Seronegative Lyme disease. Dissociation of specific T- and B-lymphocyte responses to Borrelia burgdorferi

Management of Lyme arthritis

Musculoskeletal complaints and findings can be features of Lyme disease and can occur following treatment. Only with a good understanding of the pathogenesis of these problems can further evaluation and a proper therapeutic scheme be developed.

Maternal Lyme disease and congenital heart disease: A case-control study in an endemic area

OBJECTIVE

The purpose of this study was to determine whether maternal Lyme disease increases the risk of congenital heart defect.

STUDY DESIGN

This retrospective case-control study was carried out at a medical center in a suburban area where Lyme disease is endemic. Case patients comprised 796 children with a diagnosis of congenital cardiac anomaly. Control subjects comprised 704 children without cardiac defects selected from the records of the same pediatric cardiology service. Maternal histories were obtained through a mailed questionnaire survey. Unconditional logistic regression analyses examined the relationship between a history of preconception and prenatal clinical Lyme disease or tick bite and case or control status.

RESULTS

There was no association between congenital heart defect and maternal tick bite (adjusted odds ratio 1.1, 95% confidence interval 0.5-2.5) or maternal Lyme disease within 3 months of conception or during pregnancy (adjusted odds ratio 0.9; 95% confidence interval 0.2-3.6).

CONCLUSION

A woman who has been bitten by a tick or is treated for Lyme disease during or before pregnancy is not at increased risk for giving birth to a child with a congenital heart defect.

Successful vaccination for Lyme disease:a novel mechanism

Two vaccines are on the horizon for the prevention of Lyme disease, the most common vector-borne illness in the US and Europe. This review describes the pathogenesis and clinical illness of Lyme disease, as well as the sequence of events that led to the development of these novel vaccines. The results of the most recent Phase III human trials are reported.

Musculoskeletal manifestations of Lyme arthritis

Lyme disease is a treatable and curable infectious disease that can be diagnosed with relative confidence with attention to the details of the syndrome and proper use of serologic testing to confirm the clinical diagnosis. Lyme disease should not be a "diagnosis of exclusion," made on the basis of isolated serologic reactivity or because of the presence of symptoms compatible with Lyme disease. The pathogenesis of chronic complaints following infection with B. burgdorferi is often unclear, but such persistent complaints should not automatically be ascribed to ongoing infection. There is no proven role for long-term antibiotics or combination regimens.

Clearance of Borrelia burgdorferi may not be required for resistance to experimental lyme arthritis

Infection of inbred mouse strains with Borrelia burgdorferi results in the development of experimental Lyme arthritis. The degree of arthritic pathology has been suggested to correlate with the level of spirochete burden within tissues. To investigate this further, we infected resistant DBA/2 (DBA) and susceptible C3H/HeJ (C3H) mice in the hind footpads and monitored arthritis development for 21 days. To quantitate levels of spirochetes within tissues, we created a competitive PCR molecule containing modified ospA and fla gene segments. C3H mice developed severe arthritis of the tibiotarsal joints, while DBA mice developed only mild inflammation throughout the experimental period. At day 21, when the gross size and histologic composition of ankles revealed significant differences in arthritis between the strains, there was little difference in levels of spirochete DNA as determined by competitive PCR. Cultures of ankle tissue at day 21 were also uniformly positive in both C3H and DBA animals and contained relatively similar levels of spirochetes. These results indicate that the presence of spirochetes in the ankles of experimental animals is not sufficient for arthritis development. Since arthritic and nonarthritic animals can harbor relatively equal spirochete burdens yet retain their distinct phenotypic outcomes, an aberrant or overly exuberant immune response may be an additional requirement for pathology in arthritis-prone mice.

The polymerase chain reaction in infectious and post-infectious arthritis. A review

Polymerase chain reaction and other DNA amplification techniques to identify elusive infections should prove to be an effective tool for the clinical and investigative rheumatologist. The capability to identify and characterize infectious organisms in fluids and tissue will enable early, specific, and potentially curative treatment. Similarly, the capability to exclude infection and differentiate postinfectious diseases will enable other therapies to control the inflammation. Understanding these molecular techniques will most certainly improve clinicians' effectiveness for diagnosis and care.

Nervous system Lyme disease

Lyme disease is a multisystem infectious disease caused by tick-borne spirochetes of the Borrelia burgdorferi group. The disease occurs primarily in specific areas of North America, Europe and Asia, reflecting the distribution of the hard-shelled Ixodes ticks that are required for disease transmission. Diagnosis of this infection can be somewhat problematic, although in clinically appropriate settings, serologic testing can be highly useful, particularly if Western blots are used to confirm borderline or positive results. The organism has several specific organotropisms-involvement of the heart, joints and nervous system being particularly common. The nervous system can be involved in one or more ways. Early in infection, patients tend to get a lymphocytic meningitis, cranial neuritis (particularly the facial nerves) or a painful radiculitis. Rarely, an encephalomyelitis can occur. In patients with more protracted and indolent involvement, a more disseminated mononeuropathy multiplex may occur, or a mild, non-focal alteration of cognitive function and memory, i.e. an encephalopathy. In patients with central nervous system involvement, the most sensitive diagnostic test is the demonstration of intrathecal production of anti-Borrelia burgdorferi antibody. Culture, polymerase chain reaction and other techniques appear to be less specific. In most instances, the disease is quite responsive to antimicrobial therapy. Oral treatment with doxycycline has been shown to be effective in meningitis. In more serious cases two to four week courses of parenteral ceffriaxone or cefotaxime are effective in the vast majority of patients.

Sudeck's atrophy in Lyme borreliosis

A patient with disseminated Lyme borreliosis is reported. The patient suffered from erythema migrans and radicular pain. Serologic tests routinely performed (IFT, ELISA, Western blots with different strains and Borrelia-LTT) were negative. However, Borrelia burgdorferi (genotype Borrelia afzelii) was cultivated from a skin biopsy. Western blot with the patient's isolate and sera showed strong reactivity only with the 60 kDa protein. In spite of immediate diagnosis and intravenous antibiotic treatment according to current recommendations he developed pain in the right ankle, which was resistant to further antibiotic and anti-inflammatory therapy. Sudeck's atrophy was diagnosed by X-ray. Treatment with calcitonin brought immediate relief from pain and led to radiographically demonstrable recalcification.

Lyme disease: a review of aspects of its immunology and immunopathogenesis

Lyme disease, caused by Borrelia burgdorferi, causes a multisystem inflammatory ailment, although the precise means of tissue damage are not well understood. It is clear that the organism is present at the site of inflammation in many organs and that many of the features of the illness are relieved by antibiotic therapy. A complex interaction between spirochete and immune systems of a number of mammalian hosts, in human disease and animal models, has been described. It is clear that T cells and macrophages are intimately associated with the pathogenesis of arthritis and that immune mechanisms are involved in other aspects of disease. Inflammation directed at persistence of Borrelial antigens is a plausible explanation for persisting arthritis. Autoimmunity based on molecular mimicry may play a role in the pathogenesis of Lyme disease. Humoral immunity plays a protective role, prompting interest in vaccine development. Significant variation in certain of the outer surface proteins suggests that multiple proteins, peptides, or chimeric vaccines may be needed to provide a sufficiently broad humoral protective response.

Diagnosis and treatment of Lyme arthritis

Lyme arthritis typically causes intermittent attacks of oligoarticular arthritis in a few large joints, especially the knee. A small percentage of patients may develop chronic arthritis, again affecting primarily the knee. The diagnosis is usually based on the presence of this characteristic clinical picture, exposure in an endemic area, and a positive IgG antibody response to B. burgdorferi determined by ELISA and Western blotting. In addition, spirochetal DNA can often be detected in joint fluid by PCR. Joint involvement in this infection can usually be treated successfully with a 1- or 2-month course of oral doxycycline or amoxicillin, but patients with certain genetic and immune markers may have persistent arthritis despite treatment with oral or intravenous antibiotics. If patients have persistent arthritis despite a second course of antibiotics and if the results of PCR testing are negative, the author treats such patients with anti-inflammatory agents or arthroscopic synovectomy.

New laboratory guidelines for serologic diagnosis of Lyme disease: evaluation of the two-test protocol

Recent guidelines established by the Association of State and Territorial Public Health Laboratory Directors (ASTPHLD) and the U.S. Centers for Disease Control and Prevention (CDC) recommend the use of a two-test protocol for the serologic diagnosis of Lyme disease (LD). The two-test protocol relies on a sensitive screening test, which is followed by specific immunoglobulin M (IgM) and/or IgG immunoblotting (IB), depending on the date of disease onset, of all samples with equivocal and positive screening test results. We evaluated a commercially available IgM-IgG enzyme-linked immunosorbent assay (ELISA) and separate IB tests for IgM and IgG antibodies to Borrelia burgdorferi as candidate assays for the two-test protocol. Serum samples obtained from healthy controls (n = 29), from patients with diagnoses or laboratory findings associated with serologic cross-reactivity to LD (n = 24), and from patients with well-documented early- and late-stage LD provided by the CDC and the College of American Pathologists (n = 53) were examined to determine each assay's individual sensitivity and specificity. No false-positive results were detected among the healthy controls by either ELISA or IB, whereas four false-positive ELISA results were recorded within the cross-reactive group. None of these sera, however, were positive for either IgM or IgG reactivity according to IB band criteria. With regard to the patients with LD, we determined the sensitivity and specificity of the ELISA to be 96 and 100%, respectively, compared with the reference data provided for these specimens. When we compared our IB results with data from CDC, the assay sensitivity and specificity were 80 and 96.2%, respectively, for IgM and 81.8 and 95.8%, respectively, for IgG. Pursuant to this evaluation we assessed the suitability of the two-test protocol by performing a retrospective analysis using clinical history to define samples as positive or negative for LD. We determined clinical sensitivity and specificity for all study subjects (n = 112) to be 50 and 100%, respectively. A reduction in the clinical sensitivity of the two-test protocol was associated with a lack of antibody response or seroconversion in LD patients treated with antibiotics. We conclude that the CDC-ASTPHLD guidelines provide useful criteria for test performance and interpretation aimed at standardizing the serologic diagnosis of LD.

The outer surface lipoprotein OspA of Borrelia burgdorferi provides co-stimulatory signals to normal human peripheral CD4+ and CD8+ T lymphocytes

Studies in man and mice have indicated that T cells induced during Borrelia burgdorferi infection are involved in the pathogenesis of the disease. We analyzed the ability of B. burgdorferi to provide co-stimulatory signals to highly enriched normal human CD2+ T lymphocytes in the presence of suboptimal concentrations of immobilized anti-CD3 antibodies. Here we show that the lipid-containing recombinant outer surface lipoprotein A (rlip-OspA) of B. burgdorferi but not its delipidated derivative rNS1-OspA augmented CD3-induced T cell proliferation in a dose-dependent manner and at levels similar to that obtained with anti-CD28 antibodies. Lipopolysaccharide had no effect in this system at any concentration tested, suggesting that the active principle of co-stimulation is associated with the lipid moiety of rlip-OspA and distinct from conventional lipid A. Furthermore, incubation of CD2+ T cells or selected CD4+ as well as CD8+ subpopulations with rlip-OspA, but not with rNS1-OspA led to the production of interferon (IFN)-gamma, interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha, but not IL-4. In contrast, co-stimulation of the respective T cell populations with anti-CD28 antibodies resulted in the generation of IFN-gamma, IL-4 and TNF-alpha, but not IL-6. This indicated that the signal transduction pathway induced by rlip-OspA is distinct from that elicited via the CD28 receptor. Co-stimulation of T cells with rlip-OspA also resulted in the development of cytolytic effector cells. In light of the fact that inflamed tissues of B. burgdorferi-infected hosts contain blood leukocytes together with spirochetes, their degradation products, or both, these results suggest that infiltrating CD4+ and CD8+ T cells of any specificities, including spirochetes, autoantigens, or both, participate in the pathogenesis of Lyme disease.

Detection of Borrelia burgdorferi by DNA amplification in synovial tissue samples from patients with Lyme arthritis

OBJECTIVE

To compare the detection rates of chromosomal flagellin gene from Borrelia burgdorferi in synovial tissue (ST) and synovial fluid (SF) using polymerase chain reaction (PCR) techniques.

METHODS

B burgdorferi DNA was sought in SF and ST from 12 consecutive patients with Lyme arthritis and from 29 patients with noninfectious diseases (controls).

RESULTS

No DNA amplification was observed in samples obtained from the 29 control patients, whereas B burgdorferi DNA was detected in all ST and/or SF samples from the 12 patients with Lyme arthritis. Results from 1 ST sample were not interpretable because of PCR inhibitors. Among the 11 remaining patients, 10 had positive ST samples, whereas only 4 had positive SF samples (P < 0.05).

CONCLUSION

These data suggest that detection of chromosomal B burgdorferi DNA may be more efficient in ST than SF.

Bone marrow-derived macrophage lines and immortalized cloned macrophage and dendritic cells support priming of Borrelia burgdorferi--specific T cell responses in vitro and/or in vivo

In vitro propagated bone marrow-derived macrophage populations (BMMO) as well as cloned immortalized macrophage (MT2/1) and dendritic (D2SC/1) cell lines were analyzed for their capacity to promote activation and/or proliferation of naïve T cells to Borrelia burgdorferi antigens in vitro and in vivo. All three cell types constitutively express high levels of MHC class I structures as well as the co-stimulatory molecules B7/BB1 and heat-stable antigen (HSA); MHC class II molecules (I-A) are upregulated following incubation with either intact spirochetes or the purified lipoprotein OspA (Lip-OspA) but not with its delipidated from (MDP-OspA). Only BMMO were able to induce proliferation of naïve T cells or T cells derived from infected mice to intact spirochetes in vitro. However, all three accessory populations could support primary and secondary T cell responses to Lip-OspA but not, or only marginally, to MDP-OspA under similar conditions. The number of accessory cells required for optimal stimulation of naïve or pre-sensitized T cells was approximately 3 x lower for D2SC 1 than for BMMO or MT2/1. In addition, BMMO pre-pulsed with Lip-OspA were able to prime T cells in vivo, indicating a crucial role for the lipid moiety in antigen presentation. From two truncated lipopeptides of Lip-OspA containing either 20 or 6 aminoterminal residues, only Lip-OspApep20 but not Lip-OspApep6 induced significant proliferation in naïve for pre-sensitized T cells in vitro, suggesting that T cells mainly respond to the protein rather than the lipid moiety of OspA. Thus, the data demonstrate that BMMO, MT2/1 and D2SC/1 have differential capacities to prime spirochete-reactive T cells and to support their growth in vitro, suggesting that optimal activation and propagation of T cells also depends on the quality of the antigen.

Lymphoproliferative responses to Borrelia burgdorferi in the diagnosis of Lyme arthritis in children and adolescents

To assess the contribution of the lymphocyte proliferation assay in response to borrelial antigens to establishing a diagnosis of Lyme arthritis (LA) the response to two strains of Borrelia burgdorferi was tested in peripheral blood lymphocytes of 103 children and adolescents with arthritis, among them 55 with LA and 48 control patients. Patients with LA had a significantly higher response to borrelial antigens than control patients. However, there were several patients with false positive and false negative test results. Specificity and sensitivity of the test were 78% and 77%. In patients with LA the test may turn positive after antibiotic therapy and remain positive for up to 19 months after the disappearance of arthritis. The test does not aid in prognosis or follow up. In one patient with seronegative LA specific lymphocyte proliferation and polymerase chain reaction for borrelial fla sequences in urine were positive.

CONCLUSION

Rarely the lymphocyte proliferation assay may aid in finding the correct diagnosis when clinical presentation and anti-borrelial serology do not match.

Physician preferences in the diagnosis and treatment of Lyme disease in the United States

To assess physician preferences in the diagnosis and treatment of Lyme disease, questionnaires were sent to physicians in various Lyme disease endemic areas in the U.S. Seventy-eight responses were analyzed. Both ELISA and Western blot were ordered by 86% of responders. Fifty percent of responders believed that 25% or more of patients who have Lyme disease were seronegative. The treatment was influenced by physician specialty. Antibiotic treatment for tick bite was prescribed by 20% of responders. Erythema migrans rash was treated by all responders without serologic confirmation. The median treatment duration of erythema migrans was 4 weeks. For post-erythema migrans Lyme disease, 43% of responders treat 3 months or more; for chronic Lyme disease, 57% of responders treat 3 months or more. Our survey documents significant differences between published recommendations and actual practices. Physician education and clinical trials are needed to clarify the reasons for these differences.

Use of recombinant antigens of Borrelia burgdorferi in serologic tests for diagnosis of lyme borreliosis

Recombinant antigens of outer surface proteins (Osps) OspA, OspB, OspC, OspE, and OspF of Borrelia burgdorferi sensu stricto and of p41-G, an antigenic region of flagellin of this spirochete, were tested with human sera in class-specific and polyvalent enzyme-linked immunosorbent assays (ELISAs). In analyses for immunoglobulin M (IgM) antibodies, 18 (85.7%) of 21 serum samples from persons who had been diagnosed as having Lyme borreliosis on the basis of the presence of erythema migrans reacted positively in ELISAs with one or more Osp antigens or the p41-G antigen. Eleven serum samples contained antibodies to OspC antigen, and of these, six also reacted to the p41-G antigen and to one or more of the other recombinant antigens. The remaining five serum samples reacted solely to OspC (n = 4) or to OspC plus OspA and OspE without reactivity to p41-G (n = 1). In analyses for IgG antibodies, seropositivity was comparable to that of IgM analyses and was marked by predominant reactivity to p41-G, OspC, and OspF. Similarly, all 21 serum samples were positive in polyvalent and class-specific ELISAs with whole-cell B. burgdorferi. Minor cross-reactivity was noted when sera from persons who had syphilis, periodontitis or other oral infections, or rheumatoid arthritis were tested with OspC, OspE, OspF, and p41-G. With relatively high degrees of specificity, ELISAs with recombinant antigens, particularly OspC and p41-G, can help to confirm B. burgdorferi infections.

Polymerase chain reaction control of antibiotic treatment in dermatoborreliosis

Assessment of the efficacy of an antibiotic drug used in patients with various manifestations of dermatoborreliosis is crucial. Clinical judgement alone (resolution of the present dermatologic lesion, prevention of later major or minor sequelae) is not sufficient in erythema migrans and acrodermatitis chronica atrophicans. Thus, laboratory tests are desirable to prove the benefit of an antimicrobial agent. It was intended to establish a constant parameter--besides the clinical picture--for assessing the efficacy of antibiotic treatment in patients with dermatoborreliosis in terms of eradication of Borrelia burgdorferi from the site of infection. Polymerase chain reaction (PCR) was therefore performed from pretreatment biopsy specimens from lesional skin of 36 erythema migrans patients (m:f = 15:21, mean age 49 years) and seven acrodermatitis chronica atrophicans patients (m:f = 0:7, mean age 59 years), respectively. After antibiotic therapy with minocycline (100 mg, orally twice daily, 14 days) for erythema migrans, and ceftriaxone (2 g, intravenously once daily, 14 days) for acrodermatitis chronica atrophicans another punch biopsy was obtained and analysed by PCR. In pretreatment specimens, B. burgdorferi-specific DNA was amplified by PCR in 23/36 erythema migrans patients (69%), and in 5/7 acrodermatitis chronica atrophicans patients (71%). After antibiotic therapy, PCR yielded negative results in all of these cases. Clinically, all patients showed complete recovery or at least marked improvement of lesions at this time. PCR appears to be a reliable parameter for the assessment of the efficacy of antibiotic treatment in dermatoborreliosis.

Lyme neuroborreliosis: evidence for persistent up-regulation of Borrelia burgdorferi-reactive cells secreting interferon-gamma

The T-cell response to the aetiologic pathogen Borrelia (B.) burgdorferi in patients with Lyme neuroborreliosis (LN) and in control patients with other neurological diseases was examined by enumerating B. burgdorferi-reactive T cells secreting interferon-gamma (IFN-gamma) with an ELIspot assay. LN patients had elevated numbers of B. burgdorferi-reactive IFN-gamma secreting cells in blood and approximately 20-fold enriched in the cerebrospinal fluid (CSF). A positive correlation existed in CSF between B. burgdorferi-reactive IFN-gamma secreting cells and B cells secreting anti-B. burgdorferi IgG antibodies. The up-regulation of antigen-specific IFN-gamma secreting cells persisted in peripheral blood up to at least 9 months and in the CSF for at least 4 months after termination of treatment with antibiotics, when the patients were mostly free from clinical signs and symptoms due to LN. How IFN-gamma interplays with other cytokines and influences the pathogenesis of LN remains to be studied.

Sera from OspA-vaccinated dogs, but not those from tick-infected dogs, inhibit in vitro growth of Borrelia burgdorferi

Dogs were challenged with Borrelia burgdorferi by exposure to ticks, with or without prior protection from infection by recombinant OspA (rOspA) vaccination. Sera from these dogs were tested for their capability to inhibit the growth of B. burgdorferi in vitro. Bacterial growth was detected by a color change in the culture medium, and the optical density was measured with a spectrophotometer in microtiter plates. By growth inhibition, which was complement dependent, the color change was lacking after 5 days of incubation. Over a 1-year study, nonvaccinated dogs infected by exposure to ticks showed high antibody titers to B. burgdorferi by kinetic enzyme-linked immunosorbent assay (KELA). The same sera did not inhibit spirochetal growth or did so only at a low dilution. These results corresponded to the lack of OspA and OspB antibodies seen in Western blots (immunoblots), and these dogs were not protected from infection or disease. In contrast, dogs immunized with rOspA prior to challenge with infected ticks produced high antibody titers, as determined by KELA, but their sera also had high growth-inhibiting antibody titers. Western blot analysis showed a strong band in the 32-kDa region when the sera of these dogs were tested. When adjuvant was administered with rOspA, antibody titers by both KELA and growth inhibition were higher and persisted longer in the immunized dogs. All dogs immunized with rOspA were protected from infection and disease.

Antibodies against whole sonicated Borrelia burgdorferi spirochetes, 41-kilodalton flagellin, and P39 protein in patients with PCR- or culture-proven late Lyme borreliosis

The sensitivities and specificities of three enzyme-linked immunosorbent assays (ELISAs) for Borrelia burgdorferi antibodies were compared for 41 patients presenting with symptoms compatible with late Lyme borreliosis (LB) and 37 healthy controls. All subjects were living in southwestern Finland, where LB is endemic. Only patients with culture- or PCR-proven disease were enrolled in the study. The antigens of the ELISAs consisted of sonicated spirochetes, 41-kDa flagellin, and recombinant P39 protein of B. burgdorferi. Fifteen patients had strongly or moderately positive results in the serological assay(s), 19 patients had only weakly positive or borderline antibody levels, and the remaining 7 patients were seronegative by ELISA. The sensitivities of the ELISAs were 78.0% with sonicate antigen, 41.5% with 41-kDa flagellin, and 14.6% with P39 protein. The specificities of the tests were 89.2, 86.5, and 94.6%, respectively. The sonicate antigen ELISA seems to be an effective screening method. These results show that antibodies to B. burgdorferi may be present in low levels or even absent in patients with culture- or PCR-proven late LB. Therefore, in addition to serological testing, the use of PCR and cultivation is recommended in the diagnosis of LB.

The outer surface proteins of Lyme disease borrelia spirochetes stimulate T cells to secrete interferon-gamma (IFN-gamma): diagnostic and pathogenic implications

Late stages of borrelia Lyme disease infections may be difficult to diagnose because of unspecific symptoms and unreliable laboratory tests, being too unspecific or insensitive. The T cell immune response was thus evaluated in these patients by using a sensitive ELISPOT T cell assay that detects the secretion of IFN-gamma, i.e. a T helper 1 (Th1) response on the single-cell level. Three subcellular fractions of the Lyme borreliosis strain Borrelia afzelii were used for antigenic stimulation. The outer surface protein (Osp) fraction elicited the strongest response, discriminating between borrelia infections (n = 15) compared with other neurological diseases (n = 10) and normal controls (n = 12) (P = 0.0001). The more heterogeneous sonicated borrelia fraction also elicited a strong response, however, also in some of the controls. The flagellin fraction did not have a similar T cell-stimulating effect. When looking at subgroups of borrelia infections, central nervous system (CNS) infections (n = 7) revealed a lower T cell response in blood (P = 0.0128) compared with other borrelia manifestations (n = 8). Cerebrospinal fluid (CSF) lymphocytes were available from three patients with CNS borreliosis, and all showed a compartmentalization with higher responses to the Osp fraction in CSF compared with blood, also in the two patients without any intrathecal-specific antibody synthesis. The ELISPOT method is feasible for detecting a specific IFN-gamma T cell response in borrelia infections. This Th1 response may well be of pathogenic relevance.

Maternal Lyme disease and congenital malformations: a cord blood serosurvey in endemic and control areas

This report describes a cohort study of over 5000 infants and their mothers who participated in a cord blood serosurvey designed to examine the relationship between maternal exposure to Lyme disease and adverse pregnancy outcome. Based on serology and reported clinical history, mothers of infants in an endemic hospital cohort are 5 to 20 times more likely to have been exposed to B. burgdorferi as compared with mothers of infants in a control hospital cohort. The incidence of total congenital malformations was not significantly different in the endemic cohort compared with the control cohort, but the rate of cardiac malformations was significantly higher in the endemic cohort [odds ratio (OR) 2.40; 95% confidence interval (CI) 1.25, 4.59] and the frequencies of certain minor malformations (haemangiomas, polydactyly, and hydrocele), were significantly increased in the control group. Demographic variations could only account for differences in the frequency of polydactyly. Within the endemic cohort, there were no differences in the rate of major or minor malformations or mean birthweight by category of possible maternal exposure to Lyme disease or cord blood serology. The disparity between observations at the population and individual levels requires further investigation. The absence of association at the individual level in the endemic area could be because of the small number of women who were actually exposed either in terms of serology or clinical history. The reason for the findings at the population level is not known but could be because of artifact or population differences.

Musculoskeletal manifestations of Lyme disease

Musculoskeletal involvement, particularly arthritis, is a common feature of Lyme disease. Early in the illness, patients may experience migratory musculoskeletal pain in joints, bursae, tendons, muscle, or bone in one or a few locations at a time, frequently lasting only hours or days in a given location. Weeks to months later, after the development of a marked cellular and humoral immune response to the spirochete, untreated patients often have intermittent or chronic monoarticular or oligoarticular arthritis-primarily in large joints, especially the knee-during a period of several years. The diagnosis of Lyme arthritis is usually based on the presence of this characteristic clinical picture, exposure in an endemic area, and an elevated immunoglobulin G antibody response to Borrelia burgdorferi. In addition, spirochetal DNA can often be detected in joint fluid by polymerase chain reaction. Lyme arthritis can usually be treated successfully with 1-month courses of oral doxycycline or amoxicillin or with 2- to 4-week courses of intravenous ceftriaxone. However, patients with certain genetic and immune markers may have persistent arthritis, despite treatment with oral or intravenous antibiotics. B. burgdorferi may occasionally trigger fibromyalgia, a chronic pain syndrome with diffuse joint and muscle symptoms. This syndrome does not appear to respond to antibiotic therapy.

Diagnosis and clinical characteristics of ocular Lyme borreliosis

PURPOSE

To establish a diagnosis, in a group of patients we studied the characteristics of ocular Lyme borreliosis.

METHODS

During a two-year period, 236 patients with prolonged external ocular inflammation, uveitis, retinitis, optic neuritis, or unexplained neuro-ophthalmic symptoms were examined for Lyme borreliosis. Antibodies to Borrelia burgdorferi were measured by indirect ELISA and western blot. Cerebrospinal fluid was also analyzed by polymerase chain reaction.

RESULTS

Ocular Lyme borreliosis was diagnosed in ten patients on the basis of medical history, clinical findings, and serologic test results. Results of ELISA disclosed that five patients were seropositive, two patients showed borderline reactivity, and three patients were seronegative. Four of the five patients with borderline or negative results by ELISA had a positive result by western blot analysis. In one seropositive patient, polymerase chain reaction verified a gene of B. burgdorferi endoflagellin from the vitreous and cerebrospinal fluid specimen. In five of the six patients with known onset of the Borrelia infection, the ocular disorder appeared as a late manifestation. Abnormalities of the posterior segment of the eye, such as vitreitis, retinal vasculitis, neuroretinitis, choroiditis, and optic neuropathy were seen in six patients. Bilateral paralytic mydriasis, interstitial keratitis, episcleritis, and anterior uveitis were seen in one patient each.

CONCLUSIONS

Late-phase ocular Lyme borreliosis is probably underdiagnosed because of weak seropositivity or seronegativity in ELISA assays. Ocular borrelial manifestations show characteristics resembling those seen in syphilis.

Neopterin production and tryptophan degradation in acute Lyme neuroborreliosis versus late Lyme encephalopathy

Fourteen patients with Borrelia burgdorferi infection were investigated for possible abnormalities of tryptophan and neopterin metabolism. Four patients (2 were investigated before therapy, 2 when therapy had been already started) had acute Lyme neuroborreliosis, and 10 patients were investigated months to years after an acute infection. Increased concentrations of neopterin and of the tryptophan-degradation product, L-kynurenine, were detected in the cerebrospinal fluid of patients with acute Lyme neuroborreliosis; one patient presented with subnormal tryptophan. Similar but less marked changes were seen in the treated patients and in some of the patients with Lyme encephalopathy. No such abnormalities were seen in the serum of the patients. The data indicate a role of the immune system and particularly of endogenously formed cytokines, like interferon-gamma and tumour necrosis factor-alpha, effecting tryptophan and neopterin metabolism in patients with acute Lyme neuroborreliosis.

Western blot band intensity analysis. Application to the diagnosis of Lyme arthritis

OBJECTIVE

To determine the usefulness of quantitative band-intensity analysis of Western blots for the diagnosis of Lyme arthritis.

METHODS

IgG Western blots for antibodies to Borrelia burgdorferi were performed on sera from 39 patients with Lyme arthritis, 30 patients with syphilis, 50 patients with connective tissue diseases, and 10 healthy individuals. Band positions and band intensities were calculated using a computerized image analysis system.

RESULTS

Lyme arthritis patients had more bands and higher-intensity bands than did non-Lyme patients. The presence of at least 2 bands of moderate to high intensity (> 40 optical units) or at least 5 bands of lower intensity (> 20 optical units) was over 90% sensitive and 100% specific for the diagnosis of Lyme arthritis. A 60-kd band was present in all Lyme arthritis patients. The presence of an 83-, 39-, 21-, or 18-kd band was highly specific for Lyme arthritis.

CONCLUSION

Band intensity analysis increases the objectivity and accuracy of Western blot interpretation for the diagnosis of Lyme arthritis.

Early and specific antibody response to OspA in Lyme Disease

Borrelia burgdorferi (Bb), the cause of Lyme disease, has appeared not to evoke a detectable specific antibody response in humans until long after infection. This delayed response has been a biologic puzzle and has hampered early diagnosis. Antibody to the abundant organism-specific outer surface proteins, such as the 31-kD OspA, has rarely been detected less than 6 mo after infection. Antibody to a less organism-specific 41-kD flagellin protein, sharing common determinants with other bacteria and thus limiting its diagnostic potential, may appear after 4 to 6 wks. To investigate our hypothesis that specific antibody to OspA may actually be formed early but remain at low levels or bound in immune complexes, we analyzed serum samples from patients with concurrent erythema migrans (EM). This is the earliest sign of Lyme disease and occurs in 60-70% of patients, generally 4-14 d after infection. We used less conventional but more sensitive methods: biotin-avidin Western blots and immune complex dissociation techniques. Antibody specificity was confirmed with recombinant OspA. Specific complexed antibody to whole Bb and recombinant OspA was detected in 10 of 11 of the EM patients compared to 0 of 20 endemic area controls. IgM was the predominant isotype to OspA in these EM patients. Free IgM to OspA was found in half the EM cases. IgM to OspA was also detected in 10 of 10 European patients with EM who also had reactive T cells to recombinant OspA. In conclusion a specific antibody response to OspA occurs early in Lyme disease. This is likely to have diagnostic implications.

Sustained cellular immune responses to Borrelia burgdorferi: lack of correlation with clinical presentation and serology

Fifty-one patients with erythema migrans were followed up prospectively with serial clinical evaluations, serologic determinations for antiborrelial antibodies, and lymphocyte stimulation responses to Borrelia burgdorferi antigens to determine (i) the factors associated with sustained cellular immune responses and (ii) whether lymphocyte stimulation is a good indicator of prior exposure to B. burgdorferi in patients treated early after erythema migrans. Positive lymphocyte stimulation responses ( > 2 standard deviations above normal control values) were found in 15 (29%) of 51 patients 3 months after treatment for erythema migrans and in 8 (18%) of 44 patients 1 year posttreatment. Heightened lymphocyte responses were not associated with the number or duration of erythema migrans lesions prior to treatment, the mean size of the largest erythema migrans lesion, or the number of symptoms at the time of presentation. The development of Jarisch-Herxheimer reaction, choice of antibiotic, and clinical outcome also were not associated with a positive lymphoproliferation assay result. Changes in the lymphocyte stimulation indices between the two time points assessed (3 months and 1 year posttreatment) also did not correlate with the above variables. When serologic results and lymphoproliferative responses were evaluated as categorical or continuous variables, there were no correlations between values. One year after treatment for early Lyme disease, lymphocyte reactivity is not a good indicator of prior infection with B. burgdorferi.

Borrelia burgdorferi-induced ultrastructural alterations in human phagocytes: a clue to pathogenicity?

A chronic infection with the spirochaete Borrelia burgdorferi typically results in a multistage, multisystem illness. Thus, Lyme borreliosis may provide an interesting model to study the pathomechanisms of microbial persistence. In the present investigation, human peripheral blood monocytes, polymorphonuclear leukocytes, and synovial macrophages were incubated with B. burgdorferi and examined by light and electron microscopy. It was found that incubation with the spirochaetes induced distinct features in the phagocytes. Features which may be related to the pathogenesis of Lyme disease included the segmental uptake of spirochaetes with leaky lysosomes, the invagination of large membrane areas, the extra-lysosomal degradation of internalized B. burgdorferi cells and, finally, the formation of mononuclear syncytial cells and homotypic cell clusters. Features of unknown relevance were the occurrence of two types of cytoplasmic inclusion bodies and exocytic vesicles. These novel findings suggest that reactive alterations of the phagocytes may contribute to the pathogenesis of Lyme borreliosis, which could help to focus future histopathological studies. Moreover, these results may provide new insights into the pathogenesis of other infectious diseases characterized similarly by microbial persistence.

Evaluation of nine serological tests for diagnosis of Lyme borreliosis

Two hundred serum specimens including 13 sera from patients with early Lyme borreliosis, 21 patients with late Lyme borreliosis, 15 rheumatoid factor positive sera, 31 sera from patients with syphilis and 84 sera from healthy controls were used to evaluate the following assays for the detection of antibodies to Borrelia burgdorferi: two in-house enzyme immunoassays (EIAs), two in-house immunofluorescent antibody assays (IFAs), a commercial haemagglutination assay (HA) (Diagast) and four commercial EIAs (Diagast, Dako, Diamedix, Whittaker Bioproducts). In early and late Lyme borreliosis sera sensitivity ranged from 8% to 62% and from 62% to 86% respectively. With the exception of the Dako EIA, which was signifcantly more sensitive in early Lyme borreliosis (62%) than the Diagast HA (8%) (p = 0.05), differences in sensitivity were not significant. In healthy controls the specificity was > or = 95% for all tests. Taking into account sensitivity, specificity, intra-test and inter-test precision, ease of performance and cost, the Dako EIA and Diamedix EIA were shown to be good alternatives to the in-house EIA and in-house IFA. Because of its low sensitivity in diagnosis of both early and late Lyme borreliosis, use of the Diagast HA should be discouraged.

Predictive value of serology in diagnosing Lyme borreliosis

AIMS

To compare the predictive value of immunoblotting and enzyme linked immunosorbent assay (ELISA) in diagnosing Lyme borreliosis.

METHODS

An ELISA using a whole cell sonicate of the B31 strain of Borrelia burgdorferi was used to screen samples submitted for Lyme borreliosis serology. A total of 1222 serum samples reactive in the ELISA were tested by immunoblotting also using the B31 strain. Patients with other spirochaetal diseases were tested by both methods to assess specificity, while those with erythema migrans were used to evaluate sensitivity. Subjects with different clinical conditions, which may have been associated with Lyme borreliosis, were tested using both techniques.

RESULTS

Only 16.3% of serum samples from patients submitted for Lyme borreliosis serology which were reactive by ELISA were confirmed as positive by immunoblotting. This is unlikely to represent a sensitivity problem as 51% of samples from 53 patients with erythema migrans were detected by immunoblotting compared with only 28% by ELISA. Patients whose samples were negative by ELISA were also negative by immunoblotting. Serum samples from patients with relapsing fever were reactive in both ELISA and by immunoblotting, but for other test groups immunoblotting offered increased specificity.

CONCLUSIONS

Not all ELISA results could be confirmed by immunoblotting. Yet immunoblotting was both more sensitive and specific than ELISA techniques. As a result of these observations all ELISA results should be serologically confirmed by immunoblotting. Though immunoblotting is not suited to large scale screening of samples, it can be used satisfactorily in conjunction with ELISA methods to improve the predictive value of serological tests for Lyme borreliosis.

Physician beliefs, attitudes, and approaches toward Lyme disease in an endemic area

To assess the beliefs and practice habits regarding Lyme disease among practitioners, questionnaires were sent to physicians in a seven-county Lyme-endemic region. One hundred twenty-four evaluable responses were returned from 53 family physicians, 39 pediatricians, 27 internists, and five subspecialists who diagnosed three to four cases of Lyme disease per year, on average. The majority presented with erythema migrans (EM) or other early symptoms, although arthritis was the presenting sign in 16%. The enzyme-linked immunosorbent assay (ELISA) was the most frequently ordered diagnostic test, but 45% of respondents did not specify which test when ordering Lyme serology. The majority would use amoxicillin or doxycycline to treat EM in children or adults, respectively. Nearly all would use ceftriaxone for meningitis, and half would use it to treat Lyme arthritis or Bell's palsy. Physicians differed markedly in the duration of therapy they would prescribe. Eighty-three percent would treat a patient for possible Lyme disease with antibiotics (many intravenously), even in the absence of EM or positive serology. Thirty-five percent of practitioners prescribed antibiotics for deer-tick bites. Our survey documents significant variation in approaches to Lyme disease among primary-care physicians and suggests the need for well-designed clinical trials, continuing basic research, and physician education.

Chlamydia pneumoniae--a new causative agent of reactive arthritis and undifferentiated oligoarthritis

OBJECTIVE

To examine whether reactive arthritis (ReA) known to occur after a urogenital infection with Chlamydia trachomatis can also follow an infection with Chlamydia pneumoniae, a recently described species of Chlamydiae that is a common cause of respiratory tract infections.

METHODS

Specific antibodies (microimmunofluorescence test) and lymphocyte proliferation to C trachomatis and C pneumoniae in paired samples of peripheral blood and synovial fluid were investigated in 70 patients with either reactive arthritis (ReA) or undifferentiated oligoarthritis (UOA).

RESULTS

Five patients with acute ReA after an infection with C pneumoniae are reported. Three had a symptomatic preceding upper respiratory tract infection and two had no such symptoms. In all patients a C pneumoniae-specific lymphocyte proliferation in synovial fluid and a high specific antibody titre suggesting an acute infection was found.

CONCLUSION

C pneumoniae needs to be considered a new important cause of reactive arthritis.

Antigens of Lyme disease of spirochaete Borrelia burgdorferi inhibits antigen or mitogen-induced lymphocyte proliferation

Modulation of cellular immune responses by the spirochaete Borrelia burgdorferi, the bacteria that causes Lyme disease, was demonstrated. When cultured in the presence of sonicated Borrelia preparation (Bb), the mitogen- or antigen-stimulated proliferative responses of normal lymphocytes were consistently lowered. Bb caused the greatest reduction in Concanavalin A (ConA) or antigen-stimulated proliferation, where almost 100% reduction in proliferation could be achieved. Bb also reduced phytohemagglutinin-M (PHA) or pokeweed mitogen (PWM)-stimulated peripheral blood lymphocyte (PBL) proliferation, with the PWM proliferation being the least affected. This regulatory activity was not due to toxicity and was determined to be caused by Bb protein antigens. The degree of the proliferation reduction was directly proportional to both Bb quantity and length of exposure to lymphocytes. IL-2 production was significantly reduced from Bb-exposed lymphocytes. The entry of lymphocytes into the proliferating phases of the cell cycle was also shown to be blocked. These results have demonstrated an immune suppressive mechanism of B. burgdorferi. The magnitude of host immune responses may be dependent on the degree of suppression which is related to the spirochaete quantity and their length of presence in the host.

Prominent T lymphocyte response to Borrelia burgdorferi from peripheral blood of unexposed donors

The proliferative response of peripheral blood T cells to the spirochete, Borrelia burgdorferi, can be as pronounced in unexposed normal individuals as it is in Lyme disease patients. This finding was observed using three geographically distinct isolates of B. burgdorferi. The response is not due to a lipopolysaccharide effect of the spirochete, is sensitive to Proteinase K, and requires antigen processing. It does not result from cross-reactivity of memory T cells that may be reactive to another antigen; the proliferative response to B. burgdorferi is equally distributed between naive (CD29-, CD45RO-) and memory (CD29+, CD45RO+) T cells, whereas the tetanus response is confined to the memory subset. In support of this notion, cord blood specimens that contain almost entirely naive T cells, respond as vigorously to B. burgdorferi as T cells from normal adult peripheral blood. A large panel of CD4+ T cell clones has been derived that are specific for B. burgdorferi. The majority of these clones are reactive to B. burgdorferi in the presence only of autologous HLA-DR molecules. Collectively, these data suggest that the T cell response from normal individuals is more likely due to multiple antigenic epitopes within Borrelial proteins than a superantigen response.