From the LymeLight Newsletter of the Lyme Disease Foundation

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The long-awaited results of a government-funded chronic Lyme disease (LD) study were published July 12 in the New England Journal of Medicine. Researchers, clinicians, and patients expressed shock, disappointment and outrage that its authors and the National Institutes of Health (NIH) distorted its results and use it as an opportunity to limit access to antibiotic treatment by suggesting active infection is not the cause of persisting symptoms in previously treated patients, and that further treatment is of no benefit.

"Two Controlled Trials of Antibiotic Treatment in Lyme Patients with Persistent Symptoms and a History of Lyme Disease," consisted of two randomized trials. One group contained 78 patients who were Centers for Disease Control and Prevention (CDC)-seropositive for IgG (later stage) antibodies on Western blot and the other group had 51 patients who were CDC-seronegative. Patients received either intravenous ceftriaxone (2 grams daily for 30 days), followed by doxycycline, (200 mg for 60 days), or matching intravenous placebos.

All had a history of well-defined LD and persistent symptoms despite receiving conventional (short-term) treatment. Instruments used to measure patients' health-related quality of life were administered to study participants at base line and at 30, 90, and 180 days.

Despite extensive and costly media programs designed to obtain patients, the study never reached its statistically required enrollment number of 260 patients. After a planned interim analysis of the enrolled 129 subjects, the Data Safety and Monitoring Board recommended that the study be discontinued because data "indicated that it was highly unlikely that a significant difference in treatment efficacy between the groups would be observed with the planned full enrollment of 260 patients."

"It's the equivalent of being a third-place baseball team and, half way through the season, the league declares your chances to come in first are slim, so the remainder of the season is cancelled," said Dr. Sam Donta an infectious disease specialist from Boston University Hospital. "The only things this study showed are that many patients previously treated for Lyme are sick and that don't respond to one month of intravenous ceftriaxone treatment, or 60 days of doxycycline."

Dr. Donta is principle investigator in the study, "Tetracycline Therapy for Chronic Lyme Disease" (Clinical Infectious Disease, 1997;25 (suppl 1):S52-6). That study found in an evaluation of two hundred and seventy-seven patients with chronic LD, a 3-6 month course of tetracycline treatment is associated with cure or significant improvement in 80-90% of patients. He has been a vocal critic of the chronic study since its design was determined.

The NEJM study, led by principal investigator Mark Klempner, MD, Boston University School of Medicine, was deemed so important by NEJM, it was released early to help physicians make treatment decisions. "This is reassuring information for people who make decisions based on evidence," said editor-in-chief Dr. Jeffrey M. Drazen.

The most incredulous aspect of the Klempner study, which was touted to the lay media by some researchers as evidence that active infection is not responsible for persistent symptoms in patients previously treated for LD, was that it excluded polymerase chain reaction (PCR)-positive patients. PCR is a highly sophisticated, direct detection test that detects the DNA of the Lyme bacteria.

Viewing a question-and-answer page on the website of the National Institute of Allergy and Infectious Disease (NIAID), the NIH branch that funded the study, explains why such patients were excluded: Why are patients who test positive by polymerase chain reaction (PCR) for Borrelia burgdorferi [Bb, the causative agent of LD] at the time of initial evaluation being excluded from the study? After enrollment, patients are selected at random for assignment to the placebo or antibiotic treatment group. Patients who test positive for B. burgdorferi by PCR are considered to be actively infected. Thus, these patients are excluded from the NEMC placebo-controlled study to avoid the possibility that they will be selected at random to receive placebo instead of treatment. Such patients are referred to the NIAID intramural study on Lyme disease, which has no placebo group; there all patients are treated with an antibiotic since multiple tests (including PCR) indicate that they are probably actively infected.

(The intramural study referred to, however, does not offer antibiotic therapy to patients. Rather, it is a pathogenesis study - one that follows the disease process. Participating patients' doctors make their own decisions regarding treatment.)

"The desire to run a placebo-controlled study drove the study's design and prevented it from answering the central question: does long-term antibiotic therapy help improve the health of chronically infected patients," said LDF Chair Karen Vanderhoof-Forschner. "It forced the exclusion of patients with direct evidence of infection, and limited the duration of intravenous treatment because of the high risk of infection occurring in patients in the placebo group."

"It's a very ambiguous group," said Tony Lionetti, Medical Director of the Lyme Disease Treatment Center in Hammonton, New Jersey. "Some patients may or may not have had active infection, but the important thing to note is the deceptive spin put on the study results to the lay press. At best, it's very unscientific to say this study proves long-term therapy doesn't help LD patients. Logically, such an important study should have included patients that are PCR positive or culture positive. I, as did other physicians and patients, mentioned that to some of the investigators in the study before it began."

Dr. Lionetti said he requires most of his patients to test PCR-positive, doing multiple tests if necessary, before he makes a LD diagnosis. "I was disappointed because I had plenty of patients I wanted to refer to the study," he said. "Unfortunately, because they had positive PCR tests, they were ineligible."

Kathleen Dickson, an analytical chemist and advocate from Connecticut, is pleased that through the study's exclusion criteria, the NIH acknowledges publicly that PCR-positivity is synonymous with active infection. "I do thank them for that," she said.

Dr. Donta pointed out other problems in the design of the study. He said, intravenous ceftriaxone works by killing Bb spirochetes (LD bacteria). Doxycycline inhibits protein synthesis, which prevents Bb from reproducing. Thus, the antibiotics fight the bacteria through two totally different modes of attack. Therefore, the study can only be interpreted as a 30-day intravenous ceftriaxone study and a separate, 60-day oral doxycycline study, Donta argued. Many Lyme-literate physicians don't consider either regimens "long-term" treatment.

When pressed on the subject, Dr. Phil Baker, Lyme Disease Program Officer for NIH, conceded this point. He did express his unproven belief, however, that the protocol would undoubtedly kill all Bb in a patient.

"The 30-days of ceftriaxone I.V. would've at least knocked the bacteria down," he said. "The doxycline would've mopped up whatever bacteria was left."

Though some researchers from the "overdiagnosed/overtreated" camp touted to the lay press that the study suggests patients of chronic LD do not benefit from additional antibiotic therapy, careful analysis of a NIH press release reveals the deceptive nature of how the study was presented to the public. The release, which states "Chronic Lyme Disease Symptoms Not Helped by Intensive Antibiotic Treatment" would more accurately read "In Patients Without Direct Evidence of Persistent Infection of Lyme Disease, Persistent Symptoms Not Helped by Additional Short-Term Antibiotic Treatment."

An even better headline, however, would read, "Lyme Patients Without Direct Evidence of Persisting Infection In Extreme Pain," since the only real accomplishment of the study is that it found deficits in physical health status of patients were equal to patients with congestive heart failure or osteoarthritis. It also found that patient deficits were greater than those observed in with type 2 diabetes or recent myocardial infarction (heart attack). Alas, the study may put to rest the long-held assertion by some researchers that many symptoms in chronic LD patients are psychosomatic.

In addition, Dr. Klempner's quote in the press release, which reads not unlike an additional research proposal, reveals he doesn't rule out the existence of persistent infection in previously treated patients with persistent symptoms. He said that the research suggests the need to investigate autoimmune and other processes to determine "whether they play a role in at least some of the symptoms of chronic Lyme disease."

Though he was quoted in many national newspapers regarding the study, Dr. Klempner did not return the LDF's repeated phone messages to discuss it. His suggestion of the involvement of autoimmune mechanisms in symptoms of LD is not controversial, however.

Dr. Klempner's coinvestigator at Tufts University, Lyme disease researcher Allen Steere, MD, a recipient of numerous NIH grants to study LD, has been trying for decades to prove his theory autoimmune mechanisms are solely responsible for persistent symptoms experienced by reviously treated LD patients. He has so far failed.

"We all believe that Lyme disease is a very unusual disease that causes a lot of autoimmune dysfunction," Dr. Lionetti, explained to WTIC radio of Hartford, CT in a live on-air interview discussing the Klempner study. "But the [question] is does the autoimmune dysfunction continue on its own, or end after the bacteria has been eradicated."

Dr. Marrietta Vazquez, a Yale University School of Medicine doctor and colleague of Dr. Eugene Shapiro, who like NEJM editor-in-chief Dr. Jeffrey M. Drazen, are champions of "evidence-based" (textbook) medicine was on-air opposite Dr. Lionetti.

After denouncing clinicians who use "unproven" long-term antibiotic regimens to treat LD and assuring her audience, "We as infectious disease specialists have vast experience diagnosing and treating patients - we're the experts," she appeared caught off guard when asked about the study excluding PCR-positive patients. "Well I.I...actually don't.know the specifics of the methodology [used in the study]," she told the interviewer. "But uhm.the fact they may have excluded patients who were PCR positive patients may be because PCR tests for Lyme disease is not well standardized. It's not a test that is routinely tested on all patients."

Dr. Vazquez's theory holds little weight. Investigators in the study chose the laboratory where samples were sent for analysis. Therefore, the lab used for the study would have had to be considered "appropriate" for PCR testing. (To learn some of the problems associated with the standardization of Western blot tests, see LymeLight, Vol.1, 2001.)

To answer the extremely divisive debate about the ability of Bb to survive aggressive antibiotic treatment, one would logically conclude that it would design a study that first examines only culture positive or PCR-positive patients who had failed short-term antibiotic therapy. This is what the LDF and others asked for.

According to Dr. Baker, patients who have failed treatment like the protocol used in the Klempner study are hard, if not impossible to find. "There is no case to my knowledge of a patient who remains PCR-positive after undergoing 4-weeks of I.V. ceftriaxone treatment," he said.

The NIH LD program director should familiarize himself with the Finnish study. "Borrelia burgdorferi detected by culture and PCR in clinical relapse of disseminated Lyme borreliosis" (Ann. Med 1999: 31: 225-32). The study, conducted by frequent LDF International Scientific Conference presenter Jarmo Oksi, MD, PhD, focuses on 13 patients with clinical relapse and positive culture, PCR positivity, or positive serology for LD despite initial treatment.

All 13 patients were primarily treated for more than 3 months with intravenous and/or oral antibiotics. One patient was biopsy PCR-positive after receiving 7-weeks of intravenous ceftriaxone treatment followed by oral antibiotics. Of the 165 patients recruited for the study, 32 (19%) were regarded as having clinically defined treatment failure.

Numerous similar articles exist in the scientific literature, and such cases were presented at the LDF's 10th Annual International Scientific Conference on Lyme Disease and Other Tick-Borne Diseases, held in 1997 at NIH. However, it is likely Dr. Baker did not hear these.

In a April 17, 1997 Email document from Dr. Baker to NIH grantee Alan Barbour, Dr. Baker writes that he has "no interest" in "hearing what [Dr.s] Liegner, Burrascano, or Donta have to say." All three presenters discussed cases of refractory LD and/or the need for better diagnostic and treatment protocols.

Many physicians argue that a comprehensive study examining the efficacy of current treatment protocols is a critical first step in determining their validity in clinical practice. "A study similar to the Oksi study needs to be done to examine the efficacy of conventional Lyme treatment in the United States," said Dr. Lionetti. "It's the logical place to start. If the efficacy rate is not at least 95%, then there is a serious problem with the current protocols."

Dr. Donta and Dr. Lionetti also believe the Klempner study would have been much more valuable if it had employed longer duration I.V. ceftriaxone treatment.

Dr. Klempner and his colleagues used part of the study grant to conduct an unrelated study examining the Lyme Urine Antigen Test (LUAT) as a methodology in the diagnosis of LD. Contradicting published studies, Dr. Klempner and his team concluded the test was "highly unreliable" in the diagnosis of LD because it is prone to false-positive results. Dr. Nick Harris, president of the company that makes the LUAT, Igenex, Inc., said Dr. Klempner and his
colleagues knowingly presented and published false data about the test because serum samples used in their study were knowingly handled improperly. He said he brought the issue of improper handling of the samples to Dr. Klempner's and Dr. Baker's attention before the samples were run but was told that because the study was being paid for by NIH, the samples had to be tested.

Dr. Harris said he even offered to pay to have the entire study re-done, and his offer was refused. He now says he should have known better than to agree to participate. "I'm from an era before patents - when ethics in science was the norm," he said.

Undermining the credibility of Igenex and Dr. Harris, Dr. Klempner presented the results of the study during a major conference on tick-borne disorders held in Italy. He made no mention of the controversy.

Taking previous peer-reviewed studies published by Dr. Klempner into consideration, one would think he would emphasize Bb's ability to survive antibiotic exposure while publicly discussing the study. Several of his studies demonstrate its ability to evade antibiotic destruction.

"Fibroblasts protect the Lyme disease spirochete, Borrelia burgdorferi, from ceftriaxone in vitro" (Infectious Disease, 1992; Aug; 166(2):440-4) provides evidence of Bb's ability to become "intracellular" by penetrating living cells to evade destruction by the immune system and antibiotics. Its premise: Bb "can be recovered long after initial infection, even from antibiotic-treated patients, indicating that it resists eradication by host defense mechanisms and antibiotics."

The study found that human foreskin fibroblasts (any cell or capsule from which connective tissue is developed) "protected B. burgdorferi from the lethal action of a 2-day exposure to ceftriaxone." It also found "fibroblasts protected Bb for at least 14 days of exposure to ceftriaxone." The study didn't examine - or didn't publish - how much longer Bb may have been able to withstand exposure to ceftriaxone treatment.

Dr. Klempner's conclusion: "several eukaryotic cell types [cell nucleus that is surrounded by a membrane] provide the Lyme disease spirochete with a protective environment contributing to its long-term survival."

As late as 1993, Dr. Klempner continued to examine the intracellular phenomenon associated with Bb. "Invasion of human skin fibroblasts by the lyme disease spirochete, Borrelia burgdorferi" (Journal of Infectious Disease, 1993 May; 167(5):1074-81) found that despite the absence of visible spirochetes on cell surfaces after antibiotic treatment, viable Bb was still found inside fibroblasts. Its conclusion "suggests Bb can adhere to, penetrate, and invade human fibroblasts in organisms that remain viable."

Could this be what is happening in many patients who continue to experience LD symptoms despite receiving treatment? Dr. Baker wouldn't rule it out: "It might be. One can't say definitively."

It's significant to note Dr. Klempner's previous studies demonstrate that synovial tissue, not synovial fluid or blood, is the best place to look for evidence of the Bb spirochete. Several peer-reviewed studies conclude likewise, including "Detection of Borrelia burgdorferi DNA in Muscle of Patients with Chronic Myalgia Related to Lyme Disease" (Amer Journal of Med 1998;104:591-4), "PCR-Based Quantification of Borrelia burgdorferi Organisms in Canine Tissues Over a 500-day Postinfection Period" (J of Clinical Microbiology 2000;38:2191-9) and "Localization of Borrelia Burgdorferi in the Nervous System and Other Organs in a Nonhuman Primate Model of Lyme Disease" (Lab Invest 2000;80:1043-54).

Interestingly, however, rather than test tissue for evidence of Bb infection, Dr. Klempner chose to do PCR tests on blood and synovial fluid on patients, all of whom, of course, had to test PCR negative to get into the study. The NEJM study reports that by PCR testing, "there was no evidence of Borrelia burgdorferi in a total of more than 700 different blood and cerebrospinal fluid samples from the 129 patients in these studies." Equally interesting is the fact that Dr. Allen Steere's study, "Detection of Borrelia Burgdorferi DNA By Polymerase Chain Reaction in Cerebrospinal Fluid in Lyme Neuroborreliosis (J Infect Dis 1996 Sep;174(3):623-7), demonstrated that cerebrospinal fluid is a poor place to PCR for evidence of Bb infection.

Researchers also expressed concern over the validity of the questionnaires the study used to evaluate a change in the health status of enrolled patients during retreatment. The study used the the FIQ and the SF-36 self-report questionnares which are used to evaluate a patient's health status for some diseases, have never been validated for use in Lyme patients.

"It's very strange that patient self-report data was used in place of objective neuropsychological assessments when these assessments were a prominent part of Dr. Klempner's research proposal," said University of Rhode Island Assistant Professor of Research Stephen Brand, PhD. "Dr. Klempner's proposal indicates that neuropsychological testing would be conducted to assess treatment outcomes at follow-up, but these objective data do not appear in the NEJM paper."

Dr. Donta and others express disappointment that Dr. Klempner and other researchers are treating the study as the final and deciding word, rather than the first of many steps, to examine new antibiotic protocols in previously treated patients who still experience symptoms and have direct evidence of infection. "Would the medical establishment do just one treatment study for cancer or AIDS and draw such premature, unscientific conclusions," he asked. "I think not.

"Rather than simply saying this study found that the prescribed antibiotics didn't work, we should be investigating why they didn't work, and study different antibiotic protocols," Donta said. "The Klempner study should be a starting point and not an end point. The autoimmune theory in Lyme has been studied for years, and the only treatment under that theory is aspirin and steroids. Neither help chronic Lyme patients."

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