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

Serodiagnosis in early Lyme disease

Using a commercially available enzyme-linked immunosorbent assay (ELISA) and an immunoblot assay (IB), we tested sera from 100 patients with erythema migrans (EM) seen in 1991 a the Westchester County Medical Center Lyme Disease Diagnostic Center. Convalescent-phase sera were available from 59 patients. Fifty-five patients had EM of < 7 days' duration, 31 had EM of 7 to 14 days' duration, and 14 had EM of > 14 days' duration. During the acute phase of infection, 35 patients had a positive ELISA result and 43 had a positive IB result by the recently published criteria of Dressler et al. (F. Dressler, J. A. Whalen, B. N. Reinhardt, and A. C. Steere, J. Infect. Dis. 167:392-400, 1993) for interpretation of IB in patients with Lyme disease. A greater sensitivity of IB was observed in patients with EM of < 7 days' duration, as follows: 14 of 55 (25%) for IB versus 7 of 55 (13%) for ELISA (P = 0.144). Sera of all 14 patients with EM of > 14 days' duration were reactive by both tests, as follows: 13 positive and 1 equivocal by ELISA and 12 positive and 2 indeterminate by the IB. The band reactivity most frequently observed in the IB was to the 41- and 25-kDa antigens, the latter being the most frequent band observed in immunoglobulin M blots. Seroconversion was observed in 74 and 64% of evaluable patients by ELISA and IB, respectively, despite the use of antibiotic therapy.

Persistence of Borrelia burgdorferi in ligamentous tissue from a patient with chronic Lyme borreliosis

OBJECTIVE

To document the persistence of Borrelia burgdorferi in ligamentous tissue samples obtained from a woman with chronic Lyme borreliosis.

METHODS

Spirochetes were isolated from samples of ligamentous tissue, and the spirochetes were characterized antigenetically and by molecular biology techniques. The ligamentous tissue was examined by electron microscopy. Humoral and cellular immune responses were analyzed.

RESULTS

Choroiditis was the first recognized manifestation of Lyme disease in this patient. Despite antibiotic therapy, there was progression to a chronic stage, with multisystem manifestations. The initially significant immune system activation was followed by a loss of the specific humoral immune response and a decrease in the cellular immune response to B burgdorferi over the course of the disease. "Trigger finger" developed, and a portion of the flexor retinaculum obtained at surgery was cultured. Viable spirochetes were identified. Ultramorphologically, the spirochetes were situated between collagen fibers and along fibroblasts, some of which were deeply invaginated by these organisms. The cultured bacteria were identified as B burgdorferi by reactions with specific immune sera and monoclonal antibodies, and by polymerase chain reaction amplification and Southern blot hybridization techniques.

CONCLUSION

To our knowledge, this is the first report of the isolation of B burgdorferi from ligamentous tissue. This suggests that tendon tissues serve as a specific site of spirochete residence in human hosts.

Peripheral facial palsy: antibody levels to Borrelia in serum and CSF

Serum antibodies to Borrelia burgdorferi antigen were determined in 71 consecutive patients with an acute peripheral facial palsy. The study was conducted for one year in a south western coastal region in Sweden. Twenty-one per cent of the patients had significantly elevated serum levels of antibodies to Borrelia burgdorferi antigen. CSF was examined in 13 of the sero-positive patients. In three of these (23%) Borrelia antibodies were found. Another five patients had a pathological protein and cell pattern in the CSF. No seasonal differences were observed. Four of the sero-positive patients had a long-term history of dermatological neurological manifestations compatible with the late third stage of the disease.

Variant responses of mice to Borrelia burgdorferi depending on the site of intradermal inoculation

C3H/He mice inoculated intradermally at one of two sites with Borrelia burgdorferi responded differently to infection. Shoulder-inoculated mice developed spirochetemia, B. burgdorferi-specific antibody, and arthritis earlier than foot-inoculated mice. Lymphocyte populations derived from spleen tissue were elevated in the shoulder- but not the foot-inoculated mice, and those from lymph nodes were increased in both groups. Lymphocytes derived from blood and spleen tissue showed impaired proliferative responses to all mitogens for shoulder-inoculated mice only, whereas proliferation of lymph node cells was not affected, regardless of route. These results demonstrate that the site of initial B. burgdorferi inoculation is an important determinant in the pathogenesis of B. burgdorferi infection.

Localized scleroderma associated with Borrelia burgdorferi infection. Clinical, histologic, and immunohistochemical observations

BACKGROUND

Recent reports have implicated Borrelia burgdorferi infection as a possible cause of localized scleroderma (LS).

OBJECTIVE

Our purpose was to describe the clinical, histologic, and immunopathologic features of patients with LS who had serum antibodies to B. burgdorferi.

METHODS

Ten patients were examined clinically and by routine microscopy. Biopsy specimens from seven patients were studied immunohistochemically with monoclonal antibodies. The proliferative response of peripheral blood mononuclear cells to B. burgdorferi was investigated in seven patients by lymphocyte proliferation assay.

RESULTS

Seven patients had plaque-type morphea, and three patients had linear scleroderma. Two patients had a history of previous erythema migrans. One patient had coexistent acrodermatitis chronica atrophicans, and in two patients lichen sclerosus et atrophicus was observed. Histologically, a prominent inflammatory phase with sclerosis of the connective tissue was shown in all patients. Immunohistochemical studies revealed that the inflammatory infiltrates consisted of both B and T lymphocytes, predominantly of the CD4+ subset. All 10 patients had strongly elevated serum antibodies to B. burgdorferi. Patients with LS showed significantly elevated lymphoproliferative responses to B. burgdorferi when compared with healthy control subjects.

CONCLUSION

Our findings suggest that some cases of LS are linked to Borrelia infection.

Lyme disease and pregnancy outcome: a prospective study of two thousand prenatal patients

OBJECTIVE

The purpose of the study was to determine if prenatal exposure to Lyme disease was associated with an increased risk of adverse pregnancy outcome.

STUDY DESIGN

Approximately 2000 Westchester County, New York, women completed questionnaires and had sera tested for antibody to Borrelia burgdorferi at their first prenatal visit and at delivery. Fetal death, birth weight, length of gestation at delivery, and congenital malformations were examined in relation to maternal Lyme disease exposure before and during pregnancy.

RESULTS

Maternal Lyme disease or an increased risk of exposure to Lyme disease was not associated with fetal death, decreased birth weight, or length of gestation at delivery. Tick bites or Lyme disease around the time of conception was not associated with congenital malformations. Tick bites within 3 years preceding conception were significantly associated with congenital malformations, but this could have reflected reporting differences between exposed and unexposed women.

CONCLUSIONS

Maternal exposure to Lyme disease before conception or during pregnancy is not associated with fetal death, prematurity, or congenital malformations taken as a whole. We have not ruled out the possibility that exposure to Lyme disease as defined by maternal history increases the risk of specific malformations or has an effect if it is not treated. We have insufficient numbers of women who were seropositive at their first prenatal visit to determine if this subgroup of exposed women are at a moderately increased risk of having a child with a congenital abnormality. The low frequency of seroconversion at delivery in this endemic area suggests that preventive measures are being taken by obstetricians and patients.

Uveitis and Lyme borreliosis

In a retrospective study 56 consecutive patients with uveitis of unknown origin and 56 consecutive patients suffering from uveitis of established aetiology were investigated. The purpose of this study was to determine the frequency of positive serological tests for Lyme borreliosis among patients with uveitis and to relate laboratory data to clinical findings. The antibody titre for Borrelia burgdorferi was determined by two assays: the indirect immunofluorescence assay and the enzyme linked immunosorbent assay. A positive result according to one or both assays was found for eight patients with uveitis of unknown aetiology (14%) and three patients with uveitis of established cause (5%). On clinical examination, none of the patients fulfilled the CDC criteria for diagnosis of Lyme borreliosis.

The value of specific antibody detection and culture in the diagnosis of reactive arthritis

Joint inflammation, predominantly of the lower limbs, occurring some weeks after urogenital or gastrointestinal infection is classified as reactive arthritis (ReA) but there is no general agreement on diagnostic criteria, especially if the preceding infections are asymptomatic. The same is true for Lyme disease (LD) which is caused by Borrelia burgdorferi (BB). Determination of antibody titre or culture of urethral swabs and stools are often used as diagnostic tools. We examined 4 groups of patients: one with undifferentiated arthritis (Group I, n = 55), one with well-defined rheumatic diseases other than ReA (n = 43, Group II), one group without joint disease (n = 50, Group III) and one with ReA or LD (n = 7). Specific antibacterial antibody titres in serum were measured in all patients; stool and urethral cultures were performed in all groups except the last. A calculation of positive predictive value (PPV) was done for each test. Evidence of present or previous infection with the microbes Chlamydia trachomatis (CT), Mycoplasma urethritidis (MU), Yersinia enterocolitica (YE) and BB were found in all groups. In Group I, Group II and Group III respectively, positive serological results were found for CT IgA (20%, 31%, 16%) and IgG (49%, 51%, 34%), YE (7%, 6%, 0%) and BB (17%, 2%, 10%). Positive cultures were found in Group I and Group II respectively for CT (28%, 29%) and MU (14%, 17%). Therefore no test had a significant positive predictive value for ReA in the general population and even in the rheumatology clinic the PPV for most tests was low. We conclude that these methods are of little value in the diagnosis of reactive arthritis when the preceding infection is asymptomatic.

2nd European Symposium on Lyme Borreliosis. A NATO advanced research workshop. United Kingdom, 19-20 May 1993. Abstracts

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Long-term study of cell-mediated responses to Borrelia burgdorferi in the laboratory mouse

Borrelia burgdorferi infection of disease-susceptible (C3H) and -resistant (BALB) mice resulted in impaired proliferation to both T- and B-cell mitogens up to 30 days after inoculation. Interleukin-2 and -4 production was also impaired, paralleling the T-cell response to concanavalin A. Impaired lymphocyte proliferation could not be attributed to diminished numbers of T or B cells and was found to depend on the lymphoid organ (spleen or lymph node) examined. Prostaglandin production accounted for part of this immune dysfunction. Attempts to assess antigen-specific proliferation to B. burgdorferi were inconsistent, and delayed-type hypersensitivity responses were not detected. Adoptive transfer of T-enriched cells from chronically infected donors failed to prevent infection and disease development in recipient C3H mice. The current study emphasizes caution in the study of B. burgdorferi antigen-specific assays and argues against the role of a vigorous T-cell response in Lyme borreliosis in infected laboratory mice.

Further evidence for Borrelia burgdorferi infection in morphea and lichen sclerosus et atrophicus confirmed by DNA amplification

We present further evidence in support of the notion that Borrelia burgdorferi is possibly involved in the pathogenesis of morphea and lichen sclerosus et atrophicus (LSA). Running a nested polymerase chain reaction (PCR) with a primer set specific for the flagellin gene of B. burgdorferi enabled us to demonstrate the presence of Borrelia DNA in skin biopsies of patients with morphea (nine of nine) of LSA (six of six). Biopsy specimens obtained from patients with erythema chronicum migrans (two patients, four of four samples) and acrodermatitis chronica atrophicans (one patient, one of one sample) also showed positive PCR results. By contrast, there was no amplification of Borrelia DNA in control biopsies either from patients with chronic eczema (three of three) or psoriasis (two of two) or from normal skin (three of three). Antibodies directed against B. burgdorferi were only detected in the serum of patients with erythema chronicum migrans (two of two) and acrodermatitis chronica atrophicans (one of one) but were not present in cases of morphea (five of five), LSA (three of three), or in control subjects (three of three). These data suggest that B. burgdorferi may play a role in the pathogenesis of both morphea and LSA. Furthermore, we conclude that PCR analysis provides an important diagnostic tool, even in seronegative Borrelia infections.

The polymerase chain reaction for the detection of Borrelia burgdorferi in human body fluids

OBJECTIVE

To analyze clinical fluids for the presence of Borrelia burgdorferi DNA using the polymerase chain reaction (PCR).

METHODS

We utilized a modified, nested PCR to detect the presence of Borrelia DNA in 99 samples of serum, urine, cerebrospinal fluid (CSF), or synovial fluid obtained from 44 patients with various stages of Lyme disease and 47 control subjects. Primer specificity was corroborated by examining 2 DNA data banks, testing against DNA from other organisms, and confirming results with a second set of nested primers.

RESULTS

Nested PCR was capable of detecting DNA from fewer than 10 organisms in 1 ml of fluid. The specificity of this technique was 96.4%, with a sensitivity of 76.7%. Although the specificity was uniformly high, the sensitivity was dependent upon the body fluid being tested: CSF 100%, urine 100%, synovial fluid 80%, and serum 59%. The rate of false-positive results was 3.6%.

CONCLUSION

These data demonstrate the potential utility of PCR in confirming the clinical diagnosis of Lyme disease as well as providing insight into the pathogenesis of various stages of this disorder.

Cross-reactive antigenic domains of the flagellin protein of Borrelia burgdorferi

The p41 flagellin of Borrelia burgdorferi is the most common antigen recognized by serum of patients with Lyme borreliosis. This antigen shares amino acid homology, particularly in the amino and carboxy termini, with periflagellar antigens found in other microorganisms including Treponema pallidum. We cloned and expressed the p41 open reading frame in Escherichia coli and expressed it both as TrpE fusion and full-length unfused proteins. Also, we generated deletion constructs of various portions of the gene. Sera from patients with late Lyme borreliosis and secondary syphilis were used to identify the recombinant proteins by immunoblot analysis. Sera from 26 patients with Lyme borreliosis, 20 with secondary syphilis and 10 controls were used to identify cross-reactive domains of the B. burgdorferi flagellin. The variable region (amino acids 131-234) of the protein was recognized by 59% (15/26) of patients with late Lyme borreliosis compared to 30% (6/20) of patients with secondary syphilis and no (0/10) control patients. It appears that cross-reactive epitopes between B. burgdorferi and T. pallidum extend to the variable region of the flagellin.

Acrodermatitis chronic atrophicans: a chronic T-cell-mediated immune reaction against Borrelia burgdorferi? Clinical, histologic, and immunohistochemical study of five cases

BACKGROUND

Acrodermatitis chronica atrophicans (ACA) is a late manifestation of infection caused by Borrelia burgdorferi.

OBJECTIVE

Our purpose was to study the clinical, histopathologic, and immunohistochemical findings in patients with ACA to understand better the pathogenesis of the disease.

METHODS

Five patients were studied. Skin biopsy specimens were obtained from active lesions for histologic and immunohistochemical studies.

RESULTS

Clinical lesions included an initial erythematous discoloration in one patient and violaceous infiltrated plaques and nodules in four patients, three of whom also had late atrophic lesions. Biopsy specimens showed a dermal perivascular and interstitial lymphocytic infiltrate with plasma cells. There was a predominance of CD3+, CD4+ T cells in the dermal infiltrate. B cells were present in three patients. The dermal infiltrate showed an intense expression of lymphocyte function-associated antigen. The intercellular adhesion molecule type 1 was expressed on endothelial cells, perivascular mononuclear cells, and focally on basal keratinocytes.

CONCLUSION

Our findings suggest that a chronic, T-cell-mediated immune reaction against B. burgdorferi is involved in the pathogenesis of ACA.

Effects of adequate versus inadequate treatment of cutaneous manifestations of Lyme borreliosis on the incidence of late complications and late serologic status

Eighty-two patients who were treated at the Department of Dermatology, Innsbruck, Austria, from 1980 to 1987 for cutaneous manifestations of Lyme disease were subjected to a clinical follow-up investigation aimed at detecting dermatologic, neurologic, and internal late complications of borreliosis. Only 54 of these patients had received adequate antibiotic treatment according to current standards. Also, their sera were investigated for the presence of immunoglobulin G (IgG) and IgM Borrelia burgdorferi antibodies by an indirect immunofluorescence assay, three different enzyme-linked immunosorbent assays, and immunoblotting. As a control, the sera of 126 healthy blood donors were investigated with the same assays. Results showed no unambiguous clinical late complications of Lyme borreliosis, even in inadequately treated or untreated patients. Seropositivity varied considerably according to the assay used; the indirect immunofluorescence assay yielded the highest scores. The proportion of seropositive results (immunofluorescence assay) was 59% in patients with erythema chronicum migrans, 69% in those with lymphocytoma cutis, and 100% in those with acrodermatitis chronica atrophicans (overall 63%); in contrast, only 31% of the blood donor control group were found to be seropositive. Seropositivity did not correlate with adequacy of treatment, interval between onset of symptoms and treatment, time span since treatment, age of patients, and presence of antinuclear antibodies. Immunoblot pattern showed high incidence of antibodies against the 29/31-kD (outer surface proteins OspA and OspB) and 55/58-kD antigens in general and against the 41-kD protein (flagellin) in patients with acrodermatitis chronica atrophicans only.

Recurrent erythema migrans despite extended antibiotic treatment with minocycline in a patient with persisting Borrelia burgdorferi infection

Erythema migrans recurred in a patient 6 months after a course of treatment with minocycline for Lyme disease. Polymerase chain reaction on heparinized peripheral blood at that time demonstrated the presence of Borrelia burgdorferi-specific DNA. The patient was seronegative by Lyme enzyme-linked immunosorbent assay but showed suspicious bands on Western blot. Findings of a Warthin-Starry stain of a skin biopsy specimen of the eruption revealed a Borrelia-compatible structure. Reinfection was not believed to have occurred. Further treatment with minocycline led to resolution of the erythema migrans.

Identification of species-specific, non-cross-reactive proteins of Borrelia burgdorferi

The low specificity of diagnostic tests for Lyme disease is due to the fact that Borrelia burgdorferi possesses many antigenic proteins that are cross-reactive with other spirochetes and bacteria. The low sensitivity is a result of high (> or = 1:100) dilutions used for patient sera during testing to eliminate non-specific cross-reactivity. The present study was conducted to identify species-specific non-cross-reactive protein(s) of B. burgdorferi that might be used as antigen(s) in serologic tests. Whole-cell sonicates of B. burgdorferi were tested against pooled sera from patients with symptoms, signs, and serologic features diagnostic of Lyme disease (LD), rheumatoid arthritis, infectious mononucleosis, systemic lupus erythematosus, Rocky Mountain spotted fever, secondary syphilis, and from healthy individuals. Different LD pools were also tested against whole-cell sonicates of Treponema pallidum, Treponema phagedenis, Leptospira interrogans, and Escherichia coli. Comparison among patterns obtained by each serum pool revealed that IgM antibodies to species-specific 39-, 23-, and 22-kD proteins and IgG antibodies to 34- and 31-kD proteins were present only in the patients with LD and absent from patients with rheumatoid arthritis, infectious mononucleosis, systemic lupus erythematosus, Rocky Mountain spotted fever, secondary syphilis, and healthy individuals pools. These results suggest that 39-, 23-, and 22-kD proteins may be used in an IgM immunoassay for diagnosis of LD.

Aetiological role of bacteria associated with reactive arthritis in pauciarticular juvenile chronic arthritis

BACKGROUND

The cause of juvenile chronic arthritis (JCA) is unknown. Pauciarticular JCA is the most common subtype and can be subdivided into early (type I) and late onset (type II) forms, the latter clinically resembling reactive arthritis.

METHODS

The cellular immune responses to bacteria associated with reactive arthritis in blood and synovial fluid from 39 children with pauciarticular JCA, three children with classical reactive arthritis, and two children with psoriatic arthritis were examined. Specific titres of antibodies to bacteria in serum samples were measured in all patients.

RESULTS

A bacteria specific synovial cellular immune response was found in two of three (67%) patients with reactive arthritis and 14 of 28 (50%) patients with pauciarticular JCA type II but only in one of 11 (9%) patients with pauciarticular JCA type I and none in patients with psoriatic arthritis. Six patients responded specifically to Chlamydia trachomatis and 11 to Yersinia enterocolitica. Antigen specific lymphocyte proliferation correlated poorly with the specific antibody response.

CONCLUSIONS

These findings suggest that bacteria with associated reactive arthritis may have a causative role in pauciarticular JCA type II but not in JCA type I.

The 93-kilodalton protein of Borrelia burgdorferi: an immunodominant protoplasmic cylinder antigen

Using immunoblots, we identified proteins of Borrelia burgdorferi recognized by sera from 62 patients with either acute or chronic Lyme disease. In all groups studied, the 41-kDa flagellar protein and a relatively minor 93-kDa protein (p93) were the most commonly recognized antigens in patients with acute and chronic disease due to B. burgdorferi. A murine monoclonal antibody (MAb 181.1) was developed against p93, and the antigen was detected by immunoblot analysis in four European and American strains of B. burgdorferi. On two-dimensional gel electrophoresis, p93 had an apparent pI of 6.8. Immunoelectronmicroscopy with MAb 181.1 demonstrated that p93 is located within the protoplasmic cylinder compartment of the organism. The gene encoding p93 was retrieved from a phage expression library. The derived amino acid sequence of p93 confirmed chemical characterization of the antigen, including its amino-terminal peptide sequence. The derived amino acid sequence predicted it to be predominantly alpha helical. A prominent antigenic domain located at the carboxy portion of the protein was recognized by human and rabbit polyclonal antisera and human (MAb D4) and mouse (MAb 181.1) MAbs.

Alteration in T cell/macrophage ratio may reveal lymphocyte proliferation specific for the triggering antigen in reactive arthritis

It has previously been shown that synovial fluid (SF) mononuclear cells (MNC) from patients with reactive arthritis (ReA) and some patients with undifferentiated oligoarthritis (UOA) respond specifically to the triggering bacterium (specific responders). However, in some patients there is a response to two or more bacteria (non-specific responders) and in a third group no response is found (non-responders). We assessed whether the proportion of synovial MNC which were macrophage-monocyte (MaMo) differed among the specific responder, non-specific responder and non-responder groups. There was no difference between the specific (33 +/- 9) and the non-specific (32 +/- 26) groups; non-responders had a higher percentage of MaMo (61.3 +/- 31%) although the difference was not significant. We also investigated whether the specificity of the response to antigen in ReA or UOA SF was altered by changing the T-cell/MaMo ratio. In all five specific responders the immune response remained specific whatever the ratio tested. However, four of the five non-specific responders, but none of the non-responders, developed a specific response to one of the tested antigens by increasing the T cell/MaMo ratio. We conclude that in some patients with a non-specific response, alteration of the T cell/MaMo ratio uncovers a specific response which may identify the triggering antigen.

Molecular analysis of the outer surface protein A (OspA) of Borrelia burgdorferi for conserved and variable antibody binding domains

The outer surface protein A (OspA) of Borrelia burgdorferi is a major candidate for development of a borrelia vaccine. However, vaccine development may be aggravated by the immunological heterogeneity of OspA. In this respect the knowledge about conserved and variable epitopes is of major interest. In this study truncated proteins derived from two different OspA serotypes of B. burgdorferi were mapped for conserved and specific antibody-binding domains. The OspA fragments were reacted in the Western blot with eight different OspA-specific monoclonal antibodies recognizing between one and seven of the seven OspA serotypes previously described. The two broadly reacting antibodies (recognizing all serotypes) react with N-terminal fragments of 93 and 214 amino acids, respectively, whereas antibodies recognizing only one and two to four of the seven serotypes are reactive with C-terminal fragments of amino acid 143-273 and 109-273, respectively. Thus, conserved antibody-binding domains are located nearer to the N terminus than serotype-specific ones. Comparison of the results from western blot mapping with OspA sequence data suggested certain conserved or variable regions as probable candidates for antigenic sites involved in linear or conformationally dependent epitopes. This, however, needs to be confirmed by epitope mapping using the respective synthetic peptides.

Cellular immune reactivity to recombinant OspA and flagellin from Borrelia burgdorferi in patients with Lyme borreliosis. Complexity of humoral and cellular immune responses

Patients with Lyme borreliosis (LB) usually develop a vigorous T cell response against the causative pathogen Borrelia burgdorferi, but little is known about the antigens recognized in the cellular response. Therefore, T cell reactivities against whole bacteria, recombinant 31-kD (outer surface protein A, [OspA]), and 41-kD proteins (flagellin) from B. burgdorferi were studied in patients with LB, non-LB patients, and healthy donors. In parallel, specific antibodies were determined by Western blot analysis. Virtually all patients with LB exhibited marked cellular responses to whole B. burgdorferi, which were significantly elevated compared with the control groups in both early and late disease stages. However, analyses using the purified antigens OspA and flagellin revealed considerable heterogeneity in the cellular reactivities among individuals as well as variations during the course of infection. T cell responses to OspA were significantly increased in patients with early LB compared with both control groups whereas in late-stage disease responses only exceeded those of non-LB patients and were not different from normal donors. Cellular immune reactivities to flagellin were significantly higher only in early LB compared with both control groups. Reciprocally, several control subjects demonstrated marked cellular responses to OspA and flagellin, suggesting that reactions to these proteins may not always be related to LB. T cell reactivity did not correlate well with the presence of specific antibodies. Almost all seropositive patients in both early and late stage LB had serum antibodies against flagellin, but antibodies to OspA were detectable only in a subset of late LB sera. These data demonstrate the complexity of the humoral and the cellular immune responses to components of B. burgdorferi.

In vitro susceptibilities of Borrelia burgdorferi to five oral cephalosporins and ceftriaxone

We determined the in vitro susceptibilities of eight Borrelia burgdorferi isolates to five oral cephalosporins. MICs for B. burgdorferi 297 were 23 micrograms/ml (cephalexin), 45 micrograms/ml (cefadroxil), 91 micrograms/ml (cefaclor), 0.13 microgram/ml (cefuroxime), 0.8 microgram/ml (cefixime), and 0.02 microgram/ml (ceftriaxone). When B. burgdorferi isolates were exposed to concentrations twice the MIC of cefuroxime, cefixime, or ceftriaxone, at least 72 h of incubation was required to kill 99% of the organisms.

Evidence for B-lymphocyte mitogen activity in Borrelia burgdorferi-infected mice

Borrelia burgdorferi produces a mitogen for murine B lymphocytes which can be measured in vitro by polyclonal stimulation of proliferation and immunoglobulin production (R. Schoenfeld, B. Araneo, Y. Ma, L. Yang, and J. J. Weis, Infect. Immun. 60:455-464, 1992). Sonicated B. burgdorferi cells also stimulated IL-6 production by splenocyte cultures. We have used the murine model for Lyme disease described by Barthold et al. (S. W. Barthold, D. S. Beck, G. M. Hansen, G. A. Terwilliger, and K. D. Moody, J. Infect. Dis. 162:133-138, 1990) to determine whether the B. burgdorferi B-cell mitogen is expressed during active infection. To correlate arthritic changes with immune events, we have studied two strains of mice injected with B. burgdorferi; one of them, C3H/HeJ, developed severe disease, and the other, BALB/c, developed only mild disease. C3H/HeJ mice displayed a persistent 10-fold increase in circulating immunoglobulin G (IgG) levels, a 2-fold increase in IgM levels, and a 15-fold increase in peripheral lymph node B-cell numbers, providing evidence of mitogenic activity. Infected BALB/c mice also had evidence for mitogen activity, since the IgG level in serum increased three- to fourfold. The bulk of the increase in circulating IgG levels was not directed against B. burgdorferi antigens, supporting the occurrence of polyclonal B-cell activation. Analysis of IgG isotypes pointed out a contrast between C3H/HeJ and BALB/c mice in that levels of all isotypes were elevated somewhat in both strains of infected mice but IgG2a levels were much more dramatically increased in the C3H/HeJ mice (28-fold) than in the BALB/c mice (4-fold). In this study, interleukin-6 levels were found to be persistently elevated in the serum of infected C3H/HeJ mice. Interestingly, interleukin-6 levels in serum were much lower in the infected BALB/c mice. These findings indicate that the B. burgdorferi mitogen is active in infected animals and may contribute to the inflammatory and immune response to infection.

Is it Lyme disease? How to interpret results of laboratory testing

Although laboratory testing is likely to have a greater role in diagnosis and monitoring of treatment of Lyme disease in the future, at present physicians must rely on a combination of history taking, clinical manifestations, and laboratory results. Unwarranted antibiotic therapy is to be avoided. Asymptomatic persons with positive serologic results who live in an endemic area present a challenge, and borderline serologic results in patients with manifestations of late Lyme disease are also troubling. All relevant clinical information must be considered before treatment is undertaken, until more specific and sensitive tests are available.

Molecular diagnosis of Borrelia burgdorferi infection (Lyme disease)

In spite of significant advances in immunologically based testing, accurate diagnosis of Lyme borreliosis remains problematic. To address this issue, a DNA amplification-based diagnostic test was developed utilizing the polymerase chain reaction (PCR) and oligonucleotide primers specific for the OspA and OspB genes of Borrelia burgdorferi. In this approach, a relatively large DNA fragment is amplified with an outer set of primers, and a "nested" internal sequence of the PCR product subsequently reamplified with an inner set of primers. This nested approach coupled with simple differential centrifugation allowed specific detection of as few as four B. burgdorferi organisms mixed in 2 ml of blood. This methodology was utilized on patients' samples, and it allowed detection of B. burgdorferi in the peripheral blood and urine of several individuals with clinical evidence of Lyme borreliosis. PCR became negative and symptoms improved following antibiotic therapy of treated individuals. These studies suggest that direct detection of Borrelia in infected individuals can aid in diagnosis and evaluation of therapy for Lyme borreliosis.

Demonstration of a B-lymphocyte mitogen produced by the Lyme disease pathogen, Borrelia burgdorferi

Lyme disease refers to the multisymptomatic illness in humans which results from infection with the tick-borne spirochete Borrelia burgdorferi. The white-footed mouse is the major reservoir for B. burgdorferi and, upon infection, certain inbred mice develop symptoms similar to those reported in human disease. Sonicated preparations of washed spirochetes were found to have potent mitogenic activity when cultured with lymphocytes from naive C57BL/6, C3H/HeJ, or BALB/c mice. The activity of the B. burgdorferi sonicate was approximately fourfold greater than that of a similarly prepared Escherichia coli sonicate. Polymyxin B efficiently inhibited the mitogenic activity of the E. coli sonicate but only slightly inhibited that of the B. burgdorferi sonicate, suggesting that a lipid A-containing lipopolysaccharide was not responsible for the B. burgdorferi activity. Kinetic analysis indicated peak proliferation at 2 to 3 days of culturing, suggesting polyclonal activation. B- and T-lymphocyte depletion experiments indicated that the major cell type responding to the B. burgdorferi mitogen was the B lymphocyte. This mitogen stimulated murine B cells not only to proliferate but also to differentiate into antibody-secreting cells, as demonstrated by the production of immunoglobulin by stimulated splenocytes. Furthermore, the sonicated preparation stimulated the B-cell tumor line CH12.LX to secrete immunoglobulin in the absence of accessory cells. B. burgdorferi also stimulated interleukin-6 production in splenocyte cultures. The observation that B. burgdorferi can stimulate activation of and immunoglobulin production by normal B lymphocytes may directly reflect on the development of arthritis associated with persistent infection by this organism.

Concurrence of multiple sclerosis and Hodgkin's disease

Although multiple sclerosis and Hodgkin's disease are reported to have similar epidemiologic features, this is only the first case report in which there was concurrence of these diseases. Fourteen years after successful treatment of Hodgkin's disease, this 31-year-old white male developed multiple sclerosis. The diagnosis of multiple sclerosis was made on the basis of clinical and paraclinical findings that were characteristic of multiple sclerosis. In addition, specific tests were performed to rule out a variety of infectious, metabolic, and neoplastic diseases that simulate multiple sclerosis.

The neuropsychiatric manifestations of Lyme borreliosis

Lyme borreliosis (Lyme disease), a tick-borne spirochetal illness, has multisystemic involvement and is rapidly increasing in certain areas of the United States. Although its neurologic manifestations are becoming increasingly well recognized, its psychiatric presentations are not well known. The first section of this paper will provide an overview of Lyme borreliosis and a review of the relevant neuropsychiatric literature. The second section will provide clinical descriptions of some common neuropsychiatric symptoms as well as a discussion of the problems typically faced by patients with this illness. Guidelines to assist the clinician in working with these patients will be presented.

Cardiovascular manifestations of Lyme disease

Although the cardiac manifestations of Lyme disease may be diverse, in general they are treatable with currently available therapies. A high index of suspicion is required to make a diagnosis, especially for patients who may lack a suggestive history of tick exposure or residence in an endemic region. Lyme disease-related heart block may require pacemaker insertion and supportive care. The efficacy of antibiotics in the therapy of acute and chronic cardiac Lyme disease will require further study. Serologic testing and cardiac histopathology are the most precise methods of diagnosis. There is a need to develop more sensitive and specific diagnostic tests for Lyme disease and for Lyme carditis in particular.

Lyme disease in Rio de Janeiro, Brazil

Five patients living in Rio de Janeiro, Brazil, were found to have Lyme disease. These are among the first known cases in South America.

Perspective on the development of vaccines against Lyme disease

Lyme disease, the multisystem illness caused by the tick-borne spirochaete, Borrelia burgdorferi, has emerged as a threat to public health worldwide. It is a particularly vexing problem in the United States where it is growing in range and intensity. In fact, in some hyperendemic regions of New York and New England, Lyme disease is now such a threat that it interferes with all sorts of outdoor activities, and has even led to depreciation of real estate values. Family dogs in these areas seem to have been particularly hard hit by a near epidemic of lameness caused by Lyme arthritis. Persons at high risk for infection, such as outdoor workers, campers and hikers, suburbanites with lawns to cut, and pregnant women exposed to potentially infected Ixodes ticks, are clamouring for some means of protection beyond simple behaviour modification and tick avoidance which are known not always to work. Hence, the interest in human and veterinary vaccines against Lyme disease is growing.

Detection of the Lyme disease bacterium, Borrelia burgdorferi, by using the polymerase chain reaction and a nonradioisotopic gene probe

A 419-bp region of the flagellin gene sequence of Borrelia burgdorferi was used as a target for the polymerase chain reaction. With a nonradioactively labeled gene-specific probe, sensitivity to as few as 1 to 10 spirochetes was observed. The targeted gene fragment was conserved in the American and European strains of B. burgdorferi tested and among several other pathogenic borreliae.

Lyme disease. Difficulties in diagnosis and management

LB is a multisystem illness caused by the spirochete B. burgdorferi. As with other spirochetal diseases, LB evolves in stages. Some manifestations are the result of persistent infection, whereas other symptoms are a consequence of immunologic changes secondary to the infection. Most disease manifestations are not specific to this illness. In addition, in endemic areas, almost 100% of the tick vector, the Ixodes species, are infected and the incidence rate of LB is as high as 1%. Because of these factors, the illness is overdiagnosed and overtreated. We have reviewed the current state of diagnosis and treatment of LB as well as questions that arise during the management of this illness.

Can protracted relapsing fever resemble Lyme disease?

We report the case of a Protestant missionary who contracted tick-borne relapsing fever in 1979 while serving in the Sudan. Despite tetracycline treatment, his acute illness ran a protracted course, with migratory polyarthralgias lasting approximately 10 months. Symptoms recurred in 1984 and have persisted. At regular intervals, the patient has experienced recurrent episodes of fever, generalized fatigue, bilateral upper and lower extremity muscle weakness, and asymetric large joint polyarthralgia. Indirect fluorescent antibody testing of sera demonstrated titers of 1:16 for B. burgdorferi and 1:64 for B. hermsii, and immunoblotting confirmed past exposure to relapsing fever, but not Lyme disease. It is hypothesized that this individual's chronic symptoms have been related to relapsing fever, and that in certain situations or in select individuals, relapsing fever can be capable of producing a chronic clinical picture analogous to Lyme disease.

Synovial T lymphocyte-specific immune response to Chlamydia trachomatis in Reiter's disease

We studied the lymphocyte proliferative response to Chlamydia trachomatis in Reiter's syndrome (RS) compared with that in other rheumatic diseases. RS patients showed significantly increased C trachomatis-specific synovial fluid (SF) T cell proliferation. Proliferating cells were found in both CD4+ and CD8+ T cell subsets. The SF lymphocyte proliferative response to C trachomatis in RS was inhibited by anti-class I and class II major histocompatibility complex monoclonal antibodies, while the response to tuberculin purified protein derivative was inhibited only by anti-class II monoclonal antibodies. T cell receptor gamma/delta-bearing T cells were not consistently increased in RS SF compared with peripheral blood, nor did such cells consistently expand upon in vitro culture with C trachomatis. Finally, there was no correlation between the cellular immune response and levels of antibody to C trachomatis antigens. Our results indicate that a specific T cell response to C trachomatis within the joint plays a role in the pathogenesis of RS.

T cell proliferation induced by Borrelia burgdorferi in patients with Lyme borreliosis. Autologous serum required for optimum stimulation

The cellular immune response to Borrelia burgdorferi was studied in 24 patients with seropositive and seronegative Lyme borreliosis, 30 patients with arthritides of different origin (non-Lyme arthritides), and 20 normal blood donors. By far, the strongest T cell stimulation was induced by incubation with autologous serum; there was a significantly lower response or no response after incubation with allogeneic or heterologous sera. In patients with Lyme borreliosis, including seronegative patients, there was a strikingly elevated proliferation in response to whole B burgdorferi bacteria (mean 64,750 dpm) compared with that of normal donors (mean 19,700 dpm; P less than 0.0001) and especially that of non-Lyme arthritis patients (mean 11,600 dpm; P less than 0.0001). Levels of proliferation declined significantly in patients with Lyme borreliosis after successful antibiotic treatment. Parallel cultures using B burgdorferi and Treponema phagedenis as antigens showed that cells from patients with Lyme borreliosis responded significantly more to B burgdorferi than to T phagedenis, but this did not occur with cells from individuals with non-Lyme arthritides. There was no correlation between disease stages and proliferation values. These data indicate that lymphocyte proliferation assays may provide an important tool for the diagnosis of Lyme borreliosis, most notably in patients with arthritides and in those who are seronegative. Conversely, the lack of reactivity appears to be a strong indicator of the absence of active Lyme disease. It seems to be crucial, however, to use autologous sera in these assays.

Lyme borreliosis: host responses to Borrelia burgdorferi

The chronic inflammatory condition that develops after infection by B. burgdorferi is a complex process resulting from host responses to a limited number of organisms. Amplification mechanisms driven by potent proinflammatory molecules, i.e., IL-1, may explain the vigorous response to a paucity of organisms. Spirochete dissemination to distant locations involves adherence to and penetration across endothelium and may be facilitated by host responses that increase vessel permeability. The apparent lack of tissue tropism in Lyme disease is reflected in the organism's ability to adhere to different eucaryotic cell types in vitro and the wide distribution of B. burgdorferi in various organs of infected humans and experimentally infected animals. While phagocytosis and complement activation have been observed in vitro, the specific immune response that develops in humans is inefficient in eradicating the organisms, which may possess some mechanism(s) to evade this response. There is significant evidence for host autoreactivity based on antigenic cross-reactivity between the 41-kDa flagellar subunit and stress proteins of the spirochetes and endogenous host cell components. Although the outer surface proteins appear to be suitable candidates as targets for vaccination in animal studies, fundamental differences in the immune response to spirochetal components may preclude their use in humans.