R. Relapsing fever with nephritis and subarachnoid haemorrhage. *Lancet* **1945**, *2*, 630. [CrossRef]

397. Coghill, N.F.; Lawrence, J.; Ballantine, I.D. Relapsing fever in Cyrenaica. *Br. Med. J.* **1947**, *1*, 637–640. [CrossRef]

398. Leen, I.; Bruynseels, P.; Mukadi, B.K.; van Oort, M.; van den Akker, M. A 13-year old girl with pancytopenia at the presentation of a Borrelia hispanica infection: A case report and review of the literature. *J. Med. Case Rep.* **2017**, *11*, 51. [CrossRef] [PubMed]

399. Sarih, M.; Garnier, M.; Boudebouch, N.; Bouattour, A.; Rihani, A.; Hassar, M.; Gern, L.; Postic, D.; Cornet, M. Borrelia hispanica relapsing fever, Morocco. *Emerg. Infect. Dis.* **2009**, *15*, 1626–1629. [CrossRef] [PubMed]

400. Goutier, S.; Ferquel, E.; Pinel, C.; Bosseray, A.; Hoen, B.; Couetdic, G.; Bourahoui, A.; Lapostolle, C.; Pelloux, H.; Garnier, M.; et al. Borrelia crocidurae meningoencephalitis, West Africa. *Emerg. Infect. Dis.* **2013**, *19*, 301–304. [CrossRef] [PubMed]

401. Gras, E.; Bailly, E.; Le Brun, C.; Lemaignen, A.; Lanotte, P. Borrelia crocidurae tick-borne relapsing fever upon return from Senegal. *Med. Mal. Infect.* **2019**, *49*, 624–625. [CrossRef]

402. Guiheneuf, E.; Desjardins, N.; Guiheneuf, R. It is not always malaria: Diagnosis of Borrelia recurrent fever on blood smear. *Ann. Biol. Clin.* **2018**, *76*, 118–119. [CrossRef]

403. Million, M.; Cazorla, C.; Doudier, B.; La Scola, B.; Parola, P.; Drancourt, M.; Brouqui, P. Molecular identification of Borrelia crocidurae in a patient returning from Senegal. *BMJ Case Rep.* **2009**, *2009*, bcr0620080298. [CrossRef]

404. Colin de Verdiere, N.; Hamane, S.; Assous, M.V.; Sertour, N.; Ferquel, E.; Cornet, M. Tickborne relapsing fever caused by Borrelia persica, Uzbekistan and Tajikistan. *Emerg. Infect. Dis.* **2011**, *17*, 1325–1327. [CrossRef]

405. Cutuli, S.L.; De Pascale, G.; Spanu, T.; Dell'Anna, A.M.; Bocci, M.G.; Pallavicini, F.; Mancini, F.; Ciervo, A.; Antonelli, M. Lice, rodents, and many hopes: A rare disease in a young ref. *Crit. Care* **2017**, *21*, 81. [CrossRef] [PubMed]
406. Antinori, S.; Mediannikov, O.; Corbellino, M.; Grande, R.; Parravicini, C.; Bestetti, G.; Longhi, E.; Ricaboni, D.; Ehounoud, C.B.; Fenollar, F.; et al. Louse-Borne Relapsing Fever (*Borrelia recurrentis*) in a Somali Refugee Arriving in Italy: A Re-emerging Infection in Europe? *PLoS Negl. Trop. Dis.* **2016**, *10*, e0004522. [CrossRef] [PubMed]

407. Antinori, S.; Tonello, C.; Edouard, S.; Parravicini, C.; Gastaldi, D.; Grande, R.; Milazzo, L.; Ricaboni, D.; Fenollar, F.; Raoult, D.; et al. Diagnosis of Louse-Borne Relapsing Fever despite Negative Microscopy in Two Asylum Seekers from Eastern Africa. *Am. J. Trop. Med. Hyg.* **2017**, *97*, 1669–1672. [CrossRef] [PubMed]

408. Colomba, C.; Scarlata, F.; Di Carlo, P.; Giammanco, A.; Fasciana, T.; Trizzino, M.; Cascio, A. Fourth case of louse-borne relapsing fever in Young Migrant, Sicily, Italy, December 2015. Mini Review Article. *Public Health* **2016**, *139*, 22–26. [CrossRef] [PubMed]

409. Zammarchi, L.; Antonelli, A.; Bartolini, L.; Pecile, P.; Trotta, M.; Rogasi, P.G.; Santini, M.G.; Dilaghi, B.; Grifoni, S.; Rossolini, G.M.; et al. Louse-Borne Relapsing Fever with Meningeal Involvement in an Immigrant from Somalia to Italy, October 2015. *Vector Borne Zoonotic Dis.* **2016**, *16*, 352–355. [CrossRef] [PubMed]

410. Lucchini, A.; Lipani, F.; Costa, C.; Scarvaglieri, M.; Balbiano, R.; Carosella, S.; Calcagno, A.; Audagnotto, S.; Barbui, A.M.; Brossa, S.; et al. Louseborne Relapsing Fever among East African Refugees, Italy, 2015. *Emerg. Infect. Dis.* **2016**, *22*, 298–301. [CrossRef] [PubMed]

411. Grecchi, C.; Zanotti, P.; Pontarelli, A.; Chiari, E.; Tomasoni, L.R.; Gulletta, M.; Barbui, A.; Caligaris, S.; Matteelli, A.; Castelli, F. Louse-borne relapsing fever in a refugee from Mali. *Infection* **2017**, *45*, 373–376. [CrossRef]

412. Tordini, G.; Giaccherini, R.; Corbisiero, R.; Zanelli, G. Relapsing fever in a traveller from Senegal: Determination of Borrelia species using molecular methods. *Trans. R. Soc. Trop. Med. Hyg.* **2006**, *100*, 992–994. [CrossRef] [PubMed]

413. Nitzan, O.; Blum, A.; Marva, E.; Katz, A.; Tzadok, B.S.; Nachum-Biala, Y.; Baneth, G.; Peretz, A. Case Report: Infectious Diseases in Pilgrims Visiting the Holy Land. *Am. J. Trop. Med. Hyg.* **2017**, *97*, 611–614. [CrossRef]

414. Burn, L.; Pilz, A.; Vyse, A.; Gutierrez Rabá, A.V.; Angulo, F.J.; Tran, T.M.P.; Fletcher, M.A.; Gessner, B.D.; Moisi, J.C.; Stark, J.H. Seroprevalence of Lyme Borreliosis in Europe: Results from a Systematic Literature Review (2005–2020). *Vector Borne Zoonotic Dis.* **2023**, *23*, 195–220. [CrossRef]

415. Montero, E.; Folgueras, M.; Rodriguez-Perez, M.; Perez-Ls, L.; Diaz-Arias, J.; Meana, M.; Revuelta, B.; Haapasalo, K.; Collazos, J.; Asensi, V.; et al. Retrospective study of the epidemiological risk and serological diagnosis of human babesiosis in Asturias, Northwestern Spain. *Parasites Vectors* **2023**, *16*, 195. [CrossRef] [PubMed]

416. Fernandez-Jorge, B.; Almagro-Sanchez, M.; Escudero-Nieto, R.; Fonseca-Capdevila, E. Erythema migrans due to Borrelia afzelii. *Med. Clin.* **2006**, *126*, 237–238. [CrossRef] [PubMed]

417. Rigaud, E.; Jaulhac, B.; Garcia-Bonnet, N.; Hunfeld, K.-P.; Femenia, F.; Huet, D.; Goulvestre, C.; Vaillant, V.; Deffontaines, G.; Abadia-Benoist, G. Seroprevalence of seven pathogens transmitted by the Ixodes ricinus tick in forestry workers in France. *Clin. Microbiol. Infect.* **2016**, *22*, 735.e1–735.e9. [CrossRef]

418. Jaulhac, B.; Chary-Valckenaere, I.; Sibilia, J.; Javier, R.M.; Piemont, Y.; Kuntz, J.L.; Monteil, H.; Pourel, J. Detection of *Borrelia burgdorferi* by DNA amplification in synovial tissue samples from patients with lyme arthritis. *Arthritis Rheum.* **1996**, *39*, 736–745. [CrossRef]

419. Riescher, S.; Dos Santos, A.; Lecomte, R.; Lenoble, C.; Guillon, B. A case report of unilateral cerebral vasculitis in adults: Keep in mind Lyme neuroborreliosis. *BMC Infect. Dis.* **2023**, *23*, 283. [CrossRef]

420. Bernard, A.; Kodjikian, L.; Abukhashabh, A.; Roure-Sobas, C.; Boibieux, A.; Denis, P.; Broussolle, C.; Seve, P. Diagnosis of Lyme-associated uveitis: Value of serological testing in a tertiary centre. *Br. J. Ophthalmol.* **2018**, *102*, 369–372. [CrossRef]

421. Jeantin, L.; Rodriguez-Regent, C.; De Martino, S.; Gayraud, M.; Cosserat, J. Intrathecal antibody kinetics in neuroborreliosis: A report on three cases and a literature review. *Infect. Dis. Now* **2021**, *51*, 627–629. [CrossRef] [PubMed]

422. Christiann, F.; Rayet, P.; Patey, O.; Ngueodjibaye, D.B.; Theron-le Gargasson, J.-F.; Lafaix, C. Lyme borreliosis in central France: A sero-epidemiologic examination involving hunters. *Eur. J. Epidemiol.* **1997**, *13*, 855. [CrossRef]

423. Christiann, F.; Rayet, P.; Ngueodjibaye, D.B.; Patey, O.; Godefroy, A.; Klein, J.; Lapegue, R.; Theron-Le Gargasson, J.-F.; Godfroid, E.; Lafaix, C. Endemic level of Lyme borreliosis in a region of central France: A sero-epidemiologic examination involving blood donors. *Eur. J. Epidemiol.* **1997**, *13*, 361–362. [CrossRef] [PubMed]

424. Guet-Revillet, H.; Levy, C.; Vallet, C.; Maghraoui-Slim, V.; Dommergues, M.-A.; Hentgen, V.; Paget, C.; Laugel, V.; Cohen, R.; Ferroni, A. Lyme neuroborreliosis in children: Report of nine cases and a review of the literature. *Arch. Pediatr.* **2019**, *26*, 133–137. [CrossRef]

425. Gibaud, M.; Pauvert, O.; Gueden, S.; Durigneux, J.; Van Bogaert, P. Opsoclonus in a child with neuroborreliosis: Case report and review of the literature. *Arch. Pediatr.* **2019**, *26*, 118–119. [CrossRef] [PubMed]

426. Mereaux, J.-L.; Hebant, B.; Magne, N.; Quesney, G.; Lefaucheur, R. Bilateral facial palsy in an older person. *Age Ageing* **2020**, *49*, 887–888. [CrossRef] [PubMed]

427. Nubling, M.; Rieger, M.A.; Batsford, S.; Wagner, M.; Wertenschlag, E.; Hofmann, F. Seroprevalence of infection with Borrelia burgdorferi s. l. in two adjacent regions of eastern France and southwestern Germany. *Int. J. Med. Microbiol.* **2002**, *291* (Suppl. 33), 218. [CrossRef] [PubMed]

428. Sevestre, J.; Benichou, A.; Rio, V.; Delaunay, P.; Gonfrier, G.; Martaresche, C.; Carlo, V.; Nakam, S.; Mondain, V.; Carles, M.; et al. Emergence of Lyme Disease on the French Riviera, a Retrospective Survey. *Front. Med.* **2022**, *9*, 737854. [CrossRef] [PubMed]

429. Letrilliart, L.; Ragon, B.; Hanslik, T.; Flahault, A. Lyme disease in France: A primary care-based prospective study. *Epidemiol. Infect.* **2005**, *133*, 935–942. [CrossRef] [PubMed]
430. Frey, M.; Jaulhac, B.; Piemont, Y.; Marcellin, L.; Boohs, P.-M.; Vautravers, P.; Jesel, M.; Kuntz, J.-L.; Monteil, H.; Sibilia, J. Detection of Borrelia burgdorferi DNA in muscle of patients with chronic myalgia related to Lyme disease. *Am. J. Med.* **1998**, *104*, 591–594.
[CrossRef] [PubMed]

431. Mercier, G.; Burckel, A.; Lucotte, G. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in urine specimens of patients with erythema migrans lesions. *Mol. Cell. Probes* **1997**, *11*, 89–94. [CrossRef] [PubMed]

432. Christiann, F.; Rayet, P.; Patey, O.; Lafaix, C. Epidemiology of lyme disease in France: Lyme borreliosis in the region of Berry sud: A six year retrospective. *Eur. J. Epidemiol.* **1996**, *12*, 479–483. [CrossRef]

433. Dhôte, R.; Basse-Guerineau, A.L.; Beaumesnil, V.; Christoforov, B.; Assous, M.V. Full spectrum of clinical, serological, and epidemiological features of complicated forms of Lyme borreliosis in the Paris, France, area. *Eur. J. Clin. Microbiol. Infect. Dis.* **2000**, *19*, 809–815. [CrossRef]

434. Arzouni, J.P.; Laveran, M.; Beytout, J.; Ramousse, O.; Raoult, D. Comparison of western blot and microimmunofluorescence as tools for lyme disease seroepidemiology. *Eur. J. Epidemiol.* **1993**, *9*, 269–273. [CrossRef]

435. Septfons, A.; Rigaud, E.; Benezet, L.; Velay, A.; Zilliox, L.; Baldinger, L.; Gonzalez, G.; Figoni, J.; de Valk, H.; Deffontaines, G.; et al. Seroprevalence for Borrelia burgdorferi sensu lato and tick-borne encephalitis virus antibodies and associated risk factors among forestry workers in northern France, 2019 to 2020. *Eurosurveillance* **2023**, *28*. [CrossRef]

436. Bonnet, C.; Figoni, J.; Souty, C.; Septfons, A.; de Martino, S.; de Valk, H.; Fournier, L.; Hanslik, T.; Jaulhac, B.; Blanchon, T. Prevalence and factors associated with a prescription of a Lyme borreliosis serology for erythema migrans diagnosis in general practice: A study from the French sentinel network, 2009–2020. *BMC Prim. Care* **2023**, *24*, 163. [CrossRef]

437. Zhioua, E.; Rodhain, F.; Binet, P.; Perez-Eid, C. Prevalence of antibodies to Borrelia burgdorferi in forestry workers of Ile de France, France. *Eur. J. Epidemiol.* **1997**, *13*, 959–962. [CrossRef]

438. Corre, C.; Coiffier, G.; Le Goff, B.; Ferreyra, M.; Guennic, X.; Patrat-Delon, S.; Degeilh, B.; Albert, J.-D.; Tattevin, P. Lyme arthritis in Western Europe: A multicentre retrospective study. *Eur. J. Clin. Microbiol. Infect. Dis.* **2022**, *41*, 21–27. [CrossRef]

439. Jaulhac, B.; Heller, R.; Limbach, F.X.; Hansmann, Y.; Lipsker, D.; Monteil, H.; Sibilia, J.; Piemont, Y. Direct Molecular Typing of *Borrelia burgdorferi* Sensu Lato Species from Synovial Samples from Patients with Lyme Arthritis. *J. Clin. Microbiol.* **2000**, *38*, 1895–1900. [CrossRef]

440. Gocko, X.; Lenormand, C.; Lemogne, C.; Bouiller, K.; Gehanno, J.-F.; Rabaud, C.; Perrot, S.; Eldin, C.; de Broucker, T.; Roblot, F.; et al. Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies. *Med. Mal. Infect.* **2019**, *49*, 296–317. [CrossRef]

441. Assous, M.V.; Postic, D.; Paul, G.; Nevot, P.; Baranton, G. Western blot analysis of sera from Lyme borreliosis patients according to the genomic species of the Borrelia strains used as antigens. *Eur. J. Clin. Microbiol. Infect. Dis.* **1993**, *12*, 261–268. [CrossRef]

442. Bauvin, O.; Schmutz, J.-L.; De Martino, S.; Busato, T.; Cribier, B.; Barbaud, A.; Wahl, D.; Bursztejn, A.-C. A foot tumour as late cutaneous Lyme borreliosis: A new entity? *Br. J. Dermatol.* **2017**, *177*, 1127–1130. [CrossRef]

443. del Giudice, P.; Reverte, M.; Giraudon, E.; Durant, J.; Ahmed Abdoulah, S.; Jaulhac, B.; Poirier, J.-P. First case of documented Lyme borreliosis in the Alpes-Maritimes department of South-Eastern France: Erythema chronicum migrans associated with Borrelia afzelii. *Ann. Dermatol. Venereol.* **2022**, *149*, 146–147. [CrossRef]

444. Gallais, F.; De Martino, S.J.; Sauleau, E.A.; Hansmann, Y.; Lipsker, D.; Lenormand, C.; Talagrand-Reboul, E.; Boyer, P.H.; Boulanger, N.; Jaulhac, B.; et al. Multilocus sequence typing of clinica *Borrelia afzelii* strains: Population structure and differential ability to disseminate in humans. *Parasites Vectors* **2018**, *11*, 374. [CrossRef]

445. Lenormand, C.; Jaulhac, B.; Debarbieux, S.; Dupin, N.; Granel-Brocard, F.; Adamski, H.; Barthel, C.; Cribier, B.; Lipsker, D. Expanding the clinicopathological spectrum of late cutaneous Lyme borreliosis (acrodermatitis chronica atrophicans [ACA]): A prospective study of 20 culture- and/or polymerase chain reaction (PCR)-documented cases. *J. Am. Acad. Dermatol.* **2016**, *74*, 685–692. [CrossRef]

446. Coipan, E.C.; Jahfari, S.; Fonville, M.; Oei, G.A.; Spanjaard, L.; Takumi, K.; Hovius, J.W.; Sprong, H. Imbalanced presence of Borrelia burgdorferi s.l. multilocus sequence types in clinical manifestations of Lyme borreliosis. *Infect. Genet. Evol.* **2016**, *42*, 66–76. [CrossRef]

447. Jacquot, M.; Abrial, D.; Gasqui, P.; Bord, S.; Marsot, M.; Masseglia, S.; Pion, A.; Poux, V.; Zilliox, L.; Chapuis, J.-L.; et al. Multiple independent transmission cycles of a tick-borne pathogen within a local host community. *Sci. Rep.* **2016**, *6*, 31273. [CrossRef]

448. Eiferman, V.; Guenno, G.L.; Boiret-Dupre, N.; Barres, B.; Luciani, L.; Fournier, P.E. Atypical *Borrelia garinii* infection in an immunocompromised patient mimicking high-grade lymphoma. *Int. J. Infect. Dis.* **2022**, *121*, 102–104. [CrossRef]

449. Duffau, P.; Korbi, S.; Guillotin, V.; Talagrand-Reboul, E.; Menard, A.; Peuchant, O. An unexpected case of *Borrelia garinii* liver infection. *Ann. Clin. Microbiol. Antimicrob.* **2022**, *21*, 15. [CrossRef]

450. Limbach, F.X.; Jaulhac, B.; Puechal, X.; Monteil, H.; Kuntz, J.L.; Piemont, Y.; Sibilia, J. Treatment resistant Lyme arthritis caused by Borrelia garinii. *Ann. Rheum. Dis.* **2001**, *60*, 284–286. [CrossRef]

451. Calderaro, A.; Montecchini, S.; Gorrini, C.; Piccolo, G.; Chezzi, C.; Dettori, G. Presence of anti-Borrelia burgdorferi antibodies and Borrelia burgdorferi sensu lato DNA in samples of subjects in an area of the Northern Italy in the period 2002–2008. *Diagn. Microbiol. Infect. Dis.* **2011**, *70*, 455–460. [CrossRef]

452. Santino, I.; Iori, A.; Sessa, R.; Sulli, C.; Favia, G.; Del Piano, M. *Borrelia burgdorferi* s.l. and *Ehrlichia chaffeensis* in the National Park of Abruzzo. *FEMS Microbiol. Lett.* **1998**, *164*, 1–6. [CrossRef]