A case of Borrelia afzelii hepatitis in an immunocompromised patient highlights increased clinician awareness and the need for molecular testing.

We report a case of Borrelia afzelii hepatitis in an immunosuppressed patient receiving anti-CD20 therapy and venetoclax. Diagnosis was made by metagenomic sequencing and PCR. This case underscores the need to consider Lyme borreliosis in unexplained hepatitis and highlights the value of molecular diagnostics in immunosuppressed patients when serological tests are negative.