About 500 million cases of malaria occur annually. However, a substantial number of patients who actually have relapsing fever (RF) Borrelia infection can be misdiagnosed with malaria due to similar manifestations and geographic distributions of the two diseases. More alarmingly, a high prevalence of concomitant infections with malaria and RF Borrelia has been reported. Therefore, we used a mouse model to study the effects of such mixed infection. We observed a 21-fold increase in spirochete titers, whereas the numbers of parasitized erythrocytes were reduced 15-fold. This may be explained by polarization of the host immune response toward the intracellular malaria parasite, resulting in unaffected extracellular spirochetes and hosts that succumb to sepsis. Mixed infection also resulted in severe malaria anemia with low hemoglobin levels, even though the parasite counts were low. Overall, coinfected animals had a higher fatality rate and shorter time to death than those with either malaria or RF single infection. Furthermore, secondary malaria infection reactivated a quiescent RF brain infection, which is the first evidence of a clinically and biologically relevant cue for reactivation of RF Borrelia infection. Our study highlights the importance of investigating concomitant infections in vivo to elucidate the immune responses that are involved in the clinical outcome.In the developing world, concomitant infections are the rule rather than the exception, and the complete clinical picture involves several microorganisms that influence each other as well as the host (8). Malaria is by far the most devastating acute febrile illness in humans, and it is caused by parasitic protozoa of the genus Plasmodium. The World Health Organization (WHO) has estimated that this disease is responsible for 1.5 to 2.7 million deaths annually, and about 1 million of those cases occur in children under the age of 5 years (24,28). Considering that the most prominent symptom of malaria is fever (4) and that the WHO advises that a presumptive malaria diagnosis be made in areas where malaria is endemic, it is plausible that misdiagnoses can be made in patients who are not suffering from malaria or who have a concomitant infection (14). This assumption is supported by the results of a field study conducted by our research team in Togo, West Africa, in which 8.8% of febrile patients diagnosed as having malaria were subsequently found to have relapsing fever (RF) borreliosis, which is caused by spirochete bacteria of the genus Borrelia (21). This could be simply due to incorrect malaria diagnosis, which is plausible since both Plasmodium and RF Borrelia cause systemic infections with similar manifestations that involve recurrent fever, anemia, and hepatosplenomegaly. It could also be due to malaria/RF coinfection, which makes a correct diagnosis even more complex. Moreover, medical personnel are generally not aware of the existence of RF borreliosis, even though the incidence of that condition in countries such as Senegal is the highest des...