Over recent years, a multitude of pathogens have been reported to be tick-borne. Given this, it is unsurprising that these might co-exist within the same tick, however our understanding of the interactions of these agents both within the tick and vertebrate host remains poorly defined. Despite the rich diversity of ticks, relatively few regularly feed on humans, 12 belonging to argasid and 20 ixodid species, and literature on co-infection is only available for a few of these species. The interplay of various pathogen combinations upon the vertebrate host and tick vector represents a current knowledge gap. The impact of co-infection in humans further extends into diagnostic challenges arising when multiple pathogens are encountered and we have little current data upon which to make therapeutic recommendations for those with multiple infections. Despite these short-comings, there is now increasing recognition of co-infections and current research efforts are providing valuable insights into dynamics of pathogen interactions whether they facilitate or antagonise each other. Much of this existing data is focussed upon simultaneous infection, however the consequences of sequential infection also need to be addressed. To this end, it is timely to review current understanding and highlight those areas still to address.
Keywords: Anaplasma; Babesia; Borrelia; Co-infections; Relapsing fever; Rickettsia; TBEv; Tick-borne pathogens; Vector-host transmission.
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