John
Millar, MD - Provincial Health Officer, British Columbia
Diane Kindree, BSN - Lyme Borreliosis Society of British Columbia
Martina H. Ziska, MD - Lyme Disease Foundation
Welcome
and Opening Remarks
No
abstract available
James
Katzel, MD
Ukiah Valley Medical Center
Lyme
Borreliosis Clinical Overview
No
abstract available
James
H. Oliver, Jr., PhD
Callaway Professor of Biology,
Director, Institute of Arthropodology and Parasitology
Georgia Southern University
Update
on the Enzootiology of B. burgdorferi in the Southern US
We
have isolated B. burgdorferi from cotton mice (Peromyscus
gossypinus), cotton rats (Sigmodon hispidus), woodrats
(Neotoma floridana) and the ticks Ixodes scapularis
and Ixodes dentatus. Locations of isolates extend along
the coast from Cape Canaveral , FL northward to the northern
coasts of South Carolina and inland in central Georgia and southeast
Missouri. Prevalence of B. burgdorferi in rodents may
be quite high in some foci (75%). Currently it is unclear whether
there are several separate parallel enzootic cycles operating
or if there are weblike overlap among them. B. burgdorferi
strains are more genetically heterogenous in the southern U.S.
than those reported from the northern states. Infectivity varies
among the isolates and one wonders if there are resulting differences
in clinical symptoms and pathology produced in humans.
John
F. Anderson, PhD
Director
The CT Agricultural Experiment Station
Ecology
of Lyme Disease in Northeastern United States
Some
of the highest incidence rates of Lyme disease (>200,000 cases/100,000
population/county) occur in Northeastern United States. The primary
tick vector is Ixodes scapularis which is extremely abundant
in many wooded and suburban areas where white-tailed deer are
common. This tick has been recorded feeding on 120 different
species of animals (birds, mammals, lizards). The causative-agent,
Borrelia burgdorferi sensu stricto, has frequently been
recovered from humans, Ixodes scapularis, and white-footed
mice. Variants of the spirochete have been recovered from Ixodes
scapularis, the rabbit associated tick Ixodes dentantus,
and cottontail rabbit. Variants have not been recovered from
humans, and therefore are not known to cause human disease. The
interaction of the spirochete with its tick vector and wild host
reservoirs will be discussed.
Satyendra
Nath Banerjee, MD
Head, Vector-borne Diseases
British Columbia Centre for Disease Control
Isolation
of Borrelia burgdorferi in British Columbia During 1992-1994
S.N. Banerjee, M. Banerjee, K. Fernando, M.Y. Dong, M. Altamirano
and J.A. Smith. Provincial Laboratory, BC-CDC
The
survey of ticks in B.C. during 1988 to 1991 was limited to adult
ticks. In 1992 we began trapping rodents in 20 selected sites
and juvenile ticks were retrieved from them. Tick guts as well
as six organs from rodents, viz., ear, bladder, kidney, spleen,
liver and heart were cultured in BSK II medium with antibiotics.
All isolates were immunostained with Mab for P31, P34, P39 and
P41 ag. SDS-PAGE profiles, PCR for OSPA gene and DNA sequence
of 16SrRNA gene were analyzed for all axenic cultures. Up to
1991 when we had only adult ticks for culture, no spirochete
was isolated 0/1360 (0%). In 1992 B. burgdorferi (Bb)
was isolated from 1/539 (0.2%) ticks and 0/28 (0%) mice. In 1993
20/2086 (1%) ticks and 11/243 (4.5%) mice had Bb. In 1994, 7/691
(1%) ticks and 9/211 (4.1%) mice had Bb. SDS-PAGE protein
profiles of isolates were comparable to that of Bb. All Bb
were positive by Mab tests and by PCR for OSPA. DNA sequences
of 16SrRNA gene were similar to Bb-B31. Bb was
isolated from I. angustus and I. pacificus ticks.
The presence of spirochetes in juvenile and adult ticks as well
as in rodents suggests establishment of Bb in B.C. Our
results show that culture of host organs and culture of juvenile
ticks retrieved from hosts may be more successful than culture
of adult ticks only.
Patricia
Daly, MD, FRCPC
Associate Director, Epidemiology
B.C. Centre for Disease Control
Lyme
Disease in British Columbia
Patricia Daly(1), Satyen Banerjee(2), Craig Stephen(1) (1) Communicable
Disease Epidemiology Services, British Columbia Centre for Disease
Control; (2) Provincial Laboratory, British Columbia Centre for
Disease Control
In
June, 1994, borreliosis was made a reportable disease under the
Communicable Disease Regulations of the Health Act in the province
of British Columbia. This action was taken because of several
pieces of evidence. Since 1988, there have been several cases
of clinically suspected Lyme disease with positive serology for
Borrelia burgdorferi who appear to have acquired Lyme
disease from within the province. At the same time, studies have
identified the presence of tick species in British Columbia that
are known to transmit B. burgdorferi. Further studies,
which are ongoing, have revealed the presence of B. burgdorferi
in several tick species form the southwest coastal regions of
the province, as well as in deer mice hosts. The case definition
to be used for reporting purposes is that developed by the Canadian
consensus conference on Lyme disease in 1991 (CDWR 1991; 17(13):66).
Based on the Canadian consensus conference guidelines, British
Columbia is considered an endemic area for Lyme disease, although
the geographical boundaries for endemicity have not been defined
and will require further study.
Raj
Gill, BSc
Health Science Officer, Provincial Laboratories
B.C. Centre for Disease Control
Lyme
Disease Cases Acquired in British Columbia 1992-1994
Raj Gill, Satyendra Banerjee and Maya Banerjee
Research
on Lyme borreliosis in British Columbia has been on going since
1986. Our first positive case was a 2 year old female from Burns
Lake in 1988. Two patients were found to be positive in 1989;
a 44 year old female from Salt Spring Island and a 71 year old
female form Galiano Island. Only on 46 year old male was positive
in 1992 from Kootenay Lake. In 1993, three cases were reported;
one 58 year old female from Oliver, a 74 year old female from
Nanaimo and a 66 year old male from Cortes Island. As of October
1994 4 cases have been confirmed; two males from Agassiz and
Lumby and 2 females form Port Coquitlam and Port Moody. This
makes a total of 11 cases of Lyme disease acquired in B.C. during
1988-1994 out of a total of 43 cases seen at the Provincial Laboratory,
B.C.C.D.C. Only 2 cases showed the classical EM rash, most patients
were febrile with headache, fatigue and muscle pain. Elderly
patients presented with arthralgia and myalgia. All patients
were positive by the ELISA method and confirmed by Western Blot
sets and clinical diagnosis by physicians. It is pertinent to
note that during 1993-94 Dr. S. Banerjee's Vector Borne Disease
Laboratory isolated B. burgdorferi the etiologic agent
from the deer mice Peromyscus maniculatus and two species
of ticks viz. Ixodes pacificus and I. angustus
collected from the places where cases were identified. On the
basis of our findings and the Lyme disease consensus report on
case definitions, B.C. should be considered an endemic area for
Lyme disease.
Julie
A. Rawlings, MPH
Texas Department of Health
Surveillance
for Tick-borne Relapsing Fever in Texas Caverns
Tick-borne
relapsing fever (TBRF) is caused by Borrelia spirochetes
and is transmitted by Ornithodoros ticks. In Texas, the
vector is O. turicata, found in caves frequented by sheep
and goats or rodent and snake burrows; the agent is B. turicatae.
Spelunkers may be at risk of acquiring TBRF as they explore Texas
caves. In an attempt to establish the prevalence of exposure
to B. turicatae in caverns, a questionnaire was administered
to and sera was collected from 112 persons attending a Texas
Speliological Society meeting in October, 1994. Data collected
by questionnaire were analyzed to identify risk factors for disease
were analyzed to identify risk factors for disease and evaluate
histories of illness in these caverns. Each specimen was tested
by indirect immunofluorescent antibody test (IFA) for antibody
to three species of Borrelia. Eighteen were reactive.
Ron
F. Schell, PhD
Professor and Chief Bacteriologist
Wisconsin School of Medicine
Introduction
of Lyme Arthritis and Role for Borrelia burgdorferi Specific
T-Lymphocytes
Lony C.L. Lim and Ronald F. Schell
We
showed that severe destructive Lyme arthritis developed in vaccinated
hamsters after challenge with isolates of Borrelia burgdorferi
sensu lato and suggested a role for cell-mediated immunity.
Specifically, severe destructive arthritis was readily evoked
in immunocompetent inbred LSH hamsters vaccinated with a whole-cell
preparation of Formalin-inactivated B. burgdorferi organisms
in adjuvant when challenged with the homologous (vaccine) isolate
before high levels of protective borreliacidal antibody developed.
Once high levels of protective borreliacidal antibody developed,
vaccinated hamsters were protected from homologous challenge
and development of arthritis. Vaccinated hamsters, however, still
developed severe destructive arthritis when challenged with other
isolates of B. burgdorferi sensu lato. We now show that
B. burgdorferi specific T-lymphocytes were responsible
for the development of severe destructive arthritis. B. burgdorferi
specific T-lymphocytes obtained from immunocompetent hamsters
vaccinated with a whole-cell vaccine conferred on naive recipient
hamsters the ability to develop severe destructive arthritis
when challenged with B. burgdorferi sensu stricto isolates.
The successful demonstration that B. burgdorferi T-lymphocytes
were responsible for the adoptive transfer of severe destructive
arthritis was confirmed by immunological enrichment for T-lymphocytes
and characterization of the transferred cells. These studies
are important for the development of a safe vaccine (whole or
sub-unit) and for determining immunologic modulators to prevent
the development of the signs and symptoms of Lyme arthritis.
Mario
T. Philipp, PhD
Chairman, Department of Parasitology
Tulane Regional Primate Research Center
Efficacy
of Recombinant OspA Vaccine Formulations in the Rhesus Monkey
Philipp M (1), Lobet Y (2), Robert D (1), Dennis V (1), Desmons
P (2), Gu Y. (1), Hauser P (2), Lowrie Jr. R (1). (1) Tulane
University Primate Res. Center, Louisiana, USA; (2) SmithKline
Beecham Biologicals, Belgium
Three
different vaccine formulations, NS1-OspA/aluminium hydroxide
(Alum), NS1-OspA/Alum/MPL (an immunostimulant), lipidated OspA/Alum,
and one placebo (Alum) were used in a vaccination trial involving
16 male 2-3-year-old Chinese Macaca mulatta (rhesus). Four animals
were randomly assigned to each of 4 groups, and each group received
one of the vaccine formulations. Three 10 µg doses of each
vaccine were given to each animal intramuscularly into the cranial
thigh, at 4-week intervals. All animals were exposed to the bite
of Ixodes scapularis nymphs infected with the B31 strain of Borrelia
burgdorferi (Bb), 5 weeks after the last injection. Of the
50 ticks that fed upon the animals in the placebo group, 48 contained
spirochetes detectable by a direct fluorescence assay (DFA) with
an anti-Bb polyclonal antibody, whereas only one of 130
ticks on the vaccinated animals had detectable Bb by DFA.
On Western blots of whole Bb antigens, serum antibody
from each of the control animals reacted with 10-16 antigens
4 weeks post-challenge (PC), and 22-36 by week 40. Vaccinated
animals failed to develop any detectable anti-Bb antibodies
during the same study period, except for the anti-OspA response
induced by the vaccine. Skin biopsy and blood samples obtained
weekly during the first 4 weeks PC from both control and vaccinated
animals yielded no spirochetes upon in vitro culture. In contrast,
skin samples from all of the control but none of the vaccinated
animals contained Bb DNA during the first 4 weeks as revealed
by PCR using primers that hybridize to a chromosomal DNA fragment
of Bb.
In
the same time period, 2/4 controls and 2/16 vaccinated animals
had deep perivascular lymphocytic infiltrates in the skin adjacent
to the infection site, with cells that stained positive with
MAbs reacting with OspA and with a 7.5 kDa lipoprotein of Bb.
Organs and tissues from several organ systems of the 4 controls
and the 4 animals vaccinated with lipidated OspA and one of the
animals vaccinated with NS1-OspA/MPL and with NS1-OspA were analyzed
postmortem. No gross pathology was observed in any animals. In
the control, unvaccinated animals, inflammation often accompanied
by positive immunostaining with anti-7.5 kDa protein and anti-OspA
MAbs, and by positive PCR was observed in the kidney (in 2 out
of 4 animals), urether (2/4), heart (3/4), joints (1/4), nerves
(4/4). In the vaccinated monkeys, no inflammation was observed
in the kidneys, ureter and joints, while an inflammation milder
than that seen in control animals was detected in the heart (2/6)
and nerves (2/6). The lungs of 4/4 control animals and 5/6 vaccinated
animals showed lymphocytic hyperplasia. Some macrophages within
these cell clusters stained positive with the anti-7.5 and anti-OspA
MAbs. PCR of lung tissue was positive for 2/4 control and 3/4
vaccinated animals.
The
difference in the tick infection rate between ticks that fed
on vaccinated and control monkeys, the lack of seroconversion
in the vaccinated animals and the absence of spirochetal DNA
in the skin of the vaccinated animals in the weeks following
the challenge, indicate that the vaccinated monkeys were protected
against the tick challenge. The post mortem analysis, however,
suggests that a very low spirochete burden (non-immunogenic)
or a transient infection may have occurred in some of the vaccinated
animals. These last observation warrant further analyses of the
remaining animals.
Alan
Barbour, MD
Departments of Medicine and Microbiology
University of Texas Health Science Center
The
Borrelia turicatae-mouse Model of Lyme Disease
Prevention
of Lyme disease through vaccination is now seen as a reasonable
and perhaps necessary strategy for control of infection in humans
and domestic animals. The focus of vaccine development has been
on OspA, an outer membrane protein of the species of Borrelia
that causes Lyme disease in North America, Europe, and Asia.
Studies in animals showed the effectiveness of recombinant OspA
in protecting against syringe- and tick- delivered challenges.
In the last two years human trials of OspA as a vaccine have
begun. The progress in one set of these human trials of safety,
immunogenicity, and efficacy will be presented. An additional
emphasis will be on vaccine candidates in earlier stages of investigation.
Bettina
Wilske, MD
Pettenkofer - Institute, Germany
Antigenic
Variation of Borrelia burgdorferi sensu lato: Implications
for Pathogenesis, Diagnosis, and Prophylaxis of Lyme Disease
B. Wilske, V. Preac-Mursic, V. Fingerle, S. Jauris-Heipke, D.
Roosler, and G. Will, Pettenkofer Institute
Wild
type strains of Borrelia burgdorferi sensu lato express
OspA or OspC (or both) in abundant amounts. Expression of the
two proteins is negatively correlated and appears to vary with
the environment. Osp A is regularly expressed in Ixodes ricinus
whereas OspC is rarely detected. Analysis of the human antibody
response by Western blot suggest the inverse situation in the
human host (strong expression of OspC, in contrast to low expression
of OspA). Using a panel of OspA-specific monoclonal antibodies
(MAbs) we previously classified European strains into seven OspA-serotypes
(confirmed by sequence analysis) (1). Phenotypic analysis with
OspC MAbs revealed at least 13 different types (2). OspC sequence
analysis confirmed the immunological heterogeneity at a molecular
level. In some strains (including also American strains) OspC
was considerably heterogenous whereas OspA was highly conserved.
Analysis
of a large number of European isolates from patients (n=102)
revealed a significant association of the OspA-serotype with
the clinical manifestation of the disease:
|
source |
type 1 |
type 2 |
type 3 |
type 4 |
type 5 |
type 6 |
type 7 |
total |
|
|
CSF |
8 |
5 |
3 |
12 |
3 |
10 |
2 |
43 |
|
skin |
4 |
57 |
0 |
2 |
1 |
4 |
0 |
68 |
|
The high diversity
of strains isolated from patients with neuroborreliosis (all
seven serotypes were found) has important implications for microbiological
diagnosis (serodiagnosis, PCR) as well as for vaccine development.
(1) Wilske, B. et al., J. Clin. Microbiol.: 31 (1993) 340-350
(2) Wilske, B. et al., J. Clin. Microbiol. (1995), in press
David W. Dorward,
PhD
Rocky Mountain Laboratories, NIAID
National Institutes of Health
Virulent Borrelia
burgdorferi Specifically Attach to, Activate, and Kill TIB-215
Human B-lymphocytes
David W. Dorward and Elizabeth R. Fischer. NIH/Rocky Mountain
Laboratories
In order to
examine the effects of Lyme disease spirochetes on immune effector
cells, experimental co-incubations of B. burgdorferi Sh-2-82
and cultured human and B- and T-lymphocytes, TIB-215 and H9 cells
respectively, were begun in the fall of 1994. Comparisons were
made in the structure and viability of B- and T-cells incubated
with varying concentrations of virulent or attenuated B. burgdorferi,
or virulent B. hermsii after 1, 24, 48 and 72 hr. The
levels of IgM antibody secretion of B-cells exposed to spirochetes
and /or the known B-cell activators IL-5 and IL-6 were also compared.
Examination by light and electron microscopy showed that at relative
concentrations of 100:1, low passage B. burgdorferi attach
rapidly to 90=% of B-cells. Video microscopy revealed that initial
attachment involved spirochetal apices. Within one hour, affected
B-cells began to aggregate in culture wells. After 24 hours,
numerous spirochetes covered B-cell surfaces, and up to 50% of
B-cells were lysed. Such effects were dependent on infectious
dose. No significant attachment and killing was noted in co-incubations
involving high passage B. burgdorferi, virulent B.
hermsii, or T-cells. Furthermore, heat killed or sonicated
spirochetes, or spirochetal culture supernatants had no apparent
effects on B-cells, suggesting that attachment and cytolysis
require inducible factors. Since there was no evidence of B-cell
invasion, and cytolysis was serum complement-independent, B-cell
killing may involve a previously undocumented toxigenesis. Electrophoretic
and western blot analysis, using convalescent human Lyme disease
serum, showed that at least four proteins and human immunogens
were produced by virulent spirochetes in response to co-incubation
with this B-cell line. Whether any or all of these factors are
involved in B-cell killing remains to be determined. Quantitative
comparisons of IgM secretion by B-cells, incubated with spirochetes
and/or interleukins 5 and 6, showed that all three spirochetal
populations effectively activated the B-cells and stimulated
IgM secretion. Such activation is consistent with previous studies
with normal human B-cells. These studies document that B.
burgdorferi exhibits specific cytopathic effects on cultured
B-cells, and provide a model for examining the possibility that
such interactions between spirochetes and B-cells may play a
role in colonization and persistence of B. burgdorferi
in mammals.
Alan Barbour,
MD
Departments of Medicine and Microbiology
University of Texas Health Science Center
The Borrelia
turicatae - Mouse Model of Lyme Disease
Mice infected
with Borrelia burgdorferi develop arthritis and carditis,
in common with humans with Lyme disease. However, mice and other
non-primate animal models of B. burgdorferi infection
only transiently or inconsistently have involvement of the central
nervous system. We have found that a strain of B. turicatae,
an agent in relapsing fever in southwestern North America, produces
infection and involvement of both peripheral and central nervous
system of mice. In addition, the neurotropism of this species
appears to be limited to certain serotypes. Serotype A notably
infects the brain, but serotype B does. In contrast serotype
B infections are characterized by a severe polyarticular arthritis;
serotype A produces only mild arthritis. The only discernible
difference between serotype A and B of B. turicatae is
in an outer membrane protein that is homologous to OspC proteins
of B. burgdorferi. These findings suggest that disease
manifestations of Lyme disease and other borrelial infections
are in part determined by features of an infecting organism.
Manuel Altamirano,
MD
Clinical Assistant Professor, University of British Columbia
DNA Sequences
of 16S RNA of B. burgdorferi Isolates from Canada and
U.S.A.
M. Altamirano, S. Banerjee, M. Banerjee, K. Fernando, M. Dong
and G. McDonald-Jones; Provincial Laboratories, British Columbia
Centre for Disease Control; Vancouver General Hospital; Pathology
and Laboratory Medicine, University of British Columbia
The phylogenetic
relationship between some of the Borrelia isolates form Canada
and U.S.A. has been investigated by amplification of a 276 base
pairs segment of the 16S RNA gene. The DNA sequences were compared
with those analyzed for B. burgdorferi B31 and other groups
such as B. hermsii, B. anserina and B. garinii.
Primers for the Polymerase Chain Reaction (PCR) were selected
from conserved regions of the gene that codes for the 16S RNA
in Borrelia strains. DNA extracted from isolates was amplified
by PCR in a 50 ul reaction for 35 cycles, using 48¡ C for
annealing temperature. The PCR products were purified by HPLC
and both strands were sequenced using florescent labeled primers
in cycling reactions in the presence of Thermus thermophylus
DNA Polymerase. The sequencing reaction were analyzed in the
automatic laser DNA sequencer. The 16S RNA sequences from the
Canadian isolates were clustered and similar to B. burgdorferi
B31 strain. Differences in sequences were seen in some isolates
previously identified as B. burgdorferi. The phylogenetic
relationships of those isolates along with further molecular
biology studies shall be discussed.
Judit Miklossy,
MD
Division of Neuropathology
University Institute of Pathology, Switzerland
Further Evidences
for a Spirochetal Etiology of Alzheimer's Disease
Recently we
reported that spirochetes were found by dark field microscopy
in the blood, cerebrospinal fluid and were isolated form the
brain tissue of Alzheimer's disease (AD) cases, including two
familial AD cases. Moreover the spirochetes were cultured from
the cortex tissue in three out of four AD cases investigated.
Reference strains of spirochetes showed a positive immunoreaction
with a monoclonal antibody against the § amyloid precursor
protein (APP) of AD, indicating that spirochetes may contain
APP or at least an APP-like (APLP) protein. Using scanning and
atomic force microscopy we observed that the isolated and cultured
microorganisms from the AD brain possess axial filament. Using
a monoclonal antibody against Borrelia burgdorferi we
found a positive immunoreaction in senile plaques and in neurons
in the brain of a patient with concurrent AD and Lyme disease.
Individual spirochetes free in the neuropil were also observed.
The 4',6-diamidine-2-phenylindole dihydrochloride (DAPI) Which
binds selectively to DNA is frequently used for the visualization
of the bacterial DNA of Mycoplasma in cell cultures. We expected
that DAPI would also bind to the DNA of spirochetes. If AD is
caused by spirochetes, consequently in addition to resident cell
nuclei we would find DNA also in senile plaques, neurofibrillary
tangles and in the neuropil threads. Indeed when stained with
DAPI reference spirochetes may be visualized, but also senile
plaques, neurofibrillary tangles and neuropil threads in AD exhibit
fluorescence which can be abolished be DNAase pretreatment. Further
investigations demonstrated some similar histochemical properties
of reference spirochetes and those of the AD type histological
changes. These observations seem to reinforce the hypothesis
that AD may correspond to the tertiary stage of neurospirochetosis.
Willy Burgdorfer,
PhD
Rocky Mountain Laboratories
National Institutes of Health
Is "Coll/Ag-30"
the Answer to Lyme Borreliosis and other Infectious Diseases?
This presentation
relates to the recent announcement by Dr. M. Paul Farber of his
forthcoming book "Coll/Ag-30 (Mild Silver Protein) the Silver
Bullet" considered by the author to be the answer to numerous
infectious diseases including Lyme disease, AIDS, multiple sclerosis
and candida infections.
Colloidal
silver preparations have commonly been used as a successful broad-spectrum
antimicrobial agent against at least 650 different diseases during
the early part of this century. However, because of high costs,
this colloidal silver therapy became obsolete with the advent
of the less expensive antibiotics.
In his struggle
to overcome and recover from the debilitating clinical manifestations
of late Lyme disease and from a serious candida yeast infection
as a result of prolonged treatment with antibiotics, as well
as from early symptoms of multiple sclerosis, Dr. Farber conducted
an extensive literature research and rediscovered the claim of
Colloidal Silver as an effective treatment from microbial diseases.
Treating himself
with a recently developed and less expensive version of Mild
colloidal silver (Coll/Ag-30), Dr. Farber claims to have fully
recovered from his illnesses. Dr. Farber's Coll/Ag-30 therapy
and its results in several pioneering patients on Coll/Ag-30
are presented.
Claude F.
Garon, PhD
Chief, RML Microscopy Branch
National Institute of Allergy and Infectious Disease
Rocky Mountain Laboratories
Borrelia
burgdorferi's
Subsurface DNA Network Represents a Possible Target for a New
Category of Antimicrobial Agent
The total
DNA content of a number of B. burgdorferi isolates from
around the world has been characterized. These assays have revealed
a collection of both linear and circular molecules ranging in
size form two to one thousand kilobasepairs. In addition, the
relative number of copies of these molecules appears to be tightly
controlled. In contrast to some microbial extrachromosomal elements
which are replicated autonomously and are present in hundreds,
if not thousands, of copies for each chromosome, the number of
individual DNA molecules seen in B. burgdorferi does not
appear to vary over many generations of culture. Since important
genes have been mapped to the chromosome, and to both linear
and circular plasmids, this linkage control mechanism appears
to be important and may be exploited using new biochemical agents
which target DNA replication. B. burgdorferi cells grown
in the presence of radioactively labeled 5-bromo-2-deoxy-uridine
readily incorporated label into both linear and circular DNA
molecules of all sizes and at a roughly similar rates. Cis-platinum
staining of spirochetes followed by high resolution backscattered
electron detection located nucleic acid molecules in blebs and
over the entire inner surface of the spirochete membrane. A gentle,
en bloc DNA purification procedure visually confirmed
the presence of a nucleic acid network containing both linear
and circular molecules. The network contained radioactive DNA
precursor label, could be stained with specific nucleic acid
stains, and could be disrupted with both DNAase and proteinase
by not RNAase treatments. However with the exception of trioxalen
crosslinking, B. burgdorferi seemed relatively insensitive
to known eukaryotic and prokaryotic DNA replication inhibitors.
Dagmar Hul’nsk‡,
RNDr, PhD
WHO Collaborating Center for Lyme Borreliosis,
National Institute of Public Health, Czech Republic
Cellular Infection
of Human Fibroblasts, Langerhans Cells, and Leukocytes by Liquor
and Blood Isolates of B. garinii and B. afzelii with
Emphasis to Antibiotic and Antibodies Treatment
The present
study of the uptake of B. garinii strains M92, MI92, K24
and B. afzelii strains Kc90 and HII8 by fibroblasts and
Langerhans cells revealed that Borreliae were internalized by
both conventional and by coiling phagocytosis after 24 hr. Leukocytes
phagocyted borreliae more quickly, after 10-30 min. Spirochetes
wrapped up by coiled pseudopodes which created transmembrane
channels were protected against antibiotic and antibodies treatment.
Spirochetes engulfed by conventional phagocytosis of leukocytes
were altered after 60-120 min and ionized the phagosomes of fibroblasts
after 48 hr. High and low passage B. garinii and B.
afzelii opsonized with antibodies against OspA formed blebs
and vesicles which were associated with cultured eukaryotic cells.
Borrelial vesicles were endocyted by fibroblasts Which were associated
with cultured eukaryotic cells. Borrelial vesicles were endocyted
by fibroblasts after 10-30 min. Prior vesicle-fibroblasts association
influenced father engulfment of B. garinii by conventional
but not by coiling phagocytosis after 24 hr. Vesicles, isolated
experimentally by differential centrifugation and filtration
of BSK cultures were internalized inside the endocytic vesicles
of fibroblasts after 30 min. The low passage B. garinii
strain possessed OspA and OspB proteins at molecular weight of
32 kDa and 35 kDa. Complement with surface proteins of low passage
strains had a cytotoxic effect on fibroblasts after 3-6 hr. The
liquor isolate M92 was negative for OspA protein but after father
coculturing with fibroblasts the strain changed phenotype and
developed OspA protein after two week.
Sam T. Donta,
MD
Professor of Medicine
Boston University Medical Center
Evidence for
an Intracellular Reservoir for Lyme Borreliae
The mechanisms
responsible for relapsing symptoms in patients with Lyme disease
remain to be delineated. The organism can only rarely be found
following the initial infection and dissemination. In examples
of other infectious diseases characterized by recurring or persistent
infection, the reservoir of microorganisms is intracellular.
These include viruses (e.g. herpes, hepatitis B/C), parasites
(e.g. malaria, leishmania), and fungi (e.g. histoplasma). Whether
other fungi (e.g. cryptococci, pneumocystis) remain dormant inside
cells or on their surfaces is unclear. Some bacteria persist
in endosomes at a neutral pH (e.g. chlamydia, legionella) whereas
others (e.g. M. tuberculosis) can survive in endolysosomes.
Where T. pallidum survives is unknown. Tissue culture
models of intracellular infection by B. burgdorferi have
been described; in the fibroblast model, ceftriaxone was ineffective
against intracellular borreliae, data consistent with the poor
intracellular penetration of betalactam antibiotics from the
results of clinical studies, beta lactams have been less effective
than would be predicted from their in vitro activities.
Tetracycline has been a generally effective agent. The macrolides
have been less effective than would be predicted by their in
vitro activities and their intracellular penetration, suggesting
that the Lyme borreliae persist in endolysosomal-like vesicles
at an acidic pH. The addition of the lysosomotropic agent hydroxychloroquine
to macrolide therapy results in generally successful treatment
outcomes.
Benjamin J.
Luft, MD
SUNY at Stony Brook School of Medicine
Use of Recombinant,
Chimeric Proteins for the Diagnosis of Lyme Disease
B.J. Luft, R.J. Dattwyler, Department of Medicine, SUNY Stony
Brook. B.J. Johnson, Centers for Disease Control, B.C. McGrath,
J.J. Dunn, Biology Department, Brookhaven National Laboratory.
Lyme disease
is a multisystem disorder whose etiologic agents are spirochetes
of the genus Borrelia. The ability to detect Lyme borreliosis
early in the disease has been hindered by the unavailability
of a fast, and accurate diagnostic test. Currently, a need exists
for a sensitive and specific diagnostics that can detect a wide
array of naturally occurring antigenic variants of Borrelia.
In this study
we have developed recombinant, chimeric antigens which provide
reactivity to serum samples obtained from Lyme disease patients.
The chimeric proteins containing peptides from OspA, OspB, OspC,
p 41 and P 93 were prepared, and then tested as antigen against
sera obtained from patients at various stages of Lyme disease.
The results indicated that at least two of these chimeric proteins
were effective in detecting serum antibodies against Borrelia.
These studies demonstrate the feasibility of a specific, broad-spectrum
diagnostic test for Lyme disease based upon a recombinant multivalent
antigen.
Mark M. Manak,
PhD
Sr. Vice President
Biotech Research Laboratories
Detection
of B. burgdorferi Sequences in Clinical Specimens by a
PCR Capture Assay M. Manak (1), I. Gonzalez-Villase–or (1),
K. Wu (1), S. Crush-Stanton (1), and R.C. Tilton (2) (1) Biotech
Research Laboratories, (2) Boston Biomedica/North American Laboratory
Group
A simplified
PCR-based DNA format developed for the direct detection of B.
burgdorferi nucleic acid sequences in blood, urine and other
biological fluids to aid in the diagnosis of Lyme disease. Conserved
sequences in the OspA gene were labeled with biotin and used
as primers for PCR amplification of DNA extracted from clinical
specimens. The resulting biotin labeled products were captured
in microtiter plates by specific hybridization with internal
sequences of these products. Detection was accomplished by streptavidin
conjugated peroxidase followed by colorimetric detection of the
enzyme substrate. As few as 3-10 copies of B . burgdorferi
DNA could be detected. We have examined a total of 1200 specimens
representing over 350 patients suspected of Lyme disease. The
vast majority of specimens tested were negative by PCR and had
no serological markers indicative of Borrelia infections.
Positive results were found in 87 specimens representing urine,
blood, serum, joint fluid and CSF samples. The results to date
suggest that whole blood or serum specimens are a more reliable
indicator of active infection than is urine. Although the majority
(89%) of patients with positive PCR results were also positive
for serological markers (WB, ELISA, IgM Capture), a significant
number of patients were positive by OspA gene sequences in clinical
samples and promises to be a valuable adjunct to the current
serological diagnostic tests to help control Lyme disease infections.
Bruno Schmidt,
MD
Dipl.Ing.Dr., LBI for Dermato-Venerological Serodiagnosis, KH
Lainz
Detection
of Borrelia burgdorferi-DNA in Urine from Patients with
Lyme Borreliosis
B.L. Schmidt, Ch. Wagner, E. Aberer, A. Luger
Direct demonstration
of Borrelia burgdorferi (Bb) by culture is not a rapid
method and a high sensitivity can only be obtained by taking
skin biopsies as specimen. In order to improve detection, different
PCR-methods (high cycle, nested- and heminested, drop in/drop
out) were developed and compared on different genes. The most
sensitive and specific assay was based on a simple preparation
of Bb-DNA out of human urine and a new nested PCR using
a specific part of the flagellin gene as target.
Up to now
more than eight hundred patients with various clinical manifestations
of Lyme borreliosis (mostly dermatological) have been examined.
As an example, results of 90 erythema migrans (EM) patients are
presented: PCR was reactive in 80 patients (88.9%). In comparison,
serology was reactive for IgG in 11.1% to 16.7% of patients using
tests with a B. garinii antigen. Only 2 out of 66 tested
sera had antibodies to the p39 antigen. Specific IgM could be
detected in 25, 6%-40, 5% of the patients depending on the different
tests used.
In conclusion,
detection of Bb in EM-patients can be improved dramatically
by examining urine for presence of Bb-DNA.
Richard C.
Tilton, PhD
North American Laboratory Group
A Solid-phase
Enzyme-linked Immunosorbent Antigen Detection for Lyme Disease
Diagnosis
C.C. Tai (1), M. Manak (1), H. Weissberger (1), T. Patamawenu
(1), and R.C. Tilton ( 2) (1) Biotech Research Laboratories,
(2) Boston Biomedica/North American Laboratory Group
An enzyme-linked
immunosorbent assay system was developed for the detection of
antigens of Borrelia burgdorferi in urine and other body
fluids form patients suspected of having Lyme disease. A species-specific
rabbit antiserum against OspA, OspB, and OspC was used for both
capture and detection of Borrelia antigens in samples.
F(a,b)2 fragments of purified IgG from the antiserum were coated
on polystyrene microtiter plate. Test samples were added directly
to the wells without concentration. Following incubation at room
temperature and the removal of unreacted reagents, antigens adsorbed
to the plate were detected by IgG from the same rabbit antiserum.
The immuno-reactivity on the plate was amplified by a protein
A-biotin/streptavidin-HRP reporting system. Color generated by
the enzyme-substrate reaction was read at 450 nm. All reagents
used in the assay were optimized by cross titrations against
crude cell protein and also against cultured cells, serially
diluted in normal human urine. Standard curves were constructed
for both the antigen and intact cells using data obtained from
the above titrations, respectively. The optimized assay system
was shown to have an efficient detecting range of 10-200 ng of
crude cell protein, and as little as 100-200 cultured cells of
B. burgdorferi, in the presence of a detergent. The performance
of this assay was validated by testing confirmed clinical specimens
from patients with or without infection by B. burgdorferi.
Steven Schutzer,
MD
Division of Allergy and Immunology
University of Medicine and Dentistry of NJ - NJ Medical School
The Immune
Response and its Application toward Diagnosis
The immune
response to an infectious agent involves complex interaction
among T helper and suppressor cells, macrophages, and B cells.
The B cells which differentiate into antibody producing cells
first produce IgM, then IgG, then IgA to the antigenic components
of the agent. Initially, and in certain other instances, the
predominance of the antibody may be found bound to the agent
in an antigen-antibody or immune complex.
Serologic
diagnosis of infection with the spirochete Borrelia burgdorferi
(Bb), the cause of Lyme disease has been hampered by the
variability among existing tests as well as the prolonged time
needed for the humoral response to reach thresholds of detection
by conventional assays. As specific antibody (Ab) made be found
bound to an infectious agent, especially early in the infection,
and during active infection, we hypothesized that this could
be occurring in Lyme disease. We isolated and dissociated serum
immune complexes from Lyme disease patients, fulfilling modified
CDC criteria, and controls. Immune complexes were first collected
by polyethylene glycol (PEG). Following dissociation by high
pH, the dissociated constituents were analyzed by ELISA and Western
blots. Specificity of the reactive Ab was evaluated by probing
for the target antigen using monoclonal and polyclonal Abs, as
well as recombinant proteins.
Complexed
Ab to Bb was found in 10 of 11 very early cases(p=2 x
10E-7), 55 of 56 (p= or less than 10E-3) symptomatic patients
with Lyme disease, 0 of 50 healthy controls, 2 of 50 patients
from the endemic areas with other diseases including those likely
to have elevated levels of immune complexes, 13 of 13 (p= or
less than E-8) persistently seronegative patients who had erythema
migrans and a subset of 4 of 4 who were also positive on a T
cell proliferative assay to Bb, and 0 of 8 patients who
had recovered. In the early acute cases complexed IgM was the
first antibody to be detected. Predictive values (PV), based
upon a sensitivity of 98% and a specificity of 98% were PV+ of
36% (prevalence of 1%) to 98.6% (prevalence of 50%) and PV- of
99.9% to 99.7% between these prevalences.
The data suggest
that this relatively simple technique has potential to support
or exclude a clinical diagnosis of early as well as active Lyme
disease.
Patricia K.
Coyle, MD
Department of Neurology
Suny at Stony Brook School of Medicine
New tools
in the Diagnosis of Neurologic Lyme Disease
The diagnosis
of neurologic Lyme disease has been hampered by the lack of reliable
and available active infection assays. New tools are becoming
available with regard to analysis of cerebrospinal fluid (CSF),
as well as use of new test modalities, to help define Borrelia
burgdorferi- related neurologic syndromes.
CSF diagnostic
tests include spirochete culture; detection of Borrelial antigens
or DNA; and detection of specific IgM antibodies, complexed antibodies,
or intrathecal antibody production. Although specificity of all
these tests is high, sensitivity for neurologic Lyme disease
varies greatly depending on the syndrome and timing of infection.
This paper
will discuss the current status of these tests in different neurologic
syndromes attributed to Lyme disease. Other diagnostic tools
include evaluation of brain blood flow deficits by SPECT, and
of cognitive processing and hearing deficits by evoked potential
testing. Neuropsychologic test which evaluate reaction time,
attention, and learning/retrieval of verbal memory appear to
be preferentially affected. These new tools should help refine
the diagnosis as well as the optimal management of neurologic
Lyme disease.
Alan B. McDonald,
MD
Pathology Department
St. Elizabeth's Hospital
Morphologic
Heterogeneity of Borrelia burgdorferi
Detection
of B. burgdorferi in tissue specimens is prima faciea
evidence of Lyme borreliosis. Recovery of Borrelia burgdorferi
from in vitro cultures is equivalent to direct visualization
of the pathogen in tissue specimens. All other laboratory diagnostic
modalities (routine serology, Western blot, PCR, antigen capture)
are easier to obtain from reference laboratories. The morphologic
diversity of the spirochete in tissue sections is mow well established
from the published work of European and American investigators;
and the wide range of "legitimate" spirochetal form
for B. burgdorferi is mirrored by the plethora of morphologic
variants of T. pallidum which were published by Warthin
and Starry, Coutts & Coutts, Delammater, Ovcinnikov, Rose and
Morton, and J. L. Smith in their classical pathologic tissue
studies of syphilitic tissues.
The original
discovery by Burgdorfer of the spirochetal etiology of Lyme borreliosis
was predicated on the astute observation in a Giemsa stained
preparation of a cytology smear from the intestinal tract of
an Ixodid tick. Dr. Burgdorfer recognized that wavy threadlike
profiles (which were not corkscrew shaped profiles) were spirochete
profiles.
Fewer that
five board certified histopathologists have published papers
on the morphology of B. burgdorferi in tissues. The experience
of these workers will be the subject of this presentation.
Craig Cleveland,
MD
East Hyde Park Internal Medicine
Poster Session
No abstracts
availble
Edward Masters,
MD
Family Physicians Group Inc.
Clinical Presentations
of Borreliosis in the Lower Midwest
This presentation
focuses on clinical Lyme disease in the Midwest. Examples of
erythema migrans along with serological and histological findings
are presented. Potential tick vectors are discussed, especially
the association of Amblyomma americanum (lone star) ticks
with erythema migrans. Examples of late sequelae are presented
along with comparisons to other geographic areas. Clinical differentiation
of the erythema migrans rash from the brown recluse spider bite
is elucidated. Also presented are other clinical and epidemiologic
findings associated with clinical Lyme disease.
George Price,
MD
Clinical Associate Professor, Division of Rheumatology
University of British Columbia
Lyme Arthritis
in British Columbia, Canada
G.E. Price
and S.N. Bannerjee; Seymour Medical Clinic and Provincial Laboratory,
BC-CDC The first known locally acquired case of Lyme arthritis
in B.C. is described. The patient had frequent tick exposure
where he lived, on a forested island on the south coast of the
province. The diagnosis was established by a compatible clinical
picture of arthritis, and multiple bands on IgG and IgM Western
blot analysis. The arthritis, which had been intermittent for
more than six months, responded quickly to treatment with doxycycline
with no recurrence after two years.
Bruce McManus,
MD, PhD
Chairman, Pathology and Laboratory Medicine
St. Paul's Hospital
University of British Columbia
Cardiovascular
Manifestations of Lyme Disease
Cardiac abnormalities
in association with acute or chronic borreliosis have been described
since the late 1970's and worldwide there have been about 200
such patients reported. A high frequency of electrophysiological
perturbations has been documented, with a prominence of third
degree atrioventricular block and, less commonly, second and
first degree block. Perimyocarditis and clinical heart failure
are seen in about 15% of patients with evident heart involvement.
Diagnosis of cardiac disease in patients with Lyme disease depends
on a degree of suspicion when other symptoms and signs of borreliosis
(especially neurological changes) are present and when the patient
exhibits presyncope, syncope, palpitations, shortness of breath,
chest pain, and electrocardiographic abnormalities. The endomyocardial
biopsy may be helpful in the diagnosis of Lyme carditis, and
the organism of cause may be stained (with silver), cultured,
and/or detected by molecular means. The use of anti-myosin or
gallium scanning and magnetic resonance imaging in the assessment
of patients with Lyme carditis has recently been suggested.
Therapy for
cardiac involvement by Lyme disease includes a general strategy
of antibiotics, and the expectation that a temporary pacemaker
may be valuable (one-third of patients) during the acute inflammatory
phase, when heart block is common. anti-inflammatory drugs, steroidal
and nonsteroidal, have been used in therapeutic regimens. Outcome
of Lyme carditis is generally very favorable with about 95% of
patients apparently having full functional recovery. Thus, permanent
pacemakers are typically not required. Only a rare report has
raised the possibility of chronic heart muscle disease secondary
to Lyme carditis, while no particular relationship between serological
results and chronicity of cardiac disease has been defined. Rare
fatalities have been attributed to cardiac involvement by Lyme
disease. Opportunities to define the pathological and pathobiological
nature of Lyme carditis should be emphasized to clarify the manner
in which the offending organisms and the immune responses participate
in injury of the heart muscle and what factors may induce or
facilitate chronic cardiac dysfunction.
Ernie Murakami,
MD
Clinical Associate Professor
University of British Columbia Medical School
Lyme Disease
Case in the Lower Mainland, and a New Wood Tick Removal Technique
Ernie Murakami, MD, Department of Family Practice, UBC; Nima
Shojamia, Medical Student, UBC; Satyen N. Banerjee, PhD, Provincial
Laboratory, BC-CDC
A 57 year
old man presented to the medical clinic at an Agassiz Correctional
Institute in B.C. on April 18, 1994. Complaining of a circular
rash on his right leg, neck stiffness and right shoulder chronicum
migrans was the diagnosis and serologically Lyme disease was
confirmed. Since this patient was incarcerated for three years
the local animal vector had to be present at the Agassiz Institution,
(rats, mice, cats and raccoons). Erythromycin was given to this
patient and he improved clinically. Wood ticks carry disease
(second only to mosquitoes) to man and animals: i.e. Rocky Mountain
spotted fever, Colorado tick fever, tularemia, babesiosis and
Lyme disease. Pediatric abstract summarized five popular methods
of removal: jelly, nail polish, alcohol, hot match, forceps and
fingers (Pediatric, volume 74, June 1985). All these above method
may cause increased intraabdominal pressure thus host infection
possibilities are greatly increased. The method proposed for
the removal involves the injection of Xylocaine intradermally
and the hydrostatic pressure causes the tick to fall off the
host voluntarily. In some cases a sharp needle or scalpel is
required for extraction. This method avoids and prevents any
regurgitation of insect abdominal contents. The wood tick is
complete and alive for speciation and culturing for infective
agents.
This technique
has been practiced in Hope, B.C. for the past five years by myself
and my associates. All research for this project was done in
Hope, B.C.
Rudolph J.
Scrimenti, MD
Medical College of Wisconsin
Acrodermatitis
Chronica Atrophicans
ACA, the first
manifestation of LB to be described, is an outstanding example
of prolonged latency and chronic infection. It is rarely reported
in America. Our knowledge is drawn from a rich European experience.
It consists of an early inflammatory stage and a late atrophic
stage. A poorly demarcated acral erythema or edema usually ushers
in the disease. It disseminates primarily to other acral sites
often sparing the torso. Juxta articular modules and fibrotic
linear bands may develop over the extensor surfaces of the extremities.
Over many months to many yeast, atrophy may develop. Eventually,
lymphadenopathy, weight loss, fatigue, neuropathies, phalangeal
joint luxations may appear. Sclerotic and atrophic lesions, indistinguishable
clinically and histopathologically from morphea and lichen sclerosus
atrophicans (LSA) may be seen. Histopathology reveals a predominant
CD4 lymphocytic infiltrate, lymphatic telengiectasis and lymphedema.
With progression, atrophy of the skin and elastic fibers develops.
A rich admixture of plasma cells, if present may distinguish
sclerotic and atrophic ACA from morphea and LSA et A. in the
absence of the spirochete. Many lymphocytes and keratinocytes
express HLA-DR and HLA-DQ antigens which disappear with therapy.
Bb specific IgG titers are usually high. Doxycycline is
the usual therapy for uncomplicated ACA. Benzyl penicillin IV
and oral doxycycline is the preferred therapy if neurologic and/or
arthritic complications are present.
Irwin T. Vanderhoof,
PhD, CLU - New York University - Stern School of Business
R. C. Smithson, PhD - Lockhead Palo Alto Research laboratory
Symptoms and
Characteristics of Chronic Lyme Disease Patients
Over the years
the Lyme Disease Foundation and the Society of Actuaries have
compiled a data base of symptoms, characteristics, and treatment
of over 1,000 Lyme disease patients. The data is based upon a
questionnaire filled out by the members of the studied group.
Since the participants were self selected it is not surprising
that the group is primarily composed of patients with long standing
illness - the chronic cases.
The analysis
is of two types. The first is the calculation of the descriptive
statistics of the group. These include symptoms, test results,
geographic locations, and cure or continuing impairment. Cost
of treatment information is also studied and an attempt is made
to correlate this with the other dimensions of the data.
The second
type of analysis is the use of a probabilistic neural network
technique developed at Lockheed to try to find a pattern for
those patients that have continuing illness as opposed to those
who are eventually symptom free.
Julian E.
Davies, PhD
Professor and Head, Department of Microbiology & Immunology
University of British Columbia
Antibiotic
Resistance in Spirochetes
The Gram-negative
spirochetes are a diverse group of bacteria with a broad ecological
distribution. The diseases caused by spirochetes are usually
treated with antibiotics or antibiotic combinations. There have
been very few reports of antibiotic resistance developing during
clinical treatment.
Antibiotic
prophylaxis is often used, which may increase the possibility
of emergence of antibiotic resistant strains. If recently history
is any guide, the problem of antibiotic resistance in bacteria
is usually considered after the fact. The review of biochemical
mechanisms of antibiotic resistance and their dissemination among
bacteria will be reviewed and indication of relevance of these
mechanisms to spirochetes will be given.
Kenneth B.
Liegner, MD
New York Medical College
Spectrum of
Antibiotic-Responsive Meningoencephalomyelitides
Two cases
of chronic Lyme meingoencephalomyelitis (CMEM), one culture-proven
initially seronegative case with spastic paraparesis and cranial
nerve dysfunction and the other initial seronegative ultimately
fatal case of CMEM with massive hydrocephalus shown to be OspA
antigen positive in the cerebrospinal fluid followed by a skin
eruption centered about the bite site evolved to CMEM negative
for bb by all available diagnostic methodologies, yet which responded
both clinical and as shown by progressive improvement of abnormal
parameters on serial CSF examination, to an 8 month course of
daily intravenous (I.V.) cefotaxime (CFOTX). A fourth case of
CMEM meeting clinical and CSF diagnostic criteria for multiple
sclerosis (MS) and also lacking any laboratory support of the
diagnosis of Lyme disease (LD) but with considerable epidemiologic
risk for LD, showed clear improvement both clinical and in abnormal
CSF parameters in response to 4 month of daily I.V. CFOTX. Conclusion:
Potential responsiveness of CMEM to intensive antibiotic treatment
is not excluded by inability to prove a diagnosis of CNS borrelial
disease with presently available methods, regardless of whether
standard of research assays are utilized. A randomized trial
of intensive intravenous antibiotic treatment of MS patients
should be considered.
Joseph J.
Burrascano, Jr., MD
Southampton Hospital
Management
of Chronic Lyme Disease
The management
of patients with chronic Lyme disease can be challenging. Not
enough is known about the pathophysiology of this condition,
why patients' presentations differ, and why response to treatment
is so variable. In addition, tests do not exist that allow us
to establish the diagnosis or follow the outcome of our interventions
with absolute accuracy.
The approach
to treatment of chronic Lyme begins with the assessment of whether
prior antibiotic treatments were adequate. It is truly a myth
that a patient with disseminated disease is cured with four weeks
of antibiotic therapy. There are now over one dozen literature
reports documenting failure of this approach, which is not surprising
in light of the unscientific and arbitrary nature of this recommendation.
Mechanisms of resistance of B. burgdorferi to eradication
in the human include biologic properties of this organism such
as latency and S-layers, presence of Bb in privileged
sites such as in intracellular and intraocular locations, inadequate
understanding of antibiotic pharmacology in killing this germ
and in the common practice of ignoring basic, well understood
pharmacological principles such as half lives, tissue and cell
penetration and serum, CSF and tissue levels. If treatment was
not optimal, then a more aggressive approach is indicated, in
terms of both dose and duration.
Any time oral
antibiotics are used, serum peak and trough levels should be
documented whenever possible, for my studies have shown, for
example, an unexplained 100 fold variability in serum ampicillin
levels in patients matched by age, body size and drug dose. Intramuscular
benzathine penicillin has been shown to be unexpectedly effective,
as has intravenous but not oral doxycycline in the chronic patient.
Intravenous antibiotics offer huge potential advantages in efficacy
compared to oral regimens, and newer methods of administration,
such as interrupted and pulse dosings have made such medications
safer and more effective in this setting.
If the patient
has received what would appear to be adequate treatment and still
has not responded, then the diagnosis must be reassessed, and
any other concurrent conditions present must be identified and
corrected, such as superinfections, nutritional inadequacies,
and subtle immune deficiencies. It is crucial to find out whether
steroids or other immunosuppressives were given during the course
of the infection, as such medications can have a negative impact
on the patients ultimate therapeutic outcome. My studies have
shown that many patients with resistant infections have deficiencies
in B, T, and/or killer cell function. If these abnormalities
can be corrected then treatment response improves.
James H. Katzel,
MD
Ukiah Valley Medical Center
Diagnosis
and Treatment of Disseminated Lyme Disease
Recognizing
disseminated Lyme disease (LD) is paramount to successful treatment
outcome, since each stage of the disease requires a different
treatment strategy.
The latent
period is either observed clinically or treated with prophylactic
antibiotics.
Early localized
infection is treated with anti-spirochetal antibiotics for 3-4
weeks or until the erythema migrans (EM) is eradicated.
Disseminated
disease...
...requires
a much more aggressive approach to both diagnosis and treatment.
These patients are ill and often appear septic, although only
a few days from the time of the infecting tick bite. Antibiotics
are needed at higher doses and for longer periods of time to
fully eradicate the widely disseminated spirochetal infection,
and to restore the patient's feeling of clinical well being.
Intravenous antibiotics are used for Lyme meningitis, children
with central neurologic problems and pregnant patients. However,
the vast majority are successfully treated with longer term oral
anti-spirochetal antibiotic regimens. The distinction must be
made, between patients with a single EM lesion and no flu like
illness, and those patients with more than one EM lesion and/or
a systemic flu like illness. The latter group respond better
to aggressive early treatment and usually avoid chronic persistent
disease.
Brian A Fallon,
MD
Director, Lyme Disease Program; Assistant Professor
Columbia University and NYS Psychiatric Institute
Persistent
Lyme Encephalopathy: To-Treat or Not-to-Treat?
Brian A. Fallon, MD, N. Weiss MA, A. Goldstein BA, Mr Liebowitz
MD. The NYS Psychiatric Institute
Problems with
fatigue, memory, attention, depression, and mental disorganization
are central features of Lyme encephalopathy (LE). When faced
with a LE patient who has already received months of antibiotics
and 6-12 weeks of IV antibiotics, clinicians must ask several
questions. First, is the diagnosis of LE correct? Second, are
there other comorbid disorders that could be treated better (e.g.,
depression, panic disorder, ADD)? Third, are somatoform features
involved (e.g., psychogenic seizures)? Fourth what has been the
course of antibiotic treatment and response. Clinical data will
be presented to support this approach as well as research data
from an ongoing study of the efficacy of repeated courses of
IV antibiotics among patients with persistent L.E. In this naturalistic
pilot study of LE patients who have received no more than 16
weeks of prior IV antibiotics, patients are tested at baseline
and 4 months later using standardized measures of memory, intelligence,
attention, psychomotor performance, depression, anxiety, and
disability. Preliminary findings, contrasting patients who did
receive more IV antibiotics to patients who did receive more
IV antibiotics to patients who did not, will be discussed.
Joseph J.
Burrascano, Jr., MD
Southampton Hospital
Public Forum
Public forum
free for residents of British Columbia. All scientific presenters
are present to answer questions from the public.
