Clinical comparison of immunoblot and antibody index for detection of intrathecal synthesis of specific antibodies in Lyme neuroborreliosis

Comparison of the Euroimmun Borrelia 'antibody index' with Virotech immunoblot-based detection of intrathecal Borrelia antibody production for the diagnosis of Lyme neuroborreliosis

For diagnosis of neuroborreliosis, calculation of the antibody index, based on Euroimmun Anti-Borrelia plus VlsE ELISA was compared to Virotech Borrelia Europe plus TpN17 immunoblot-based detection of Borrelia-specific intrathecal antibody production. CXCL13 results in cerebrospinal fluid were used to evaluate discordant results. A total of 64 serum/CSF pairs were analysed. Patients were classified according to European Federation of Neurological Societies criteria incorporating Virotech results. For the Euroimmun assay, a sensitivity of 100% and specificity of 94% was found. Agreement between the both tests was almost perfect (κ 0.81). Both methods are appropriate for the detection of Borrelia-specific intrathecal antibody production.

Chronic Lyme neuroborreliosis

Introduction. Lyme neuroborreliosis is an infectious disorder of the central and/or peripheral nervous system caused by the tick stump of the genus Ixodes rici, infected with species Borrelia burgdorferi sensu lato (in Europe). The disease manifests as meningitis, encephalitis, meningoradiculitis, vasculitis, paresthesia of the facial nerve and painful radiculopathy. Case report. A 44-year-old patient reports fatigue, forgetfulness, headache, confusion, depression, drowsiness, irritability, instability, her undercooks are crushed, sheeps of a bride and does not recall being called an object. Muscular reflexes of the undergrowth are reduced. Plantar response flexion, Lazarevic sign is positive at 45 degrees from the surface. No weakness of the dorsal and plantar flexion of the fingers of the feet. Relieves sensitivity in the region of inertia nerv peroneus and tibialis. Sphincters were fine. The patient had a diagnosed Lyme disease, five months prior to the exacerbation of anxiety. Due to erythema migrans and subfebrility, diagnosis and seropositivity to Borrelia burgdorferi were established in both classes of the enzymelinked immunosorbent assay antibodies and a confirmed Western blot test. She took doxycycline 200 milligrams/day, three weeks. The analysis of cerebrospinal fluid revealed proteinhorn (0.42 g/L), normal glycorrhachia, pleocytosis, and positive intrathecal IgG antibodies. Electromyography pointed to axonal degeneration of the lower extremities. The magnetic resonance is neat. The therapy includes ceftriaxone, 2 grams/day, vitamins and analgesic therapy. Neuroborreliois was maintained by the laboratory during one-year follow-up. Mental disorders, headaches, confusion and irritability, neurological signs have significantly regressed. Conclusion. The gold standard in diagnostics of neuroborelliosis is the determination of intrathecal antibodies. For the definitive diagnosis, clinical signs of disease, pleocytosis and positive antibodies are necessary. Intrathecal antibodies remain long positive and they are not recommended for monitoring for the effects of therapy.

Laboratory diagnosis of Lyme neuroborreliosis is influenced by the test used: comparison of two ELISAs, immunoblot and CXCL13 testing

PURPOSE

To compare Borrelia-specific intrathecal antibodies by two different ELISAs, an immunoblot (IB) and CXCL13.

METHODS

Twenty-seven adults and 23 children with clinical symptoms compatible with NB were tested for Borrelia-specific intrathecal antibodies by flagellum ELISA-AI (flELISA), a recombinant ELISA-AI (rELISA) and by IB. Patients were classified according to the European Federation of Neurological Societies (EFNS) criteria as definite NB, possible NB, or non-NB. CSF CXCL13 levels were measured by ELISA.

RESULTS

Among 50 patients, definite NB was diagnosed with the rELISA-AI in 29 (58%) patients, confirmed by IB in 19/29 patients, with flELISA-AI in 17 (34%) patients, confirmed by IB in 15/17 patients, and with IB in 20 (40%) patients. CXCL13 was positive in 22 (44%) patients. In 4 of 8 patients with negative AI, IB showed many detectable bands both in the CSF and serum.

CONCLUSIONS

The diagnosis of NB strongly relies on the used test method. The rELISA-AI test appears to be the most sensitive while the flELISA-AI is the least sensitive. However when the ELISA-AIs were confirmed by IB, different patients were identified as NB, while only 26% were identified by all performed test methods. There is a demand for standardized test methods with well-defined sensitivity and specificity to establish validated diagnostic criteria for NB including the use of the IB assay and CXCL13 as an additional non-Borrelia specific determinant in early NB.

Can ELISPOT Be Applied to A Clinical Setting as A Diagnostic Utility for Neuroborreliosis?

The aim of this prospective study was to investigate the diagnostic performance of Borrelia (Bb)-induced interferon (IFN)-γ secretion detected by ELISPOT modified to be feasible for clinical laboratories as a supplementary test to the laboratory diagnosis of Lyme neuroborreliosis (LNB) in an endemic setting. Between 2002 and 2004, patients with symptoms of suspected clinical LNB were included in a study conducted on the Åland islands in the Finnish archipelago, which is a hyper-endemic area for Lyme borreliosis (LB). Fourteen patients with confirmed LNB and 103 patients with non-LNB were included, and the numbers of spontaneous and Bb-induced IFN-γ-secreting cells were assayed by the ELISPOT test. The ELISPOT assay showed a weak diagnostic performance with a sensitivity of 36% and a specificity of 82%. The findings in this study show that this ELISPOT-assay modified to be feasible in clinical routine laboratories is not useful as a supplementary diagnostic tool in the laboratory diagnosis of patients with clinically suspected LNB.

Neuroborreliosis manifested as persistent vomiting in three children

Neuroborreliosis usually presents with facial palsy and meningitis, but unspecific symptoms may also occur and can result in delayed diagnosis. We report on 3 children in whom persistent vomiting was the key clinical finding of neuroborreliosis.

Intrathecal antibody production in a mouse model of Lyme neuroborreliosis

Intrathecal antibody (ITAb) production is a common feature of neurological diseases, yet very little is known about its mechanisms. Because ITAb is prominent in human Lyme neuroborreliosis (LNB), in the present study we established a mouse model of LNB to study ITAb production. We injected different strains of Borrelia burgdorferi into a variety of mouse strains by the intracerebral (i.c.) route to develop the model. Spirochetal infection and ITAb production were identified by complementary methods. This study demonstrates that the mouse model of LNB can be utilized to test hypotheses related to the mechanisms of ITAb production.

Different B-cell populations are responsible for the peripheral and intrathecal antibody production in neuroborreliosis

The diagnosis of neuroborreliosis (NB)--a serious complication of Lyme disease--relies on demonstration of intrathecal borrelia antibody production. We hypothesized that if a qualitative difference between the cerebrospinal fluid and the serum immunoblot-banding patterns was observed, then the borrelia antibodies found in the CSF could not be the result of leakage of serum antibodies to the CSF due to blood-brain barrier damage, but rather had to be produced intrathecally. CSF/serum pairs from 69 NB patients and from 85 control patients with other neurological disorders were investigated. All samples were tested blindly by immunoblot and a commercial capture ELISA kit for NB. The concordance between the two methods was 85.7%. When using the other method as reference, the accuracy of the two assays in the two patient materials was similar: 80% for sensitivity and 95% for specificity. Four types of comparative immunoblot-banding patterns that reflected intrathecal borrelia antibody synthesis were distinguished. The study showed that a simple comparison between the immunoblot pattern of serum and CSF samples allows for a reliable diagnosis of NB by demonstration of intrathecal antibody production. This is the first study to show that a qualitative difference of the antibody response between the immune response of serum and CSF is a rule. The findings also imply that partly different B-cell populations are responsible for the antibody production in the blood and in the central nervous system. In addition, our observation provides possible implications for other infectious diseases with CNS involvement.

Preferential presence of decorin-binding protein B (BBA25) and BBA50 antibodies in cerebrospinal fluid of patients with neurologic Lyme disease

Borrelia burgdorferi antibodies preferentially present in cerebrospinal fluid (CSF) were examined by differentially probing a B. burgdorferi expression library with CSF and sera from patients with neurologic Lyme disease. Several phage clones selectively reacted with CSF, and these genes were then expressed in recombinant form and used to detect specific antibody in an enzyme-linked immunosorbent assay. Decorin-binding protein B (BBA25) and BBA50 (hypothetical protein) elicited immunoglobulin G (IgG) or IgM detectable in CSF-but not sera-of patients, demonstrating preferential antibody production during neuroborreliosis.

Lyme disease presenting with persistent headache

Increased intracranial pressure in patients with Lyme disease is an uncommon but reported finding. We discuss 2 patients from Lyme endemic areas who initially presented with headache, nausea, and vomiting and were eventually found to have increased intracranial pressure, a mild cerebrospinal fluid pleocytosis, and positive Lyme titers. It has been shown that increased intracranial pressure in association with neuroborreliosis can lead to blindness. In endemic areas, it is important for practitioners to consider Lyme disease when patients present with persistent headache, especially in those who have evidence of increased intracranial pressure.

Lymphocyte subset numbers in cerebrospinal fluid: comparison of tick-borne encephalitis and neuroborreliosis

OBJECTIVE

The aim of this study was to analyze lymphocyte subset numbers in cerebrospinal fluid (CSF) from patients with tick-borne encephalitis (TBE) and acute neuroborreliosis.

METHODS

CSF lymphocyte subsets were enumerated in 42 TBE and nine neuroborreliosis patients using flow cytometry.

RESULTS

The CSF numbers of CD4+, CD8+, HLA-DR+ and total-T lymphocytes, B lymphocytes, and NK cells were all greater in neuroborreliosis patients than in TBE patients. Neuroborreliosis patients showed positive correlation of CSF protein levels with the numbers of CD4+, HLA-DR+ and total-T lymphocytes. Also, the numbers of CSF B lymphocytes correlated positively with intrathecal Borrelia burgdorferi-specific IgG antibodies. Conversely, TBE patients demonstrated intrathecal protein levels that correlated positively with all investigated CSF lymphocyte subsets.

CONCLUSION

These results suggest an intensive recruitment of lymphocyte subsets into the central nervous system (CNS) during acute neuroborreliosis, whereas TBE is characterized by a lower accumulation of lymphocyte subsets in the CSF.