Circulating immune complexes in Lyme arthritis. Detection by the 125I-C1q binding, C1q solid phase, and Raji cell assays

Immune Response to Borrelia: Lessons from Lyme Disease Spirochetes

The mammalian host responds to infection with Borrelia spirochetes through a highly orchestrated immune defense involving innate and adaptive effector functions aimed toward limiting pathogen burdens, minimizing tissue injury, and preventing subsequent reinfection. The evolutionary adaptation of Borrelia spirochetes to their reservoir mammalian hosts may allow for its persistence despite this immune defense. This review summarizes our current understanding of the host immune response to B. burgdorferi sensu lato, the most widely studied Borrelia spp. and etiologic agent of Lyme borreliosis. Pertinent literature will be reviewed with emphasis on in vitro, ex vivo and animal studies that influenced our understanding of both the earliest responses to B. burgdorferi as it enters the mammalian host and those that evolve as spirochetes disseminate and establish infection in multiple tissues. Our focus is on the immune response of inbred mice, the most commonly studied animal model of B. burgdorferi infection and surrogate for one of this pathogen's principle natural reservoir hosts, the white-footed deer mouse. Comparison will be made to the immune responses of humans with Lyme borreliosis. Our goal is to provide an understanding of the dynamics of the mammalian immune response during infection with B. burgdorferi and its relation to the outcomes in reservoir (mouse) and non-reservoir (human) hosts.

The Pathogenesis of Rheumatoid Arthritis is Associated with Milk or Egg Allergy

BACKGROUND

Rheumatoid arthritis (RA) is a very complicated autoimmune disease with apparent synovial hyperplasia and cartilage and bone destruction.

AIMS

In the present study, we aimed to determine whether the pathogenesis of RA correlates with food allergy and which allergen(s) are relevant.

MATERIALS AND METHODS

We used type-II collagen (CII) to induce arthritis (collagen-induced arthritis, CIA) model in Wistar rats, and the development of arthritis was evaluated accordingly by scoring system. Proinflammatory cytokine levels in plasma were measured by enzyme-linked immunosorbent assay (ELISA), and concentrations of circulating immune complexes (CICs) were analyzed by C1q solid phase method. Furthermore, food-specific immunoglobulin G (IgG) and immunoglobulin E (IgE) levels were determined in the CIA model.

RESULTS

In the CIA model, we found that levels of tumor necrosis factor-alpha (TNF-a), interleukin (IL)-1, IL-6, and IL-17, as well as CICs, were elevated significantly. Moreover, concentrations of milk- or egg-specific IgG and IgE were enhanced strikingly in CIA rats.

CONCLUSION

The results suggest that pathogenesis of RA correlates closely to increased egg- or milk-specific antibodies.

Musculoskeletal features of Lyme disease: understanding the pathogenesis of clinical findings helps make appropriate therapeutic choices

Patients with Lyme disease, that is, active infection with Borrelia burgdorferi, experience many types of musculoskeletal complaints, with different explanatory mechanisms. Appropriate therapy depends on understanding the underlying cause of the complaint and addressing that specific root cause. In the case of active infection the dosage, duration, drug, and method of administration of antibiotics should be determined by the state of the infection and history of prior therapy, according to the established and validated recommendations of the Infectious Disease Society of America. Many patients have musculoskeletal complaints not attributable to active infection; some patients have residual complaints following a documented infection that has been adequately treated with antibiotics previously, and others never had true B. burgdorferi infection in the first place. For such patients, antibiotics are not warranted and in fact may be physically and emotionally harmful. Complaints following an episode of Lyme disease are not necessarily due to ongoing infection, especially adequately treated. Consideration of other diagnoses may suggest use of other effective modalities, including physical therapy and emotional support. Appropriate ordering and interpretation of the various validated seroconfirmatory tests available to study B. burgdorferi infection are critical, as these tests are often misapplied and misconstrued in pursuit of strategies aimed at eliminating patients' suffering. Although seronegative Lyme disease has been reported, seronegativity in a reputable laboratory makes the likelihood of Lyme arthritis very low. On the other hand, a positive result from certain unvalidated laboratories or novel assays proves nothing and should not be viewed as substantiating the diagnosis.

Close to home: a history of Yale and Lyme disease

Yale scientists played a pivotal role in the discovery of Lyme disease and are credited as the first to recognize, name, characterize, and treat the affliction. Today, Lyme disease is the most commonly reported vector-borne illness in the United States, affecting approximately 20,000 people each year, with the incidence having doubled in the past 10 years [1]. Lyme disease is the result of a bacterial infection transmitted to humans through the bite of an infected deer tick, which typically results in a skin rash at the site of attack. While most cases, when caught early, are easily treated by antibiotic therapy, delayed treatment can lead to serious systemic side effects involving the joints, heart, and central nervous system. Here we review Yale's role in the discovery and initial characterization of Lyme disease and how those early discoveries are crucial to our current understanding of the disease.

Genome-Wide Expression Analysis of Placental Malaria Reveals Features of Lymphoid Neogenesis during Chronic Infection

Chronic inflammation during placental malaria (PM) is most frequent in first time mothers and is associated with poor maternal and fetal outcomes. In the first genome-wide analysis of the local human response to sequestered malaria parasites, we identified genes associated with chronic PM and then localized the corresponding proteins and immune cell subsets in placental cryosections. B cell-related genes were among the most highly up-regulated transcripts in inflamed tissue. The B cell chemoattractant CXCL13 was up-regulated >1,000-fold, and B cell-activating factor was also detected. Both proteins were expressed by intervillous macrophages. Ig L and H chain transcription increased significantly, and heavy depositions of IgG3 and IgM were observed in intervillous spaces. The B cell phenotype was heterogeneous, including naive (CD27-negative), mature (CD138-positive), and cycling (Ki-67-positive) cells. B cells expressed T-bet but not Bcl-6, suggesting T cell-independent activation without germinal center formation. Genes for the Fc binding proteins FcgammaRIa, FcgammaRIIIa, and C1q were highly up-regulated, and the proteins localized to intervillous macrophages. Birth weight was inversely correlated with transcript levels of CXCL13, IgG H chain, and IgM H chain. The iron regulatory peptide hepcidin was also expressed but was not associated with maternal anemia. The results suggest that B cells and macrophages contribute to chronic PM in a process resembling lymphoid neogenesis. We propose a model where the production of Ig during chronic malaria may enhance inflammation by attracting and activating macrophages that, in turn, recruit B cells to further produce Ig in the intervillous spaces.

Autoantibodies from synovial lesions in chronic, antibiotic treatment-resistant Lyme arthritis bind cytokeratin-10

Although the causative agent of Lyme disease is definitively known to be the tick-borne spirochete, Borrelia burgdorferi, the etiology of chronic joint inflammation that ensues in a subset of patients remains less well understood. Persistence of arthritis after apparent eradication of the spirochete suggests an autoimmune reaction downstream of the original bacterial infection. We have generated recombinant Ab probes from synovial lesions within affected arthritic joints in an attempt to recapitulate disease-relevant Ag-binding specificities at the site of injury. Using this panel of intra-articular probes, as well as Ab fragments derived from patient peripheral blood, we have identified cytokeratin 10, present in synovial microvascular endothelium, as a target ligand and a putative autoantigen in chronic, antibiotic treatment-resistant Lyme arthritis. Furthermore, there is cross-reactivity between cytokeratin 10 and a prominent B. burgdorferi Ag, outer surface protein A. Release of the self protein in the context of inflammation-induced tissue injury and the resulting in situ response to it could set in motion a feed-forward loop, which amplifies the inflammatory process, thereby rendering it chronic and self-perpetuating, even in the absence of the inciting pathogen.

In Situ Diversification of the Antibody Repertoire in Chronic Lyme Arthritis Synovium

Lyme arthritis is initiated by the tick-borne spirochete, Borrelia burgdorferi. In a subset of patients, symptoms do not resolve in response to standard courses of antibiotics. Chronic joint inflammation may persist despite spirochetal killing, suggesting an autoimmune etiology. The pathogenic mechanisms that sustain chronic Lyme arthritis have not been fully elucidated, although T cells are believed to play a role. The synovial lesion contains elements of a peripheral lymph node, with lymphoid aggregates, plasma cells and follicular dendritic cells. An analysis of activated cells at the site of injury could yield clues regarding the nature of the response and the identity of potential autoantigens. Using laser-capture microdissection, we have isolated plasma cells from the joint tissue of chronic Lyme arthritis patients who underwent synovectomy. Expressed Ig V regions were amplified by RT-PCR. A majority of isolated cells expressed gamma H chains, which is indicative of a class-switched response. There were a large number of nucleotide substitutions from germline, with a higher fraction of replacement mutations in the CDRs, suggesting a process of Ag-driven selection. We have recovered clonal clusters of cells containing identical junctions and V(D)J rearrangements. Sequence analysis reveals a hierarchy of shared somatic mutations between members of a given clone. Intraclonal diversity among plasma cells of close physical proximity points toward an ongoing process of diversification and affinity maturation, possibly driven by the chronic presence of an autoantigen.

Infection and inflammation in skeletal muscle from nonhuman primates infected with different genospecies of the Lyme disease spirochete Borrelia burgdorferi

Lyme borreliosis is a multisystemic disease caused by various genospecies of the spirochete Borrelia burgdorferi. To investigate muscle involvement in the nonhuman primate (NHP) model of Lyme disease, 16 adult Macaca mulatta animals inoculated with strain N40 of B. burgdorferi sensu strictu by syringe or by tick bite or with strain Pbi of B. burgdorferi genospecies garinii by syringe were studied. Animals were necropsied while immunosuppressed on day 50 (two animals each inoculated with B. burgdorferi N40 by syringe and with B. garinii Pbi by syringe) or on day 90, 40 days after immunosuppression had been discontinued (four animals each inoculated with strain N40 by syringe, with strain N40 by tick bite, and with strain Pbi by syringe). Skeletal muscles removed at necropsy were studied by (i) microscopic examination of hematoxylin-eosin-stained sections for inflammation and tissue injury; (ii) immunohistochemical and digital image analyses for antibody and complement deposition and cellular inflammation; (iii) Western blot densitometry for the presence of antibodies; and (iv) reverse transcription-PCR for measurement of the spirochetal load or C1q (the first component of the complement cascade) synthesis. The results showed that N40 was more infectious for NHPs than Pbi. NHPs inoculated with N40 but not with Pbi developed myositis. The inflammation in skeletal muscle was more severe in NHPs inoculated with N40 by syringe than in those inoculated by tick bite. The predominant cells in the inflammatory infiltrate were T cells and plasma cells. The deposition of antibody and complement in inflamed muscles from N40-inoculated NHPs was significantly higher than that in Pbi-inoculated NHPs. The spirochetal load was very high in the two N40-inoculated NHPs examined while they were immunosuppressed but decreased to minimal levels in the NHPs when immunocompetence was restored. We conclude that myositis can be a prominent feature of Lyme borreliosis depending on the infecting organism and host immune status.

Use of serum immune complexes in a new test that accurately confirms early Lyme disease and active infection with Borrelia burgdorferi

The present recommendation for serologic confirmation of Lyme disease (LD) calls for immunoblotting in support of positive or equivocal ELISA. Borrelia burgdorferi releases large quantities of proteins, suggesting that specific antibodies in serum might be trapped in immune complexes (ICs), rendering the antibodies undetectable by standard assays using unmodified serum. Production of ICs requires ongoing antigen production, so persistence of IC might be a marker of ongoing or persisting infection. We developed an immunoglobulin M (IgM) capture assay (EMIBA) measuring IC-derived IgM antibodies and tested it using three well-defined LD populations (from an academic LD referral center, a well-described Centers for Disease Control and Prevention (CDC) serum bank, and a group of erythema migrans patients from whose skin lesions B. burgdorferi was grown) and controls (non-Lyme arthritis inflammatory joint disease, syphilis, multiple sclerosis, and nondisease subjects from a region where LD is endemic, perhaps the most relevant comparison group of all). Previous studies demonstrated that specific antigen-antibody complexes in the sera of patients with LD could be precipitated by polyethylene glycol and could then be disrupted with maintenance of the immunoreactivity of the released antibodies, that specific anti-B. burgdorferi IgM was concentrated in ICs, and that occasionally IgM to specific B. burgdorferi antigens was found in the IC but not in unprocessed serum. EMIBA compared favorably with commercial and CDC flagellin-enhanced enzyme-linked immunosorbent assays and other assays in confirming the diagnosis of LD. EMIBA confirmed early B. burgdorferi infection more accurately than the comparator assays. In addition, EMIBA more accurately differentiated seropositivity in patients with active ongoing infection from seroreactivity persisting long after clinically successful antibiotic therapy; i.e., EMIBA identified seroreactivity indicating a clinical circumstance requiring antibiotic therapy. Thus, EMIBA is a promising new assay for accurate serologic confirmation of early and/or active LD.

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.

Ultrastructural demonstration of spirochetal antigens in synovial fluid and synovial membrane in chronic Lyme disease: possible factors contributing to persistence of organisms

To perform the first systematic electronmicroscopic (EM) and immunoelectron microscopy (IEM) study of the pathological changes and the evidence of spirochete presence in synovial membranes and synovial fluid (SF) cells of patients with chronic Lyme arthritis. EM examination was performed on four synovial membrane and eight SF cell samples from eight patients with chronic Lyme disease. Spirochetal antigens in the samples were sought by IEM using monoclonal antibody to Borrelia burgdorferi outer surface protein A (OspA) as the immunoprobe. Prominent ultrastructural findings were surface fibrin-like material, thickened synovial lining cell layer and signs of vascular injury. Borrelia-like structures were identified in all four synovial membranes and in two of eight SF cell samples. The presence of spirochetal antigens was confirmed by IEM in all four samples studied (one synovial membrane and three SF cell samples). OspA labelling was in perivascular areas, deep synovial stroma among collagen bundles, and in vacuoles of fibroblasts in synovial membranes; and in cytophagosomes of mononuclear cells in SF cell samples. Electron microscopy adds further evidence for persistence of spirochetal antigens in the joint in chronic Lyme disease. Locations of spirochetes or spirochetal antigens both intracellulary and extracellulary in deep synovial connective tissue as reported here suggest sites at which spirochaetes may elude host immune response and antibiotic treatment.

Lyme disease

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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.

Canine Lyme borreliosis

Lyme borreliosis is now the most commonly reported tick-transmitted disease in humans and is an important disease in dogs. Case reports of canine Lyme borreliosis have appeared in the literature during the last 6 years, but a complete description of the disease still is not available. Until an accurate diagnostic scheme is developed, the disease will remain incompletely understood. A nonlocalizing polyarthropathy is the most commonly described clinical manifestation of canine Lyme borreliosis, but other syndromes probably also exist. The difficulty in making a diagnosis is a result of the fact that dogs do not develop a characteristic skin lesion to mark the beginning of their disease, and many dogs become seropositive but never develop clinical manifestations. Also, Borrelia burgdorferi has been isolated from the blood of healthy dogs, which suggests that detecting a spirochetemia may not have diagnostic significance. Newer diagnostic tests are being evaluated, but at present the diagnosis of canine Lyme borreliosis should be one of exclusion. After other common illnesses are ruled out, serology and response to antibiotic therapy help suggest a diagnosis. Once the disease is accurately diagnosed, efficient therapeutic schemes will be developed based on randomized therapeutic trials. In addition, vaccines are being developed. Currently, without the ability to diagnose the disease accurately, their efficiency can not be demonstrated adequately. Future findings surely will change our understanding of this disease.

Cerebrospinal fluid immune complexes in patients exposed to Borrelia burgdorferi: detection of Borrelia-specific and -nonspecific complexes

We analyzed cerebrospinal fluid (CSF) from 32 patients with neurological symptoms and evidence of Borrelia burgdorferi infection (29 were seropositive as determined by enzyme-linked immunosorbent assay, 2 were cell-mediated immune positive, and 1 had been seropositive as shown by enzyme-linked immunosorbent assay 9 months previously). CSF immune complexes were found in 22 (69%) of 32 patients; in 18, there was sufficient sample to isolate immune complexes. By enzyme-linked immunosorbent assay, isolated immune complexes from 10 of these 18 patients contained antibody specific for B. burgdorferi antigens. The isotypes were IgG (n = 8), IgM (n = 3), and IgA (n = 2). By immunoblot, these antibodies were directed against B. burgdorferi 41-kDa antigen and occasionally against the 33- and 17-kDa antigens. Anti-B. burgdorferi IgM was present in patients with acute neurological symptoms, was predominantly complexed rather than free, and decreased with clinical recovery in the one serial study. Three patients were nonreactive for free CSF antibodies, but had complexed antibodies to the organism. The preliminary finding of specific B. burgdorferi components in immune complexes in CSF suggests an active process triggered by the organism, even in the absence of other CSF abnormalities.

The immunoglobulin G subclass composition of immune complexes in cystic fibrosis. Implications for the pathogenesis of the Pseudomonas lung lesion

It has been shown that pulmonary macrophage (PM) phagocytosis of Pseudomonas aeruginosa (PA) is inhibited in the presence of serum from cystic fibrosis (CF) patients colonized by Pseudomonas, and that these sera contain high concentrations of IgG2 antibodies. The goal of these studies was to investigate the role that IgG2-containing immune complexes (IC) play in this inhibition of both PM and neutrophil phagocytosis. We found that serum IgG2 concentrations were elevated significantly in CF patients with chronic PA colonization and that in selected sera from CF patients with chronic PA colonization (CF + IC, n = 10), the mean IC level was significantly elevated (2.90 +/- 0.22 mg/dl [SEM]). IgG2 comprised 74.5% of IgG precipitated in IC from CF + IC sera. An invitro phagocytic assay of [14C]PA uptake using CF + IC whole-sera opsonins confirmed that endocytosis by normal PM and neutrophils was significantly depressed. Removal of IC from CF + IC sera resulted in significantly decreased serum IgG2 concentrations without a significant change in the other subclass concentrations, and enhanced [14C]PA uptake by PM (26.6% uptake increased to 47.3%) and neutrophils (16.9% increased to 52.6%). Return of the soluble IgG2 IC to the original CF sera supernatants and the positive control sera resulted in return of the inhibitory capacity of the CF + IC sera. We conclude that immune sera from patients with chronic Pseudomonas infections characterized by elevated IgG2 subclass level functions poorly as an opsonin. In these individuals, IgG2 contributes significantly to circulating IC and removal of IC, matched by a simultaneous fall in IgG2, improves bacterial uptake by neutrophil and mononuclear phagocytes. IgG2 antibodies exert antiphagocytic effects by both direct inhibition and the formation of IC.

Pathogenesis of Lyme disease

The etiology and pathogenesis of Lyme disease are reviewed and the value of the condition as a human model for an infectious etiology of rheumatic disease is discussed. Similarities between Lyme disease and rheumatoid arthritis are considered.

Synovial fluid eosinophilia in Lyme disease

We describe three 14-year-old boys who developed synovial fluid eosinophilia associated with Lyme disease. One patient, with arthritis that began in 1975, had the first documented case of Lyme disease in New Jersey. Lyme disease should be considered when eosinophilia is noted on analysis of synovial fluid from patients with undiagnosed arthritis.

Laboratory aspects of Lyme borreliosis

Lyme borreliosis (Lyme disease), a common tick-borne disorder of people and domestic animals in North America and Europe, is caused by the spirochete Borrelia burgdorferi. Following the discovery and initial propagation of this agent in 1981 came revelations that other tick-associated infectious disorders are but different forms of Lyme borreliosis. A challenge for the clinician and microbiology laboratory is confirmation that a skin rash, a chronic meningitis, an episode of myocarditis, or an arthritic joint is the consequence of B. burgdorferi infection. The diagnosis of Lyme borreliosis may be established by (i) directly observing the spirochete in host fluid or tissue, (ii) recovering the etiologic spirochete from the patient in culture medium or indirectly through inoculation of laboratory animals, or (iii) carrying out serologic tests with the patient's serum or cerebrospinal fluid. The last method, while lacking in discriminatory power, is the most efficacious diagnostic assay for most laboratories at present.

Borrelia burgdorferi--specific and autoreactive T-cell lines from cerebrospinal fluid in Lyme radiculomyelitis

In 3 patients with Lyme radiculomyelitis, cellular immune reactions of cerebrospinal fluid (CSF) lymphocytes were analyzed. Phenotypic analysis of CSF cells demonstrated that the majority were T cells (CD3+) of the helper/inducer subset (CD4+). These T cells were directly expanded from the CSF by limiting dilution. A total of 505 T-cell lines were tested for Borrelia burgdorferi (Bb)-specific proliferation and also partly tested for reactivity to a panel of central and peripheral nervous system antigens. Proliferative assays revealed 33 of them to be Bb specific, 16 to be specific for myelin basic protein, 16 to be specific for peripheral myelin, 1 to be specific for cardiolipin, and 2 to be specific for galactocerebrosides. The antigen-specific proliferation was restricted by autologous human leukocyte antigen (HLA) class II molecules. The majority of CSF-derived T-cell lines stained positively for CD3, CD4, and HLA class II antigens and negatively for CD8 (cytotoxic/suppressor subset). One T-cell line provided help for the production of specific IgG by autologous B cells and secreted gamma-interferon upon stimulation with Bb antigen in the presence of autologous antigen-presenting cells. These data show that in patients with severe neurological manifestations of late Lyme disease, not only Bb-specific T-cell lines but also T cells reactive to central or peripheral nervous system autoantigens can be found.

Lyme carditis. Electrophysiologic and histopathologic study

To further define the nature of Lyme carditis, electrophysiologic study and endomyocardial biopsy were performed in a patient with Lyme disease, whose principal cardiac manifestation was high-degree atrioventricular block. Intracardiac recording demonstrated supra-Hisian block and complete absence of an escape mechanism. Gallium 67 scanning demonstrated myocardial uptake, and right ventricular endomyocardial biopsy revealed active lymphocytic myocarditis. A structure compatible with a spirochetal organism was demonstrated in one biopsy specimen. It is concluded that Lyme disease can produce active myocarditis, as suggested by gallium 67 imaging and confirmed by endomyocardial biopsy. Furthermore, the presence of high-grade atrioventricular block in this disease requires aggressive management with temporary pacemaker and corticosteroid therapy.

Erythema chronicum migrans of Lyme disease: diagnosis by monoclonal antibodies

We demonstrated spirochetes from a skin lesion of the erythema chronicum migrans in a patient with Lyme disease by the murine monoclonal antibody (H9724). Frozen skin biopsy specimens reacted with murine monoclonal antibodies (H5332, H9724, and H4825) and were examined by indirect immunofluorescence assay. The spirochetes stained with monoclonal antibody H9724 and fluorescein isothiocyanate-conjugated second antibody (goat antimouse IgG). The antibody H9724 is specific for the periplasmic flagellae (axial filaments) of several Borrelia species, including Ixodes dammini spirochete (Borrelia burgdorferi). No immunofluorescence staining was demonstrated with either monoclonal antibody H5332, specific for an outer membrane protein of North American strains of B. burgdorferi, or the antibody H4825, specific for an outer membrane protein of B. hermsii.

Proliferative responses of mononuclear cells in Lyme disease. Reactivity to Borrelia burgdorferi antigens is greater in joint fluid than in blood

In 27 patients with early Lyme disease, the mean response of peripheral blood mononuclear cells (PBMC) to Lyme spirochetal Borrelia burgdorferi antigens (723 counts per minute) was similar to that of control subjects. During convalescence, 2-3 weeks later, the patients' mean response was significantly higher (2,075 cpm, P less than 0.008). Compared with those with early disease, the PBMC of 22 patients with Lyme arthritis reacted even more to B burgdorferi (2,923 cpm, P less than 0.0004), and, by far, the greatest response was in concomitantly obtained synovial fluid mononuclear cells (15,238 cpm, P less than 0.001). The PBMC of patients with early Lyme disease reacted slightly less to phytohemagglutinin and pokeweed mitogen than those of normal control subjects, but patients with arthritis had greater than normal mitogen responses. In contrast, mitogen reactivity among synovial fluid cells was markedly decreased and correlated inversely with the response to antigen. Thus, in patients with Lyme disease, the antigen-specific responses of mononuclear cells increase as the disease progresses, and in those with arthritis, the greatest reactivity to antigen is found in cells in the inflamed joint.

Erythema chronicum migrans in Sweden: clinical manifestations and antibodies to Ixodes ricinus spirochete measured by indirect immunofluorescence and enzyme-linked immunosorbent assay

26 Swedish patients with erythema chronicum migrans (ECM) were studied regarding associated clinical symptoms and antibodies to Swedish Ixodes ricinus spirochete. 11/26 (42%) of the patients had associated symptoms, compared to more than 90% of 314 American patients with ECM, as described by Steere et al. Only 2/26 (8%) had multiple skin lesions, compared to 48% of the American patients. Elevated erythrocyte sedimentation rate and circulating immune complexes were demonstrated in 6/25 (24%) and 8/25 patients (32%), respectively, as against in 53% and 84%, respectively, of the American patients. The antibody response to Ixodes ricinus spirochete was measured by indirect immunofluorescence (IFA) and enzyme-linked immunosorbent assay (ELISA). Compared to the 95% percentile of controls, significantly high antibody titers were demonstrated in 3/25 (12%) by IFA, and 7/25 (28%) by ELISA. The ELISA antibody titers differed significantly (p less than 0.05) between ECM-patients and controls. The spirochetal antibody response in ECM was also compared with that in spirochete-associated disease of the central nervous system.

Erythema chronicum migrans and Lyme disease

Lyme disease is an inflammatory disorder with a wide spectrum of clinical manifestations that involve the skin, joints, heart, and nervous system (1-4). Initially described in 1977 and named after the rural town in Connecticut where the first cases were detected in 1975, Lyme disease has now been recognized in at least 24 states (5-7), Canada (8), Australia (9), France (10), Switzerland (11), and Germany (12), and in individuals who travel to or spend time in areas known to be endemic for this disorder (13).

Tick-borne Borrelia infection in Sweden

Spirochetes were cultivated from 17% of 114 Ixodes ricinus ticks in the Stockholm area. Three strains of these spirochetes were selected for studies by electron microscopy. These three strains had definite morphological similarities to spirochetes of the genus Borrelia, as judged by the number of flagella, absence of cytoplasmic tubules, and dimensions. The three strains were not identical, but seemed to consist of two different kinds of cells, one with eight and one with eleven flagella. The three strains were also shown to react with a monoclonal antibody that reacts with Lyme disease spirochetes (Borrelia burgdorferi), but not with strains of other Borreliae, Treponemes, or Leptospiras. These results indicate the possibility of transmission of Borrelia spirochetes from ticks to humans in Sweden. The antibody response to one of the spirochetal strains isolated from Swedish I. ricinus was studied in 37 patients with the typical clinical picture of erythema chronicum migrans (ECM), in 45 patients with chronic meningitis (CMe) cured by high-dose intravenous penicillin, in 298 patients with post-infectious arthritis, and in controls. The antibody response was estimated by indirect immunofluorescence assay (IFA) enzyme-linked immunosorbent assay (ELISA). The antibody levels differed significantly between patients with CMe and healthy individuals (p less than 0.001), both with respect to serum antibody levels and CSF-antibody levels. The antibody levels also differed significantly between patients with ECM and healthy controls as measured by ELISA (p less than 0.05), whereas the difference was not significant as measured by IFA. Five of 298 patients with post-infectious arthritis had higher titers than any of the controls, and two of these five patients had titers higher than any patient with CMe or ECM. These results indicate spirochetal aetiology of ECM, and in some patents with CMe or postinfectious arthritis. As a diagnostic test for ECM, both IFA and ELISA were of limited value, since only 5/37 (14%) ECM patients were positive by IFA, and 14/37 (38%) by ELISA. Regarding patients with CMe, 23/45 (51%) were seropositive by IFA and 30/45 (67%) by ELISA. However, measurement of CSF-antibodies were found to be a more sensitive method than measurement of serum antibodies both by IFA and ELISA, since 38/45 (84%) CMe patients were positive by IFA, and 41/45 (91%) by ELISA. In addition, estimation of CSF antibodies was also found to be a more specific method than estimation of serum antibodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of penicillamine on serum immunoglobulins and immune complex-reactive material in primary biliary cirrhosis

Although penicillamine is used in the treatment of primary biliary cirrhosis, its mechanism of action in this disease is unknown. As an immunologic action had been attributed to the drug, we investigated whether penicillamine might alter serum immunoglobulin levels or immune complex-reactive material in patients with primary biliary cirrhosis. Immunoglobulin levels and immune complex reactivity were measured and clinical tests were performed in 53 consecutive patients entering a double-blind randomized trial of 750 mg vs. 250 mg of penicillamine. Measurement of immune complex reactivity was determined by laser nephelometry, 125I-C1q binding, and Raji cell assays. Immune complex reactivity was detected by at least one assay in 75% of patients tested before treatment. Sixty-two percent were positive in the C1q assay, 28% in the Raji cell assay, and 39% by nephelometry. After therapy with either dose, we found no change in immune complex-reactive material by any assay. Concentrations of immunoglobulins G and M fell (p less than 0.05) after 12 mo of therapy. Concentrations of immunoglobulin A decreased (p less than 0.05) only in the high-dose group. Correlation was not consistent between results of immune complex assays and clinical liver tests. Although immunoglobulin levels fell during penicillamine therapy, no decrease in immune complex-reactive material was detected. The effect of penicillamine in primary biliary cirrhosis is not mediated through alteration of immune complex-reactive material.

Lyme disease in a 12-year-old girl

We report the case of a 12-year-old girl with erythema chronicum migrans, aseptic meningitis and knee arthralgia. Rise of specific antibody titre against an Ixodes ricinus spirochaete was demonstrated. Circulating immune complexes and high levels of C1r-C1s-C1IA complexes indicating activation of the complement system via the classical pathway were found. The clinical features and the laboratory findings warranted a diagnosis of Lyme disease.

Cellular immune findings in Lyme disease. Correlation with serum IgM and disease activity

Cellular immune findings were studied in 48 patients with various stages of Lyme disease. At each stage, some patients, particularly those with neuritis or carditis, had elevated serum IgM levels and lymphopenia. During early disease, mononuclear cells tended to respond normally to phytohemagglutinin, and spontaneous suppressor cell activity was greater than normal. Later, during active neuritis, carditis, or arthritis, the trend was toward heightened phytohemagglutinin responsiveness and less suppression than normal. By multiple regression analysis, serum IgM levels correlated directly with disease activity (p = 0.025) and inversely with the number of T cells (p = 0.02); during acute disease only, elevated IgM levels correlated with increased phytohemagglutinin responsiveness (p = 0.004) and decreased suppressor cell activity (p = 0.03). Decreased suppression, observed later in the disease, may permit damage to host tissues because of either autoimmune phenomena or a heightened response to the Lyme spirochete.

Circulating immune complexes: their immunochemistry, biology, and detection in selected dermatologic and systemic diseases

Circulating immune complexes (CICs) are a heterogeneous group of immunoreactants formed by the noncovalent union of antigen and antibody. Many factors influence the formation, immunochemistry, biology, and clearance of these soluble reactants. The recent development of sensitive assays for the detection of CICs and the capability to assess immune complex (IC) clearance mechanisms in humans in vivo have expanded our understanding of these mediators. CICs influence both the afferent and efferent limbs of the immune response and can mediate tissue damage in certain pathologic states. ICs probably play an important role in the pathogenesis of serum sickness, systemic lupus erythematosus, and cutaneous necrotizing vasculitis. Recent investigations have raised the possibility that CICs may be of significance in other types of vasculitis as well. In other instances, ICs may form in response to tissue injury and subsequently modify the immune response of the host. A review of this material with special emphasis on diseases of relevance to dermatologists is presented.

Lyme disease--a review of the literature

It appears that a tick introduces an agent--presumably a spirochete--into the skin (see Fig. 1). Immune complexes form and become systemic during the rash. Some patients (identified by the presence of cryoglobulins containing IgM, Clq-reactive material, and depressed IgG and IgA levels) then alter their immune response and may develop neurologic, cardiovascular, or joint involvement. Despite systemic clearing in some patients, the immune complexes localize to the joints where a chronic synovitis develops, similar to rheumatoid arthritis. Why the immune complexes localize to the joints is an enigma. It is tempting to postulate that this localization occurs because of an altered immune response in a genetically predisposed group. However, three of 10 patients with chronic arthritis did not have the B-cell alloantigen DRw2.

Lyme disease: a unique human model for an infectious etiology of rheumatic disease

Lyme disease is a complex immune-mediated multi-system disorder that is infectious in origin and inflammatory or "rheumatic" in expression. Through its epidemiologic characteristics, large numbers of a seasonally synchronized patient population are readily available for prospective study. Lyme disease has a known clinical onset ("zero time"), marked by the characteristic expanding skin lesion, erythema chronicum migrans, and a clearly defined pre-articular phase. At least some manifestations of the disorder are responsive to antibiotics, and the causative agent--a spirochete--is now known. These advantages make Lyme disease unique as a human model for an infectious etiology of rheumatic disease.

Phagocytic cell responses to in vivo and in vitro exposure to the Lyme disease spirochete

An experimental skin lesion induced in rabbits by the bite of infected adult Ixodes dammini showed dense dermal interstitial inflammatory cell infiltrates composed of mononuclear cells (histiocytes and lymphocytes) and granulocytes. The prevalence of phagocytic cells in this experimental lesion motivated a study on the interactions of macrophages and neutrophils with Lyme disease spirochetes. Interactions as measured by uptake of radiolabeled spirochetes and by indirect immunofluorescence were enhanced by opsonization of spirochetes with immune serum and not significantly decreased by heat inactivation of the same. Phagocytosis was inhibited by treatment of cells with Cytochalasin B. Adherence of opsonized spirochetes to neutrophils was decreased by blocking Fc receptors with heat-aggregated IgG, suggesting an important role for this receptor.

The pathogenesis of arthritis in Lyme disease: humoral immune responses and the role of intra-articular immune complexes

We studied 78 patients with Lyme disease to determine how immune complexes and autoantibodies are related to the development of chronic Lyme arthritis. Circulating C1q binding material was found in nearly all patients at onset of erythema chronicum migrans, the skin lesion that marks the onset of infection with the causative spirochete. In patients with only subsequent arthritis this material tended to localize to joints where it gradually increased in concentrations with greater duration of joint inflammation. In joints, its concentration correlated positively with the number of synovial fluid polymorphonuclear leukocytes. Despite the prolonged presence of putative immune complexes, rheumatoid factors could not be demonstrated. These observations suggest that phlogistic immune complexes based on spirochete antigens form locally within joints during chronic Lyme arthritis.

Antibodies of patients with Lyme disease to components of the Ixodes dammini spirochete

Lyme disease is an inflammatory disorder of skin, joints, nervous system, and heart. The disease is associated with a preceding tick bite and is ameliorated by penicillin treatment. A spirochete (IDS) isolated from Ixodes dammini ticks has been implicated as the etiologic agent of Lyme disease. We examined the antibody responses of Lyme disease patients to IDS lysate components in order to further understand the pathogenesis of this disease. The components were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, transferred to nitrocellulose, reacted with patients' sera, and the bound IgG was detected with 125I-labeled protein A (western blot). We found that (a) Lyme disease patients had antibodies to IDS components (b) most patients studied had antibodies to two components with apparent subunit molecular weights of 41,000 and 60,000, and (c) the patients' antibody responses during illness and remission were specific, for the most part, for the IDS. In contrast to the findings with Lyme disease sera, sera from controls showed little reactivity with IDS components in either the western blots or a derivative solid-phase radioimmunoassay.

Adoptive T cell immunotherapy of MSV-induced tumours in nude mice. Part II. Sequential analysis of serum immune complexes and blocking activity in reconstituted mice in relation to tumour biology

In seven separate experiments, nude (nu/nu) mice carrying established murine sarcoma virus (MSV) tumours were reconstituted with syngeneic (+/+) immune splenic T cells. These immune protected mice were randomly divided to provide smaller groups for serial exsanguination. At various time points mice were individually bled and CIC concentration and blocking activity of each individual serum was determined. Control sera were obtained from nu/nu and adult +/+ mice inoculated with tumour cells only, and from nu/nu mice protected with normal +/+ spleen cells. In all the mice studied, CIC and blocking appeared to be mutually independent parameters throughout the MSV tumour course. On the other hand, in immune protected mice considered alone or together with the control groups, CIC and time after tumour cell inoculation, but not tumour size, were significantly correlated. A significant relationship between blocking and tumour size was also established, although this only applied to immune protected mice. However, analysis of the combined data from sequentially bled immune protected mice in relation to different phases of tumour behaviour, did not support the notion that blocking, and more particularly the persistence of CIC, contribute to tumour regrowth and dissemination.

The spirochetal etiology of Lyme disease

We recovered a newly recognized spirochete from the blood, skin lesions (erythema chronicum migrans [ECM]), or cerebrospinal fluid of 3 of 56 patients with Lyme disease and from 21 of 110 nymphal or adult lxodes dammini ticks in Connecticut. These isolates and the original one from l. dammini appeared to have the same morphologic and immunologic features. In patients, specific IgM antibody titers usually reached a peak between the third and sixth week after the onset of disease; specific IgG antibody titers rose slowly and were generally highest months later when arthritis was present. Among 40 patients who had early disease only (ECM alone), 90 per cent had an elevated IgM titer (greater than or equal to 1:128) between the ECM phase and convalescence. Among 95 patients with later manifestations (involvement of the nervous system, heart, or joints), 94 per cent had elevated titers of IgG (greater than or equal to 1:128). In contrast, none of 80 control subjects had elevated IgG titers, and only three control patients with infectious mononucleosis had elevated IgM titers. We conclude that the I. dammini spirochete is the causative agent of Lyme disease.

Spirochetes isolated from the blood of two patients with Lyme disease

We isolated spirochetes from the blood of 2 of 36 patients in Long Island and Westchester County, New York, who had signs and symptoms suggestive of Lyme disease. The spirochetes were morphologically similar and serologically identical to organisms recently found to infect lxodes dammini ticks, which are endemic to the area and have been epidemiologically implicated as vectors of Lyme disease. In both patients, there was a rise in specific antispirochetal antibodies in paired specimens of serum. We conclude that the l. dammini spirochete has an etiologic role in Lyme disease.

Elevated circulating immune complexes in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a syndrome of unknown etiology characterized by an association with inflammatory bowel disease in 50% or more cases. Since altered immunity, including circulating immune complexes, has been implicated in the pathogenesis of inflammatory bowel disease, we postulated that humoral immune mechanisms might also be important in the development of PSC. Therefore, as an initial step in testing this hypothesis, we examined sera of patients with PSC for the presence of circulating immune complexes by two independent methods: C1q binding and Raji cell assays. Twenty-four patients with PSC, 16 of whom had coexisting chronic ulcerative colitis, were prospectively selected by predefined biochemical, histologic, and radiographic criteria. Sixteen patients with inflammatory bowel disease and normal liver tests as well as six patients with extrahepatic biliary obstruction served as disease controls. Sera were positive for circulating immune complexes by at least one method in 80% (16/20) of patients with PSC; 70% (14/20 were positive by the Raji cell assay, 58% (14/24) by the C1q binding assay, and 45% (9/20) by both methods. Levels of circulating immune complexes by each assay were higher in sera from patients with PSC than in sera from healthy controls or patients with inflammatory bowel disease alone (p less than 0.01). There were no differences in the levels of circulating immune complexes or in the frequency of positive tests in PSC patients with or without associated inflammatory bowel disease. In addition, there was no difference between the Raji cell binding of sera from six patients with extrahepatic biliary obstruction and six healthy controls tested concurrently. These data are consistent with the hypothesis that immunologic mechanisms may be important in the pathogenesis of PSC.

Evaluation of a parallel plate membrane plasma exchange system

A new parallel plate membrane plasma exchange system (Centry TPE System) has been developed and clinically evaluated. A series of 27 consecutive plasma exchanges were performed on 14 patients with autoimmune diseases. Blood access was obtained by routine means identical to centrifugal procedures. The blood flow rate was 94 +/- 20 ml/min and plasma filtration rate was 37 +/- 9 ml/min, with an average patient hematocrit of 36%. The sieving coefficients for a wide range of plasma solutes including immunoglobulins, immune complexes, and lipids, clustered about 1.00, indicating nonselective plasma filtration. The average reduction in patient plasma solutes of 60 to 70% was in close agreement with the predicted value for unhindered plasma filtration. There was no appreciable loss of blood cells, as compared to a study with a centrifugal system showing a 56% reduction in circulating platelets. Complement activation measured by C'3 conversion was undetectable in patient samples and either undetectable or minimal in plasma filtrate samples. The system was convenient to operate and problems were rare. No untoward patient effects attributable to the membrane system were observed. These results show that the parallel plate membrane plasma exchange system described in this report is capable of delivering safe, efficient plasma exchange.