The emergence of Lyme disease

Cranial nerve involvement, visual complications and headache syndromes in Lyme disease

PURPOSE OF REVIEW

To provide a summary of the visual manifestations and cranial neuropathies seen in Lyme disease.

RECENT FINDINGS

Lyme facial palsy remains the most common manifestation of Lyme neuroborreliosis. Recent investigations show likely evidence of vagal involvement in Lyme disease.

SUMMARY

The literature on Lyme neuroborreliosis continues to evolve. Lyme disease can affect nearly any cranial nerve in addition to causing various headache syndromes. The most common manifestation is Lyme disease facial palsy, occurring in up to 5-10% of patients with documented Lyme disease. Headache syndromes are common in the context of facial palsy but can occur in isolation, and more specific headache syndromes including trigeminal and geniculate neuralgias can occur rarely. Signs and symptoms indicative of vestibulocochlear nerve involvement are relatively common, although it could be that these represent other vestibular involvement rather than a specific cranial neuropathy. Optic neuritis is a controversial entity within Lyme disease and is likely overdiagnosed, but convincing cases do exist. Physicians who see any cranial neuropathy, including optic neuritis, in an endemic area can consider Lyme disease as a possible cause.

Serological investigation of seven zoonotic pathogens in companion dogs in South Korea, 2018-2021

Based on the current situation of Korean culture and society, the population of companion animals in South Korea is growing rapidly along with zoonotic risks. The current data regarding zoonotic infections in companion dogs reported in Korea is sparse. This study aims to investigate the seroprevalence of seven potential zoonotic pathogens in companion dogs in South Korea: Anaplasma phagocytophilum, Borrelia burgdoferi, Ehrlichia canis, Coxiella burnetii, Brucella canis, Leptospira spp. and canine influenza A virus. A total of 284 serum samples were collected from 2018 to 2021, and the immunoglobulin G (IgG) antibodies against 7 zoonotic pathogens were detected using enzyme-linked immunosorbent assays. Samples were divided into five groups and analysed based on age. IgG antibodies against six of the seven pathogens were detected. The highest seropositivity rate was detected for canine influenza A virus exposure (59.1%) for which the rates were the highest in dogs under 1 year old and declined with age. Positivity rates of the other pathogens were relatively low: 1.76% for Leptospira spp., 1.40% for A. phagocytophilum and E. canis, 1.06% for B. canis and 0.35% for B. burgdoferi. No antibodies against C. burnetii were detected in this study. The exposure of dogs in South Korea to six zoonotic pathogens was serologically confirmed, highlighting a potential risk for human infection. The zoonotic risk of companion dogs cannot be neglected, and implementation of One Health approach should be advocated to establish effective preventive measures.

Why Is the Duration of Erythema Migrans at Diagnosis Longer in Patients with Lyme Neuroborreliosis Than in Those without Neurologic Involvement?

In prior studies, the skin lesion erythema migrans (EM) was present for a longer time period before diagnosis of concomitant borrelial meningoradiculoneuritis (Bannwarth's syndrome) compared to EM patients without neurologic symptoms. To determine if this observation pertains to other manifestations of Lyme neuroborreliosis (LNB), we compared EM characteristics in patients with borrelial meningoradiculoneuritis (n = 122) to those with aseptic meningitis without radicular pain (n = 72 patients), and to patients with EM but without neurologic involvement (n = 12,384). We also assessed factors that might impact duration. We found that the duration of EM at diagnosis in patients with borrelial meningoradiculoneuritis was not significantly different compared with those with LNB without radicular pain (34 vs. 26 days; p = 0.227). The duration of EM for each of these clinical presentations of LNB, however, was significantly longer than in patients with EM without LNB (10 days; p < 0.001). Contributing factors to this difference might have been that patients with LNB failed to recognize that they had EM or were unaware of the importance of not delaying antibiotic treatment for EM. In conclusion, the duration of the EM skin lesion in EM patients with LNB is longer than in patients with just EM, irrespective of the type of LNB.

The Development of a Rabies Virus-Vectored Vaccine against Borrelia burgdorferi, Targeting BBI39

Lyme disease (LD) is the most common tick-borne illness in the United States (U.S.), Europe, and Asia. Borrelia burgdorferi, a spirochete bacterium transmitted by the tick vector Ixodes scapularis, causes LD in the U.S. If untreated, Lyme arthritis, heart block, and meningitis can occur. Given the absence of a human Lyme disease vaccine, we developed a vaccine using the rabies virus (RABV) vaccine vector BNSP333 and an outer surface borrelial protein, BBI39. BBI39 was previously utilized as a recombinant protein vaccine and was protective in challenge experiments; therefore, we decided to utilize this protective antigen in a rabies virus-vectored vaccine against Borrelia burgdorferi. To incorporate BBI39 into the RABV virion, we generated a chimeric BBI39 antigen, BBI39RVG, by fusing BBI39 with the final amino acids of the RABV glycoprotein by molecular cloning and viral recovery with reverse transcription genetics. Here, we have demonstrated that the BBI39RVG antigen was incorporated into the RABV virion via immunofluorescence and Western blot analysis. Mice vaccinated with our BPL inactivated RABV-BBI39RVG (BNSP333-BBI39RVG) vaccine induced high amounts of BBI39-specific antibodies, which were maintained long-term, up to eight months post-vaccination. The BBI39 antibodies neutralized Borrelia in vaccinated mice when challenged with Borrelia burgdorferi by either syringe injection or infected ticks and they reduced the Lyme disease pathology of arthritis in infected mouse joints. Overall, the RABV-based LD vaccine induced more and longer-term antibodies compared to the recombinant protein vaccine. This resulted in lower borrelial RNA in RABV-based vaccinated mice compared to recombinant protein vaccinated mice. The results of this study indicate the successful use of BBI39 as a vaccine antigen and RABV as a vaccine vector for LD.

Hemarthrosis in a Pediatric Patient With Immune Thrombocytopenia and Lyme Arthritis

The presentation of immune thrombocytopenia is dependent on the degree of thrombocytopenia, with no to mild bleeding symptoms, primarily mucocutaneous bleeding. Severe bleeding in other organ systems is a rare complication. Spontaneous hemarthrosis is rare in patients without hemophilia. We report a child presenting with oral and cutaneous petechial lesions and left knee hemarthrosis without trauma. Laboratory findings showed severe thrombocytopenia consistent with immune thrombocytopenia. Serologic tests were consistent with Lyme disease. Hemarthrosis was presumed secondary to Lyme disease monoarticular joint inflammation with bleeding exacerbated by severe thrombocytopenia. Hemarthrosis resolved and platelet counts normalized following immunoglobulin infusion, steroid course, and antibiotics.

Structure of the Borrelia burgdorferi ATP-dependent metalloprotease FtsH in its functionally relevant hexameric form

ATP-dependent proteases FtsH are conserved in bacteria, mitochondria, and chloroplasts, where they play an essential role in degradation of misfolded/unneeded membrane and cytosolic proteins. It has also been demonstrated that the FtsH homologous protein BB0789 is crucial for mouse and tick infectivity and in vitro growth of the Lyme disease-causing agent Borrelia burgdorferi. This is not surprising, considering B. burgdorferi complex life cycle, residing in both in mammals and ticks, which requires a wide range of membrane proteins and short-lived cytosolic regulatory proteins to invade and persist in the host organism. In the current study, we have solved the crystal structure of the cytosolic BB0789166-614, lacking both N-terminal transmembrane α-helices and the small periplasmic domain. The structure revealed the arrangement of the AAA+ ATPase and the zinc-dependent metalloprotease domains in a hexamer ring, which is essential for ATPase and proteolytic activity. The AAA+ domain was found in an ADP-bound state, while the protease domain showed coordination of a zinc ion by two histidine residues and one aspartic acid residue. The loop region that forms the central pore in the oligomer was poorly defined in the crystal structure and therefore predicted by AlphaFold to complement the missing structural details, providing a complete picture of the functionally relevant hexameric form of BB0789. We confirmed that BB0789 is functionally active, possessing both protease and ATPase activities, thus providing novel structural-functional insights into the protein, which is known to be absolutely necessary for B. burgdorferi to survive and cause Lyme disease.

Cellular and transcriptome signatures unveiled by single-cell RNA-Seq following ex vivo infection of murine splenocytes with Borrelia burgdorferi

Introduction

Lyme disease, the most common tick-borne infectious disease in the US, is caused by a spirochetal pathogen Borrelia burgdorferi (Bb). Distinct host responses are observed in susceptible and resistant strains of inbred of mice following infection with Bb reflecting a subset of inflammatory responses observed in human Lyme disease. The advent of post-genomic methodologies and genomic data sets enables dissecting the host responses to advance therapeutic options for limiting the pathogen transmission and/or treatment of Lyme disease.

Methods

In this study, we used single-cell RNA-Seq analysis in conjunction with mouse genomics exploiting GFP-expressing Bb to sort GFP+ splenocytes and GFP- bystander cells to uncover novel molecular and cellular signatures that contribute to early stages of immune responses against Bb.

Results

These data decoded the heterogeneity of splenic neutrophils, macrophages, NK cells, B cells, and T cells in C3H/HeN mice in response to Bb infection. Increased mRNA abundance of apoptosis-related genes was observed in neutrophils and macrophages clustered from GFP+ splenocytes. Moreover, complement-mediated phagocytosis-related genes such as C1q and Ficolin were elevated in an inflammatory macrophage subset, suggesting upregulation of these genes during the interaction of macrophages with Bb-infected neutrophils. In addition, the role of DUSP1 in regulating the expression of Casp3 and pro-inflammatory cytokines Cxcl1, Cxcl2, Il1b, and Ccl5 in Bb-infected neutrophils were identified.

Discussion

These findings serve as a growing catalog of cell phenotypes/biomarkers among murine splenocytes that can be exploited for limiting spirochetal burden to limit the transmission of the agent of Lyme disease to humans via reservoir hosts.

Risky business: human-related data is lacking from Lyme disease risk models

Used as a communicative tool for risk management, risk maps provide a service to the public, conveying information that can raise risk awareness and encourage mitigation. Several studies have utilized risk maps to determine risks associated with the distribution of Borrelia burgdorferi, the causal agent of Lyme disease in North America and Europe, as this zoonotic disease can lead to severe symptoms. This literature review focused on the use of risk maps to model distributions of B. burgdorferi and its vector, the blacklegged tick (Ixodes scapularis), in North America to compare variables used to predict these spatial models. Data were compiled from the existing literature to determine which ecological, environmental, and anthropic (i.e., human focused) variables past research has considered influential to the risk level for Lyme disease. The frequency of these variables was examined and analyzed via a non-metric multidimensional scaling analysis to compare different map elements that may categorize the risk models performed. Environmental variables were found to be the most frequently used in risk spatial models, particularly temperature. It was found that there was a significantly dissimilar distribution of variables used within map elements across studies: Map Type, Map Distributions, and Map Scale. Within these map elements, few anthropic variables were considered, particularly in studies that modeled future risk, despite the objective of these models directly or indirectly focusing on public health intervention. Without including human-related factors considering these variables within risk map models, it is difficult to determine how reliable these risk maps truly are. Future researchers may be persuaded to improve disease risk models by taking this into consideration.

What a Tick Can Tell a Doctor: Using the Human-Biting Tick in the Clinical Management of Tick-Borne Disease

With expanding concern about ticks, there is a general sense of uncertainty about the diagnosis and treatment of tick-borne diseases. The diagnosis process is often based on clinical judgment in conjunction with laboratory testing and can be pathogen specific. Treatments may require disease-dependent approaches, and co-infections complicate or increase the severity of the clinical picture. Measuring exposure indices in the tick has become popular among providers and their patients, though this practice is not universally understood, and certain public health agencies have voiced concerns regarding interpretation and rigor of testing. As many providers subscribe to or recommend these services to aid in pretest risk and exposure assessments, this work sought to clarify the role of pathogen testing human-biting ticks as a complement to the diagnostic pipeline and raises points that must be addressed through future research and interdisciplinary conversation. Future work is needed to develop quality control oversight for tick testing laboratories. Studies on the integration of tick testing with human cases to see how these services affect health outcomes are also needed. Alongside these, improvements in the quality and availability of diagnostics are of critical importance.

Diagnostic probability classification in suspected borreliosis by a novel Borrelia C6-peptide IgG1- subclass antibody test

The tick-borne multisystemic infection caused by Borrelia burgdorferi sensu lato, Lyme borreliosis, or Lyme disease, occurring in temperate regions of the northern hemisphere, continues to spread geographically with the expanding tick population. Despite the rising perceived risk of infection in the population, the clinical diagnosis of Borrelia infection is not always obvious and the most important laboratory test, antibody detection, has limited accuracy in diagnosing active disease. According to international guidelines, the primary serology test, which has a high sensitivity-low specificity, should, be verified using a high specificity confirmation test to improve the specificity. However, this enhancement in specificity comes at the cost of lower sensitivity. This two-step procedure is often omitted in everyday clinical practice. An optimal primary test would be one where no secondary tests for confirmation would be necessary. In the present study, the performance of a novel assay for quantitating IgG1-subclass antibodies to Borrelia C6-peptide was compared to a commercial reference assay of total IgG and IgM antibodies to Borrelia C6-peptide in the setting of a high endemic area for borreliosis. A derivation study on a retrospective clinical material was performed to compare the performance parameters and assess the discriminatory properties of the assays, followed by a prospective validation study. The IgG1-antibody assay achieved comparable summary performance parameters to those of the reference assay. The sensitivity was almost 100% while the specificity was about 50%. In a high-endemic setting, characterized by high background seropositivity of about 50% and disease prevalence of approximately 10%, antibody tests are unable to rule-in active Borrelia infection. The rule-out assessment of the methods revealed that of 1000 patients, 7 - 54 with negative results based on the reference method could have an active Borrelia infection. Such uncertainty was not found for the index test and may help improve the risk classification of patients.

Putative target sites in synganglion for novel ixodid tick control strategies

Acaricide resistance is a global problem that has impacts worldwide. Tick populations with broad resistance to all commercially available acaricides have been reported. Since resistance selection in ticks and their role in pathogen transmission to animals and humans result in important economic and public health burden, it is essential to develop new strategies for their control (i.e., novel chemical compounds, vaccines, biological control). The synganglion is the tick central nervous system and it is responsible for synthesizing and releasing signaling molecules with different physiological functions. Synganglion proteins are the targets of the majority of available acaricides. In this review we provide an overview of the mode-of-action and resistance mechanisms against neurotoxic acaricides in ticks, as well as putative target sites in synganglion, as a supporting tool to identify new target proteins and to develop new strategies for tick control.

The AxBioTick Study: Borrelia Species and Tick-Borne Encephalitis Virus in Ticks, and Clinical Responses in Tick-Bitten Individuals on the Aland Islands, Finland

The AxBioTick study was initiated to investigate the prevalence of ticks and tick-borne pathogens and their impact on antibody and clinical responses in tick-bitten individuals on the Aland Islands. This geographical area is hyperendemic for both Lyme borreliosis (LB) and Tick-borne encephalitis (TBE). Blood samples and ticks were collected from 100 tick-bitten volunteers. A total of 425 ticks was collected, all determined to Ixodes ricinus using molecular tools. Of them 20% contained Borrelia species, of which B. garinii and B. afzelii were most common. None contained the TBE virus (TBEV). Blood samples were drawn in conjunction with the tick bite, and eight weeks later. Sera were analyzed for Borrelia- and TBEV-specific antibodies using an ELISA and a semiquantitative antibody assay. In total 14% seroconverted in Borrelia C6IgG1, 3% in TBEV IgG, and 2% in TBEV IgM. Five participants developed clinical manifestations of LB. The high seroprevalence of both Borrelia (57%) and TBEV (52%) antibodies are likely attributed to the endemic status of the corresponding infections as well as the TBE vaccination program. Despite the similar prevalence of Borrelia spp. detected in ticks in other parts of Europe, the infection rate in this population is high. The AxBioTick study is continuing to investigate more participants and ticks for co-infections, and to characterize the dermal immune response following a tick bite.

Detection, identification and genotyping of Borrelia spp. in ticks of Coastal-Karst and Littoral-Inner Carniola regions in Slovenia

The density and spread of tick vector species have increased throughout Europe in the last 30 years, leading to an increase of Lyme borreliosis cases, including in Slovenia. The aim of this study was to isolate Borrelia strains and determine the prevalence of B. burgdorferi sensu lato and B. miyamotoi in adults of Ixodes ricinus (Linnaeus) collected in 2019 in the two regions of the country (Coastal-Karst and Littoral-Inner Carniola) by cultivation and PCR. We isolated B. burgdorferi s.l. by culture method in 28/559 (5%) ticks from both regions. Culture-negative samples (531/559, i.e., 95%) were additionally tested by real-time PCR. In 155/531 (29.2%) PCR-positive samples, a fragment of flaB or glpQ was amplified and further sequenced to identify species of the Borrelia. Using both methods, cultivation and PCR, Borrelia spp. prevalence was 32.7% in the Coastal-Karst region and 33.0% in the Littoral-Inner Carniola region. Genotyping of the Borrelia spp. isolates revealed that 17/28 (60%) were B. garinii subtype Mlg2. Of all tick samples tested for B. miyamotoi 8/398 (2%) were PCR positive. Based on previous studies in these regions, we had expected more ticks to be infected with B. afzelii, but genotyping revealed that B. garinii was the most abundant.

Role of the Hypothetical Protein BB0563 during Borrelia burgdorferi Infection in Animals

The alternative sigma factor RpoS in Borrelia burgdorferi, the etiological agent of Lyme disease, has long been postulated to regulate virulence-associated genes other than ospC and dbpA. Here, we demonstrate that bb0563, a gene encoding a hypothetical protein, is regulated by RpoS and contributes to the optimal infectivity of B. burgdorferi. When B. burgdorferi was exposed to environmental stimuli, bb0563 showed similar expression patterns as rpoS, ospC, and dbpA. Expression of bb0563 was significantly downregulated when rpoS was inactivated and was restored in the complemented strain. By using rapid amplification of cDNA ends (RACE) and luciferase reporter assays, a functional promoter was identified in the regulatory region upstream of bb0563. Gene expression from this promoter was drastically decreased in the rpoS mutant. We next investigated the role of bb0563 during animal infection. By using quantitative reverse transcription-PCR (RT-PCR), we found that bb0563 was highly expressed in mouse tissues during infection. We further created a bb0563-deficient mutant in a bioluminescent B. burgdorferi strain and examined infection dynamics using in vivo imaging. Relative to the parental and complemented strains, the mutant showed a delayed infection pattern and bacterial load was reduced. Another bb0563 deletion mutant was also created in the strain 297 background, and quantitative PCR (qPCR) analysis revealed a significantly lower spirochetal burden in tissue samples collected from animals infected with the mutant. In addition, localization studies indicate that BB0563 is not exposed on the cell surface but is associated with outer membrane. Taken together, these results suggest that bb0563 is required for optimal infectivity of B. burgdorferi during experimental infection.

Spatial correlated incidence modeling with zero inflation

Disease mapping models have been popularly used to model disease incidence with spatial correlation. In disease mapping models, zero inflation is an important issue, which often occurs in disease incidence datasets with high proportions of zero disease count. It is originated from limited survey coverage or unadvanced testing equipment, which makes some regions have no observed patients. Then excessive zeros recorded in the disease incidence dataset would mess up the true distributions of disease incidence and lead to inaccurate estimates. To address this issue, a zero-inflated disease mapping model is developed in this work. In this model, a zero-inflated process using Bernoulli indicators is assumed to characterize whether the zero inflation occurs for each region. For regions without zero inflation, a coherent and generative disease mapping model is applied for mapping the spatially correlated disease incidence. Independent spatial random effects are incorporated in both processes to account for the spatial patterns of zero inflation and disease incidence. External covariates are also considered in both processes to better explain the disease count data. To estimate the model, a Markov chain Monte Carlo algorithm is proposed. We evaluate model performance via a variety of simulation experiments. Finally, a Lyme disease dataset of Virginia is analyzed to illustrate the application of the proposed model.

Persistent Borrelia burgdorferi Sensu Lato Infection after Antibiotic Treatment: Systematic Overview and Appraisal of the Current Evidence from Experimental Animal Models

Lyme borreliosis is caused by spirochetes belonging to the Borrelia burgdorferi sensu lato group, which are transmitted by Ixodes tick species living in the temperate climate zones of the Northern Hemisphere. The clinical manifestations of Lyme borreliosis are diverse and treated with oral or intravenous antibiotics. In some patients, long-lasting and debilitating symptoms can persist after the recommended antibiotic treatment. The etiology of such persisting symptoms is under debate, and one hypothesis entails persistent infection by a subset of spirochetes after antibiotic therapy. Here, we review and appraise the experimental evidence from in vivo animal studies on the persistence of B. burgdorferi sensu lato infection after antibiotic treatment, focusing on the antimicrobial agents doxycycline and ceftriaxone. Our review indicates that some in vivo animal studies found sporadic positive cultures after antibiotic treatment. However, this culture positivity often seemed to be related to inadequate antibiotic treatment, and the few positive cultures in some studies could not be reproduced in other studies. Overall, current results from animal studies provide insufficient evidence for the persistence of viable and infectious spirochetes after adequate antibiotic treatment. Borrelial nucleic acids, on the contrary, were frequently detected in these animal studies and may thus persist after antibiotic treatment. We put forward that research into the pathogenesis of persisting complaints after antibiotic treatment for Lyme borreliosis in humans should be a top priority, but future studies should most definitely also focus on explanations other than persistent B. burgdorferi sensu lato infection after antibiotic treatment.

Knowledge, Attitudes, and Behaviors Regarding Lyme Borreliosis Prevention in the Endemic Area of Northeastern Poland

(1) Background: The incidence of Lyme borreliosis (LB) is increasing in Europe. The new LB vaccine is still in clinical development, thus the dissemination of knowledge about the disease is essential. We assessed the knowledge, attitudes and preventive practices (KAP) against tick-borne diseases (TBDs) of people living in the endemic area in northeastern Poland. (2) Methods: We surveyed 406 adults using a 37-item anonymous paper survey. The data were analyzed with regression models. (3) Results: The two most popular knowledge sources were the Internet and doctors, selected by 77.8% and 53.4%, respectively. Respondents felt moderately knowledgeable about TBDs and tick bite prophylaxis (median scores 5/10, and 6/10, respectively), considered TBDs to be a significant health threat (median 8/10), attributed high risk to tick mouthparts remaining in the skin after tick removal (median 10/10), and shared multiple misconceptions regarding LB transmission, symptoms, and management. General knowledge scores (GKS) about TBDs and tick protection practices scores (TPS) were moderate (65.0%; IQR, 55.8−71.7%, 63.6%; 54.5−72.7%, respectively). Only 48.0% had a positive attitude towards TBE vaccination. A recent tick-bite was associated with higher GKS (OR, 2.55; 95% CI, 1.27−5.10; p = 0.008), higher TPS (OR 4.76, 95% CI, 2.0−11.1; p < 0.001), and a positive attitude towards TBE vaccine (OR 2.10, 1.07−4.10, p = 0.030). A positive vaccine attitude was also associated with obtaining TBD knowledge from doctors and other verified sources (OR, 2.654, 1.66−4.23; p < 0.001). Age, place of residence, and frequent exposure to ticks in green areas were not associated with GKS, TPS, nor vaccine attitude. (4) Conclusions: Increased risk perceptions are associated with adoption of behaviors preventing TBDs. Medical professionals play an important role in communicating knowledge about TBDs. There is a need to revise current communication strategies with respect to tick bites and prevention of LB and other TBDs.

No net effect of host density on tick-borne disease hazard due to opposing roles of vector amplification and pathogen dilution

To better understand vector‐borne disease dynamics, knowledge of the ecological interactions between animal hosts, vectors, and pathogens is needed. The effects of hosts on disease hazard depends on their role in driving vector abundance and their ability to transmit pathogens. Theoretically, a host that cannot transmit a pathogen could dilute pathogen prevalence but increase disease hazard if it increases vector population size. In the case of Lyme disease, caused by Borrelia burgdorferi s.l. and vectored by Ixodid ticks, deer may have dual opposing effects on vectors and pathogen: deer drive tick population densities but do not transmit B. burgdorferi s.l. and could thus decrease or increase disease hazard. We aimed to test for the role of deer in shaping Lyme disease hazard by using a wide range of deer densities while taking transmission host abundance into account. We predicted that deer increase nymphal tick abundance while reducing pathogen prevalence. The resulting impact of deer on disease hazard will depend on the relative strengths of these opposing effects. We conducted a cross‐sectional survey across 24 woodlands in Scotland between 2017 and 2019, estimating host (deer, rodents) abundance, questing Ixodes ricinus nymph density, and B. burgdorferi s.l. prevalence at each site. As predicted, deer density was positively associated with nymph density and negatively with nymphal infection prevalence. Overall, these two opposite effects canceled each other out: Lyme disease hazard did not vary with increasing deer density. This demonstrates that, across a wide range of deer and rodent densities, the role of deer in amplifying tick densities cancels their effect of reducing pathogen prevalence. We demonstrate how noncompetent host density has little effect on disease hazard even though they reduce pathogen prevalence, because of their role in increasing vector populations. These results have implications for informing disease mitigation strategies, especially through host management.

Epidemiology of Lyme Disease

Lyme disease is the most common vector-borne illness in North America and Europe. The etiologic agent, Borrelia burgdorferi sensu lato, is transmitted to humans by certain species of Ixodes ticks, which are found widely in temperate regions of the Northern hemisphere. Clinical features are diverse but death is rare. The risk of human infection is determined by the distribution and abundance of vector ticks, ecologic factors influencing tick infection rates, and human behaviors that promote tick bite. Rates of infection are highest among children aged 5 to 15 years and adults aged more than 50 years. In the northeastern United States where disease is most common, exposure occurs primarily in areas immediately around the home. Knowledge of disease epidemiology is important for patient management and proper diagnosis.

Lyme Arthritis

Arthritis is the most common late manifestation of Borrelia burgdorferi infection in the United States, usually beginning months after the tick bite. In most patients with Lyme arthritis (LA) today, arthritis is the presenting manifestation of the disease. Patients have swelling and pain in one or a few large joints, especially the knee. Serologic testing is the mainstay of diagnosis. Responses to antibiotic treatment are generally excellent, although a small percentage of patients have persistent, postinfectious synovitis after 2 to 3 months of oral and IV antibiotics, which respond to anti-inflammatory therapies. Herein we review the clinical presentation, diagnosis, and management of LA.

Efficacy of Short-Term High Dose Pulsed Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome (PTLDS) and Associated Co-Infections: A Report of Three Cases and Literature Review

Lyme disease and associated co-infections are increasing worldwide and approximately 20% of individuals develop chronic Lyme disease (CLD)/Post-Treatment Lyme Disease Syndrome (PTLDS) despite early antibiotics. A seven- to eight-week protocol of double dose dapsone combination therapy (DDDCT) for CLD/PTLDS results in symptom remission in approximately 50% of patients for one year or longer, with published culture studies indicating higher doses of dapsone demonstrate efficacy against resistant biofilm forms of Borrelia burgdorferi. The purpose of this study was, therefore, to evaluate higher doses of dapsone in the treatment of resistant CLD/PTLDS and associated co-infections. A total of 25 patients with a history of Lyme and associated co-infections, most of whom had ongoing symptoms despite several courses of DDDCT, took one or more courses of high dose pulsed dapsone combination therapy (200 mg dapsone × 3–4 days and/or 200 mg BID × 4 days), depending on persistent symptoms. The majority of patients noticed sustained improvement in eight major Lyme symptoms, including fatigue, pain, headaches, neuropathy, insomnia, cognition, and sweating, where dapsone dosage, not just the treatment length, positively affected outcomes. High dose pulsed dapsone combination therapy may represent a novel therapeutic approach for the treatment of resistant CLD/PTLDS, and should be confirmed in randomized, controlled clinical trials.

BB0761, a MepM homolog, contributes to Borrelia burgdorferi cell division and mammalian infectivity

M23 family endopeptidases play important roles in cell division and separation in a wide variety of bacteria. Recent studies have suggested that these proteins also contribute to bacterial virulence. However, the biological function of M23 peptidases in pathogenic spirochetes remains unexplored. Here, we describe Borrelia burgdorferi, the bacterial pathogen causing Lyme disease, requires a putative M23 family homolog, BB0761, for spirochete morphology and cell division. Indeed, the inactivation of bb0761 led to an aberrant filamentous phenotype as well as the impairment of B. burgdorferi growth in vitro. These phenotypes were complemented not only with B. burgdorferi bb0761, but also with the mepM gene from E. coli. Moreover, the bb0761 mutant showed a complete loss of infectivity in a murine model of Lyme borreliosis. Resistance of the mutant to osmotic and oxidative stresses was markedly reduced. Our combined results indicate that BB0761 contributes to B. burgdorferi cell division and virulence.

Forest Diversity Reduces the Prevalence of Pathogens Transmitted by the Tick Ixodes ricinus

Tick-borne diseases represent the majority of vector-borne human diseases in Europe, with Ixodes ricinus, mostly present in forests, as the main vector. Studies show that vertebrate hosts diversification would decrease the prevalence of these pathogens. However, it is not well known whether habitat diversity can have similar impact on ticks and their infection rates. We measured the presence and abundance of different stages of I. ricinus, and the prevalence of associated pathogens in a large-scale forest experiment in which we manipulated tree diversity and moisture level. We showed that larval abundance was influenced by tree species identity, with larvae being more present in pine plots than in oak plots, while nymph abundance increased with canopy tree density. The proportion of Borrelia burgdorferi s.l.-infected nymphs decreased with increasing tree diversity. Our findings suggest that tree overstorey composition, structure and diversity, can affect tick abundance and pathogen prevalence. They support the idea that forest habitats may have “diluting” or “amplifying” effects on tick-borne diseases with direct relevance for human health.

Borrelia burgdorferi Migration Assays for Evaluation of Chemoattractants in Tick Saliva

Uptake of the Lyme disease spirochete by its tick vector requires not only chemical signals present in the tick's saliva but a responsive phenotype by the Borrelia burgdorferi living in the mammalian host. This is the principle behind xenodiagnosis, wherein pathogen is detected by vector acquisition. To study migration of B. burgdorferi toward Ixodes scapularis tick saliva, with the goal of identifying chemoattractant molecules, we tested multiple assays and compared migration of host-adapted spirochetes to those cultured in vitro. We tested mammalian host-adapted spirochetes, along with those grown in culture at 34 °C, for their relative attraction to tick saliva or the nutrient N-acetyl-D-glucosamine (D-GlcNAc) and its dimer chitobiose using two different experimental designs. The host-adapted B. burgdorferi showed greater preference for tick saliva over the nutrients, whereas the cultured incubator-grown B. burgdorferi displayed no significant attraction to saliva versus a significant response to the nutrients. Our results not only describe a validated migration assay for studies of the Lyme disease agent, but provide a further understanding of how growth conditions and phenotype of B. burgdorferi are related to vector acquisition.

Controlled Proteolysis of an Essential Virulence Determinant Dictates Infectivity of Lyme Disease Pathogens

The Borrelia burgdorferi BB0323 protein undergoes a complex yet poorly defined proteolytic maturation event that generates N-terminal and C-terminal proteins with essential functions in cell growth and infection. Here, we report that a borrelial protease, B. burgdorferi high temperature requirement A protease (BbHtrA), cleaves BB0323 between asparagine (N) and leucine (L) at positions 236 and 237, while the replacement of these residues with alanine in the mutant protein prevents its cleavage, despite preserving its normal secondary structure. The N-terminal BB0323 protein binds BbHtrA, but its cleavage site mutant displays deficiency in such interaction. An isogenic borrelial mutant with NL-to-AA substitution in BB0323 (referred to as Bb^bb0323NL) maintains normal growth yet is impaired for infection of mice or transmission from infected ticks. Notably, the BB0323 protein is still processed in Bb^bb0323NL, albeit with lower levels of mature N-terminal BB0323 protein and multiple aberrantly processed polypeptides, which could result from nonspecific cleavages at other asparagine and leucine residues in the protein. The lack of infectivity of Bb^bb0323NL is likely due to the impaired abundance or stoichiometry of a protein complex involving BB0238, another spirochete protein. Together, these studies highlight that a precise proteolytic event and a particular protein-protein interaction, involving multiple borrelial virulence determinants, are mutually inclusive and interconnected, playing essential roles in the infectivity of Lyme disease pathogens.

Inclusion of environmentally themed search terms improves Elastic net regression nowcasts of regional Lyme disease rates

Lyme disease is the most widely reported vector-borne disease in the United States. 95% of confirmed human cases are reported in the Northeast and upper Midwest (25,778 total confirmed cases from Northeast and upper Midwest / 27,203 total US confirmed cases). Human cases typically occur in the spring and summer months when an infected nymph Ixodid tick takes a blood meal. Current federal surveillance strategies report data on an annual basis, leading to nearly a year lag in national data reporting. These lags in reporting make it difficult for public health agencies to assess and plan for the current burden of Lyme disease. Implementation of a nowcasting model, using historical data to predict current trends, provides a means for public health agencies to evaluate current Lyme disease burden and make timely priority-based budgeting decisions. The objective of the study was to develop and compare the performance of nowcasting models using free data from Google Trends and Centers of Disease Control and Prevention surveillance reports. We developed two sets of elastic net models for five regions of the United States: 1. Using only monthly proportional hit data from the 21 disease symptoms and tick related terms, and 2. Using monthly proportional hit data from terms identified via Google correlate and the disease symptom and vector terms. Elastic net models using the full-term list were highly accurate (Root Mean Square Error: 0.74, Mean Absolute Error: 0.52, R2: 0.97) for four of the five regions of the United States and improved accuracy 1.33-fold while reducing error 0.5-fold compared to predictions from models using disease symptom and vector terms alone. Many of the terms included and found to be important for model performance were environmentally related. These models can be implemented to help local and state public health agencies accurately monitor Lyme disease burden during times of reporting lag from federal public health reporting agencies.

Coexisting Thyroiditis and Carditis in a Patient with Lyme disease: Looking for a Unifying Diagnosis

Background/Objective

Lyme disease, the most common vector-borne infection in the United States, causes multisystem inflammation. We describe a patient who presented with symptoms of Lyme disease, carditis, and thyroiditis.

Case Report

A 53-year-old woman developed fatigue and dyspnea on exertion 1 month after returning from a trip to Delaware. Her electrocardiogram (ECG) showed first-degree atrioventricular (AV) block with a P-R interval up to 392 milliseconds, in the setting of elevated free thyroxine and undetectable thyroid-stimulating hormone levels. Lyme serology was positive. She was hospitalized and started on ceftriaxone. During the second day of hospitalization, AV block worsened to second-degree Mobitz type II but converted back to first-degree AV block after a few hours. Her 24-hour I-123 thyroid uptake and scan revealed markedly diminished I-123 uptake of 1.2%. On day 4, the P-R interval improved, and she was discharged on doxycycline for 3 weeks. P-R interval on ECG and repeated thyroid function tests were normal after finishing antibiotic treatment.

Discussion

In our patient, known exposure to the vector, a classic rash on the chest, improvement in the symptoms, and normalization of thyroid function tests after antibiotic therapy support Lyme infection as a cause of carditis and painless, autoimmune thyroiditis.

Conclusion

Our case highlights the importance of considering Lyme disease as a cause of painless, autoimmune thyroiditis, especially in patients with concurrent cardiovascular involvement.

Emerging and Re-emerging Vector-Borne Infectious Diseases and the Challenges for Control: A Review

Vector-borne emerging and re-emerging diseases pose considerable public health problem worldwide. Some of these diseases are emerging and/or re-emerging at increasing rates and appeared in new regions in the past two decades. Studies emphasized that the interactions among pathogens, hosts, and the environment play a key role for the emergence or re-emergence of these diseases. Furthermore, social and demographic factors such as human population growth, urbanization, globalization, trade exchange and travel and close interactions with livestock have significantly been linked with the emergence and/or re-emergence of vector-borne diseases. Other studies emphasize the ongoing evolution of pathogens, proliferation of reservoir populations, and antimicrobial drug use to be the principal exacerbating forces for emergence and re-emergence of vector-borne infectious diseases. Still other studies equivocally claim that climate change has been associated with appearance and resurgence of vector-borne infectious diseases. Despite the fact that many important emerging and re-emerging vector-borne infectious diseases are becoming better controlled, our success in stopping the many new appearing and resurging vector-borne infectious diseases that may happen in the future seems to be uncertain. Hence, this paper reviews and synthesizes the existing literature to explore global patterns of emerging and re-emerging vector-borne infections and the challenges for their control. It also attempts to give insights to the epidemiological profile of major vector-borne diseases including Zika fever, dengue, West Nile fever, Crimean-Congo hemorrhagic fever, Chikungunya, Yellow fever, and Rift Valley fever.

Post-Treatment Lyme Disease Syndrome: Need for Diagnosis and Treatment

With the continued surge in Lyme disease cases, post-treatment Lyme disease syndrome (PTLDS) is becoming a more pressing health concern. The aim of this review is to identify comprehensive treatment strategies for PTLDS patients. Unfortunately, universal guidelines for diagnosing and treating PTLDS do not currently exist. Consequently, physicians cannot adequately address concerns of possible PTLDS patients. Patients are left suffering and searching for answers, and their activities of daily living and quality of life are adversely impacted. This review highlights that PTLDS clinical trials have focused mainly on treatment with antibiotics, yielding challenging results that lack consistency in inclusion criteria across trials. It will remain exceedingly difficult to extrapolate the outcomes of such studies if a standard for PTLDS diagnosis is not well-established. By focusing on treatment trials rather than establishing diagnostic criteria, research in this field ignores a critical step in investigating PTLDS. The first significant step is to create comprehensive guidelines for the diagnosis of PTLDS, which can generate uniformity and validate PTLDS treatment trials.

Modelling Spatiotemporal Patterns of Lyme Disease Emergence in Québec

Lyme disease is a growing public health problem in Québec. Its emergence over the last decade is caused by environmental and anthropological factors that favour the survival of Ixodes scapularis, the vector of Lyme disease transmission. The objective of this study was to estimate the speed and direction of human Lyme disease emergence in Québec and to identify spatiotemporal risk patterns. A surface trend analysis was conducted to estimate the speed and direction of its emergence based upon the first detected case of Lyme disease in each municipality in Québec since 2004. A cluster analysis was also conducted to identify at-risk regions across space and time. These analyses were reproduced for the date of disease onset and date of notification for each case of Lyme disease. It was estimated that Lyme disease is spreading northward in Québec at a speed varying between 18 and 32 km/year according to the date of notification and the date of disease onset, respectively. A significantly high risk of disease was found in seven clusters identified in the south-west of Québec in the sociosanitary regions of Montérégie and Estrie. The results obtained in this study improve our understanding of the spatiotemporal patterns of Lyme disease in Québec, which can be used for proactive, targeted interventions by public and clinical health authorities.

Case 292: Lyme Neuroborreliosis

History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed.

Impact of Land Use Changes and Habitat Fragmentation on the Eco-epidemiology of Tick-Borne Diseases

The incidence of tick-borne diseases has increased in recent decades and accounts for the majority of vector-borne disease cases in temperate areas of Europe, North America, and Asia. This emergence has been attributed to multiple and interactive drivers including changes in climate, land use, abundance of key hosts, and people's behaviors affecting the probability of human exposure to infected ticks. In this forum paper, we focus on how land use changes have shaped the eco-epidemiology of Ixodes scapularis-borne pathogens, in particular the Lyme disease spirochete Borrelia burgdorferi sensu stricto in the eastern United States. We use this as a model system, addressing other tick-borne disease systems as needed to illustrate patterns or processes. We first examine how land use interacts with abiotic conditions (microclimate) and biotic factors (e.g., host community composition) to influence the enzootic hazard, measured as the density of host-seeking I. scapularis nymphs infected with B. burgdorferi s.s. We then review the evidence of how specific landscape configuration, in particular forest fragmentation, influences the enzootic hazard and disease risk across spatial scales and urbanization levels. We emphasize the need for a dynamic understanding of landscapes based on tick and pathogen host movement and habitat use in relation to human resource provisioning. We propose a coupled natural-human systems framework for tick-borne diseases that accounts for the multiple interactions, nonlinearities and feedbacks in the system and conclude with a call for standardization of methodology and terminology to help integrate studies conducted at multiple scales.

Antigenic sites in SARS-CoV-2 spike RBD show molecular similarity with pathogenic antigenic determinants and harbors peptides for vaccine development

The spike protein of coronavirus is key target for drug development and other pharmacological interventions. In current study, we performed an integrative approach to predict antigenic sites in SARS-CoV-2 spike receptor binding domain and found nine potential antigenic sites. The predicted antigenic sites were then assessed for possible molecular similarity with other known antigens in different organisms. Out of nine sites, seven sites showed molecular similarity with 54 antigenic determinants found in twelve pathogenic bacterial species (Mycobacterium tuberculosis, Mycobacterium leprae, Bacillus anthracis, Borrelia burgdorferi, Clostridium perfringens, Clostridium tetani, Helicobacter Pylori, Listeria monocytogenes, Staphylococcus aureus, Streptococcus pyogenes, Vibrio cholera and Yersinia pestis), two malarial parasites (Plasmodium falciparum and Plasmodium knowlesi) and influenza virus A. Most of the bacterial antigens that displayed molecular similarity with antigenic sites in SARS-CoV-2 RBD (receptor binding domain) were toxins and virulent factors. Antigens from Mycobacterium that showed similarity were mainly involved in modulating host cell immune response and ensuring persistence and survival of pathogen in host cells. Presence of a large number of antigenic determinants, similar to those in highly pathogenic microorganisms, not merely accounts for complex etiology of the disease but also provides an explanation for observed pathophysiological complications, such as deregulated immune response, unleashed or dysregulated cytokine secretion (cytokine storm), multiple organ failure etc., that are more evident in aged and immune-compromised patients. Over-representation of antigenic determinants from Plasmodium and Mycobacterium in all antigenic sites suggests that anti-malarial and anti-TB drugs can prove to be clinical beneficial for COVID-19 treatment. Besides this, anti-leprosy, anti-lyme, anti-plague, anti-anthrax drugs/vaccine etc. are also expected to be beneficial in COVID-19 treatment. Moreover, individuals previously immunized/vaccinated or had previous history of malaria, tuberculosis or other disease caused by fifteen microorganisms are expected to display a considerable degree of resistance against SARS-CoV-2 infection. Out of the seven antigenic sites predicted in SARS-CoV-2, a part of two antigenic sites were also predicted as potent T-cell epitopes (KVGGNYNYL^444-452 and SVLYNSASF^366-374) against MHC class I and three (KRISNCVADYSVLYN^356-370, DLCFTNVYADSFVI^389-402, and YRVVVLSFELLHA^508-520) against MHC class II. All epitopes possessed significantly lower predicted IC50 value which is a prerequisite for a preferred vaccine candidate for COVID-19.

Identification and functional analysis of a galactosyltransferase capable of cholesterol glycolipid formation in the Lyme disease spirochete Borrelia burgdorferi

Borrelia burgdorferi (Bb), the etiological agent of Lyme disease, produces a series of simple glycolipids where diacylglycerol and cholesterol serve as the precursor. The cholesterol-based glycolipids, cholesteryl 6-O-acyl-β-D-galactopyranoside (ACGal) and cholesteryl-β-D-galactopyranoside (CGal) are immunogenic and proposed to contribute to the pathogenesis of Lyme disease. Detailed studies of CGal and ACGal in Bb have been hampered by a lack of knowledge of their underlying biosynthetic processes. The genome of Bb encodes four putative glycosyltransferases, and only one of these, BB0572, was predicted to be an inverting family 2 glycosyltransferase (GT2 enzyme) capable of using UDP-galactose as a substrate and forming a β-glycosidic bond. Comparison of the 42 kDa BB0572 amino acid sequence from Bb with other Borrelia spp demonstrates that this protein is highly conserved. To establish BB0572 as the galactosyltransferase capable of cholesterol glycolipid formation in Bb, the protein was produced as a recombinant product in Escherichia coli and tested in a cell-free assay with 14C-cholesterol and UDP-galactose as the substrates. This experiment resulted in a radiolabeled lipid that migrated with the cholesterol glycolipid standard of CGal when evaluated by thin layer chromatography. Additionally, mutation in the predicted active site of BB0572 resulted in a recombinant protein that was unable to catalyze the formation of the cholesterol glycolipid. These data characterize BB0572 as a putative cholesterol galactosyltransferase. This provides the first step in understanding how Bb cholesterol glycolipids are formed and will allow investigations into their involvement in pathogen transmission and disease development.

Sphingomyelinases in a journey to combat arthropod-borne pathogen transmission

Ixodes scapularis ticks feed on humans and other vertebrate hosts and transmit several pathogens of public health concern. Tick saliva is a complex mixture of bioactive proteins, lipids and immunomodulators, such as I. scapularis sphingomyelinase (IsSMase)-like protein, an ortholog of dermonecrotoxin SMase D found in the venom of Loxosceles spp. of spiders. IsSMase modulates the host immune response towards Th2, which suppresses Th1-mediated cytokines to facilitate pathogen transmission. Arboviruses utilize exosomes for their transmission from tick to the vertebrate host, and exosomes derived from tick saliva/salivary glands suppress C-X-C motif chemokine ligand 12 and interleukin-8 immune response(s) in human skin to delay wound healing and repair processes. IsSMase affects also viral replication and exosome biogenesis, thereby inhibiting tick-to-vertebrate host transmission of pathogenic exosomes. In this review, we elaborate on exosomes and their biogenesis as potential candidates for developing novel control measure(s) to combat tick-borne diseases. Such targets could help with the development of an efficient anti-tick vaccine for preventing the transmission of tick-borne pathogens.

Genetic Melting Pot in Blacklegged Ticks at the Northern Edge of their Expansion Front

Blacklegged ticks (Ixodes scapularis) are considered to be the main vector of Lyme disease in eastern North America. They may parasitize a wide range of bird and mammal hosts. Northward dispersal of blacklegged ticks has been attributed largely to movement of hosts to areas outside of the current range of the tick, in conjunction with climate change. To better understand the drivers of range expansion in the blacklegged tick, we need investigations of the genetic connectivity and differentiation of tick populations at a fine spatial scale using appropriate markers. In this study, we investigated genetic connectivity and differentiation in blacklegged ticks, in an area of putatively recent advance in Ontario and Quebec, Canada, using microsatellite markers. Our findings suggest patchy differentiation of alleles, no spatial pattern of genetic structure, and genetic subdivision within sites, which are consistent with the very limited evidence available near the leading edge of range expansion of blacklegged ticks into Canada. These findings are consistent with the prevailing hypothesis, drawn from a variety of fields of study, suggesting that migratory birds from a variety of regions may be bringing hitchhiking ticks northward into Canada.

Convergence Research for Emerging Zoonoses

Global emergence of vector-borne and zoonotic diseases presents a rapidly growing 'wicked' problem. We outline the need for a transdisciplinary research program that is grounded in ecological and evolutionary theory but integrates fundamentally with research perspectives spanning the health, social, and natural sciences.

Exploratory Space-Time Analyses of Reported Lyme Borreliosis Cases in France, 2016-2019

In recent decades, the incidence of Lyme borreliosis (LB) in Europe seems to have increased, underpinning a growing public health concern. LB surveillance systems across the continent are heterogeneous, and the spatial and temporal patterns of LB reports have been little documented. In this study, we explored the spatio-temporal patterns of LB cases reported in France from 2016 to 2019, to describe high-risk clusters and generate hypotheses on their occurrence. The space–time K-function and the Kulldorf’s scan statistic were implemented separately for each year to evaluate space–time interaction between reported cases and searching clusters. The results show that the main spatial clusters, of radius size up to 97 km, were reported in central and northeastern France each year. In 2017–2019, spatial clusters were also identified in more southern areas (near the Alps and the Mediterranean coast). Spatio-temporal clustering occurred between May and August, over one-month to three-month windows in 2016–2017 and in 2018–2019. A strong spatio-temporal interaction was identified in 2018 within 16 km and seven days, suggesting a potential local and intense pathogen transmission process. Ongoing improved surveillance and accounting for animal hosts, vectors, meteorological factors and human behaviors are keys to further elucidate LB spatio-temporal patterns.

Likely Geographic Distributional Shifts among Medically Important Tick Species and Tick-Associated Diseases under Climate Change in North America: A Review

Ticks rank high among arthropod vectors in terms of numbers of infectious agents that they transmit to humans, including Lyme disease, Rocky Mountain spotted fever, Colorado tick fever, human monocytic ehrlichiosis, tularemia, and human granulocytic anaplasmosis. Increasing temperature is suspected to affect tick biting rates and pathogen developmental rates, thereby potentially increasing risk for disease incidence. Tick distributions respond to climate change, but how their geographic ranges will shift in future decades and how those shifts may translate into changes in disease incidence remain unclear. In this study, we have assembled correlative ecological niche models for eight tick species of medical or veterinary importance in North America (Ixodes scapularis, I. pacificus, I. cookei, Dermacentor variabilis, D. andersoni, Amblyomma americanum, A. maculatum, and Rhipicephalus sanguineus), assessing the distributional potential of each under both present and future climatic conditions. Our goal was to assess whether and how species' distributions will likely shift in coming decades in response to climate change. We interpret these patterns in terms of likely implications for tick-associated diseases in North America.

Prevalence and prediction of Lyme disease in Hainan province

Lyme disease (LD) is one of the most important vector-borne diseases worldwide. However, there is limited information on the prevalence and risk analysis using correlated factors in the tropical areas. A total of 1583 serum samples, collected from five hospitals of Hainan Province, were tested by immunofluorescence assay (IFA) and western blot (WB) analyses using anti-Borrelia burgdorferi antibodies. Then, we mapped the distribution of positive rate (by IFA) and the spread of confirmed Lyme patients (by WB). Using ArcGIS, we compiled host-vector-human interactions and correlated data as risk factor layers to predict LD risk in Hainan Province. There are three LD hotspots, designated hotspot I, which is located in central Hainan, hotspot II, which contains Sanya district, and hotspot III, which lies in the Haikou-Qiongshan area. The positive rate (16.67% by IFA) of LD in Qiongzhong, located in hotspot I, was higher than that in four other areas. Of confirmed cases of LD, 80.77% of patients (42/52) whose results had been confirmed by WB were in hotspots I and III. Hotspot II, with unknowed prevalence of LD, need to be paid more attention considering human-vector interaction. Wuzhi and Limu mountains might be the most important areas for the prevalence of LD, as the severe host-vector and human-vector interactions lead to a potential origin site for LD. Qiongzhong is the riskiest area and is located to the east of Wuzhi Mountain. In the Sanya and Haikou-Qiongshan area, intervening in the human-vector interaction would help control the prevalence of LD.

A Novel Laminin-Binding Protein Mediates Microbial-Endothelial Cell Interactions and Facilitates Dissemination of Lyme Disease Pathogens

Borrelia burgdorferi conserved gene products BB0406 and BB0405, members of a common B. burgdorferi paralogous gene family, share 59% similarity. Although both gene products can function as potential porins, only BB0405 is essential for infection. Here we show that, despite sequence homology and coexpression from the same operon, both proteins differ in their membrane localization attributes, antibody accessibility, and immunogenicity in mice. BB0406 is required for spirochete survival in mammalian hosts, particularly for the disseminated infection in distant organs. We identified that BB0406 interacts with laminin, one of the major constituents of the vascular basement membrane, and facilitates spirochete transmigration across host endothelial cell barriers. A better understanding of how B. burgdorferi transmigrates through dermal and tissue vascular barriers and establishes disseminated infections will contribute to the development of novel therapeutics to combat early infection.

Lyme Disease in Humans

Lyme disease (Lyme borreliosis) is a tick-borne, zoonosis of adults and children caused by genospecies of the Borrelia burgdorferi sensu lato complex. The ailment, widespread throughout the Northern Hemisphere, continues to increase globally due to multiple environmental factors, coupled with increased incursion of humans into habitats that harbor the spirochete. B. burgdorferi sensu lato is transmitted by ticks from the Ixodes ricinus complex. In North America, B. burgdorferi causes nearly all infections; in Europe, B. afzelii and B. garinii are most associated with human disease. The spirochete's unusual fragmented genome encodes a plethora of differentially expressed outer surface lipoproteins that play a seminal role in the bacterium's ability to sustain itself within its enzootic cycle and cause disease when transmitted to its incidental human host. Tissue damage and symptomatology (i.e., clinical manifestations) result from the inflammatory response elicited by the bacterium and its constituents. The deposition of spirochetes into human dermal tissue generates a local inflammatory response that manifests as erythema migrans (EM), the hallmark skin lesion. If treated appropriately and early, the prognosis is excellent. However, in untreated patients, the disease may present with a wide range of clinical manifestations, most commonly involving the central nervous system, joints, or heart. A small percentage (~10%) of patients may go on to develop a poorly defined fibromyalgia-like illness, post-treatment Lyme disease (PTLD) unresponsive to prolonged antimicrobial therapy. Below we integrate current knowledge regarding the ecologic, epidemiologic, microbiologic, and immunologic facets of Lyme disease into a conceptual framework that sheds light on the disorder that healthcare providers encounter.

Interactions Between Ticks and Lyme Disease Spirochetes

Borrelia burgdorferi sensu lato causes Lyme borreliosis in a variety of animals and humans. These atypical bacterial pathogens are maintained in a complex enzootic life cycle that primarily involves a vertebrate host and Ixodes spp. ticks. In the Northeastern United States, I. scapularis is the main vector, while wild rodents serve as the mammalian reservoir host. As B. burgdorferi is transmitted only by I. scapularis and closely related ticks, the spirochete-tick interactions are thought to be highly specific. Various borrelial and arthropod proteins that directly or indirectly contribute to the natural cycle of B. burgdorferi infection have been identified. Discrete molecular interactions between spirochetes and tick components also have been discovered, which often play critical roles in pathogen persistence and transmission by the arthropod vector. This review will focus on the past discoveries and future challenges that are relevant to our understanding of the molecular interactions between B. burgdorferi and Ixodes ticks. This information will not only impact scientific advancements in the research of tick- transmitted infections but will also contribute to the development of novel preventive measures that interfere with the B. burgdorferi life cycle.

The Jarisch-Herxheimer reaction associated with doxycycline in a patient with Lyme arthritis

Objectives

The objective of this article was to present the clinical peculiarity of the Jarisch-Herxheimer reaction (JHR) during antibiotic treatment of Lyme arthritis.

Material and methods

Case study presentation as a basis for discussion, literature search of PubMed database particularly in the subject of combination of the JHR and Lyme borreliosis using the combination of words “Jarisch-Herxheimer reaction” and “Lyme borreliosis”, “Lyme arthritis”, “antibiotic treatment”, “generalized inflammation”, “cytokine production”, “children”, “increasing awareness”; discussion of the problem based on a clinical case and cited articles.

Results

The authors present a case of Lyme arthritis in a 13-year-old boy, as well as a discussion of clinical features of this complication of Lyme disease treatment as the Jarisch-Herxheimer reaction. On the 7^th day of doxycycline treatment the patient’s condition deteriorated: a low-grade fever occurred, and severe arthralgias with intense hip, ankle and cervical spine pain and myalgias developed. Erythrocyte sedimentation rate and C-reactive protein were elevated. The Jarisch-Herxheimer reaction was diagnosed. This complication was characterized by severity, long duration and marked signs of inflammation.

Conclusions

In the reviewed literature the Jarisch-Herxheimer reaction in patients with Lyme borreliosis is described more often in adults, with mild course and short duration of the disease. Based on the presented clinical picture this severe complication may also be associated with long duration and marked signs of inflammation. The authors suggest that informing health professionals about occurrence of the Jarisch-Herxheimer reaction should help physicians to distinguish it from allergic reactions or other conditions and improve treatment outcomes.

B. burgdorferi sensu lato-induced inhibition of antigen presentation is mediated by RIP1 signaling resulting in impaired functional T cell responses towards Candida albicans

Antigen presentation is a crucial innate immune cell function that instructs adaptive immune cells. Loss of this pathway severely impairs the development of adaptive immune responses. To investigate whether B. burgdorferi sensu lato. spirochetes modulate the induction of an effective immune response, primary human PBMCs were isolated from healthy volunteers and stimulated with B. burgdorferi s.l. Through cell entry, TNF receptor I, and RIP1 signaling cascades, B. burgdorferi s.l. strongly downregulated genes and proteins involved in antigen presentation, specifically HLA-DM, MHC class II and CD74. Antigen presentation proteins were distinctively inhibited in monocyte subsets, monocyte-derived macrophages, and dendritic cells. When compared to a range of other pathogens, B. burgdorferi s.l.-induced suppression of antigen presentation appears to be specific. Inhibition of antigen presentation interfered with T-cell recognition of B. burgdorferi s.l., and memory T-cell responses against Candidaalbicans. Re-stimulation of PBMCs with the commensal microbe C.albicans following B. burgdorferi s.l. exposure resulted in significantly reduced IFN-γ, IL-17 and IL-22 production. These findings may explain why patients with Lyme borreliosis develop delayed adaptive immune responses. Unravelling the mechanism of B. burgdorferi s.l.-induced inhibition of antigen presentation, via cell entry, TNF receptor I, and RIP1 signaling cascades, explains the difficulty to diagnose the disease based on serology and to obtain an effective vaccine against Lyme borreliosis.

Borrelia burgdorferi-Induced Changes in the Class II Self-Immunopeptidome Displayed on HLA-DR Molecules Expressed by Dendritic Cells

The MHC class II antigen processing and presentation pathway has evolved to derive short amino acid peptides from proteins that enter the endocytic pathway, load them onto MHC class II molecules and display them on the surface of antigen presenting cells for recognition by CD4+ T cells. Under normal circumstances, peptides bound to MHC class II molecules are derived from host (self) proteins and not recognized by T cells due to tolerance mechanisms. Pathogens induce significant changes in the biology of antigen presenting cells, including upregulation of MHC processing and presentation. We therefore hypothesized that exposure to pathogens may alter the repertoire of self-peptides bound to MHC class II molecules. To test this hypothesis, we isolated monocyte-derived dendritic cells from healthy subjects, exposed them to the TLR-2 agonist lipoteichoic acid or live Borrelia burgdorferi, the causative agent of Lyme disease, and isolated and characterized HLA-DR associated peptides using mass spectrometry. Our results show that lipoteichoic acid-stimulated, B. burgdorferi-stimulated and unstimulated monocyte-derived dendritic cells largely derive their self-peptides from similar overlapping sets of host proteins. However, lipoteichoic acid and B. burgdorferi stimulation promote the processing and presentation of new sets of HLA-DR associated self-peptides derived from unique protein sources. Examination of processes and compartments these proteins reside in, indicate that activation of monocyte-derived dendritic cells changes the range of host self-proteins available for processing and presentation on MHC class II molecules. These findings reveal that the HLA-DR-bound self-immunopeptidome presented by mo-DCs is dynamic in nature and changes with activation state reflective of cellular function. In addition, among the repertoire of self-peptides bound to HLA-DR are several epitopes known to be recognized by autoreactive T cells. These studies are relevant to our basic understanding of pathogen-induced changes in monocyte-derived dendritic cell function, and the mechanisms involved in infection-induced autoimmune illnesses such as Lyme arthritis.

Lyme Disease Patient Outcomes and Experiences; A Retrospective Cohort Study

Lyme disease is a vector-borne illness caused by Borrelia spp. bacterium spread by ticks to humans and other mammals. Despite being prevalent in many regions of the world, there remains considerable uncertainty surrounding many aspects of the disease, and consensus on the most appropriate and effective means of treating the illness remains to be achieved. Recommendations published by the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS), the primary guidelines followed by health care professionals treating Lyme disease, diverge in many of their key recommendations, including treatment duration. Given this lack of consensus, surprisingly little research has been conducted on patient outcomes following different treatment approaches. In this study, patient outcomes were evaluated from a cohort of 210 Canadian Lyme disease patients seeking treatment at one US Lyme disease clinic following a treatment regimen conforming to the ILADS treatment guidelines. It was found that the majority of Lyme disease patients at the clinic responded positively to treatment and a significant (p < 0.05) decrease in symptoms was observed over time. This study, along with related studies, may help to guide physicians to provide their patients with the most effective care.

Protection against Borreliella burgdorferi infection mediated by a synthetically engineered DNA vaccine

Lyme disease is the most common vector-borne disease in North America. The etiological agent is the spirochete Borreliella burgdorferi, transmitted to mammalian hosts by the Ixodes tick. In recent years there has been an increase in the number of cases of Lyme disease. Currently, there is no vaccine on the market for human use. We describe the development of a novel synthetically engineered DNA vaccine, pLD1 targeting the outer-surface protein A (OspA) of Borreliella burgdorferi. Immunization of C3 H/HeN mice with pLD1 elicits robust humoral and cellular immune responses that confer complete protection against a live Borreliella burgdorferi bacterial challenge. We also assessed intradermal (ID) delivery of pLD1 in Hartley guinea pigs, demonstrating the induction of robust and durable humoral immunity that lasts at least 1 year. We provide evidence of the potency of pLD1 by showing that antibodies targeting the OspA epitopes which have been associated with protection are prominently raised in the immunized guinea pigs. The described study provides the basis for the advancement of pDL1 as a potential vaccine for Lyme disease control.