Lyme Disease

The following presentation is an introduction to Lyme disease, a bacterial infection spread by ectoparasites, namely ticks. Lyme disease is common in North America, Europe, and is rapidly spreading around the world. This lecture features more advanced topics, such as the immune system, molecular diagnostic methods, and scientific contention.

Lyme Disease © 2022 by E. Nomi is licensed under CC BY-NC-SA 4.0

Transcript

1. Lyme Disease Lyme Disease August 2022. Photo: readersdigest.ca/health/conditions/tick-borne-diseases
2. Lyme Disease The most common zoonotic disease carried by ticks world-wide, particularly in North America and Europe1, 2, 3 – ≈476,000 people in USA diagnosed annually (data from 2010-2018)3 Estimated global prevalence in blood: ≈14.5%1 Photos: modified from © Todd Gipstein on gettyimages.com, © Brenda Leal, Aug 13, 2020, on entomologytoday.org
3. Lyme Disease – The Bacterium Caused by Borrelia bacterial spirochaetes4 – In North America: B. burgdorferi4 – In Eurasia: B. burgdorferi, B. afzelii, and B. garinii4 Photos: modified from © Jamice Haney Carr, Claudia Molins, USCDCP on pixnio.com, © Juergen Berger/science Photo Library on pixnio.com Borrelia burgdorferi
4. B. burgdorferi Morphology Gram negative, but has immunoreactive glycolipids instead of LPS layer5 Photos: Kelesidis, 2014, Figure 1., Chandler et al., 2017 Figure 2.d. outer membrane inner membrane peptidoglycan periplasmic space Glycolipid LPS glycolipids/LPS Gram negative cell wall lipoprotein Sugar Glycerol Fatty acid Fatty acid
5. B. burgdorferi Morphology Motile, using multiple internal flagella6 – Flagellar proteins (common antigens) hidden from immune detection7 Photos: Kelesidis, 2014, Figure 1., Charon et al., 2012, Figure 1.a-b. Gram negative cell wall periplasmic space
6. B. burgdorferi Morphology Spirochete: Morphology under favourable conditions8 Helical, motile, active form6 Round body: Induced by poor conditions, presence of penicillin8 Cyst-like, low metabolic rate, resistant to antibiotics, may evade immune system5 Photos: Meriläinen et al., 2015, Figures 1.a and 1.c. Changes morphology in response to environmental conditions5 5 μm 5 μm
7. Lyme Disease – The Tick Carried by the bite of an Ixodes genus tick (“hard ticks”)4,9 Photo: blog.healthywildlife.ca/lyme-disease-hits-close-to-home Adult stage Nymph stage Larva stage Engorged adult Ixodes scapularis (deer tick, common in N. America) Can have up to 3 different hosts, one at each life stage9 Parasitize wide range of animals9 B. burgdorferi transmission most likely during nymph stage9 ♀ ♂ (cm)
8. Ixodes scapularis Lifecycle Photo: health2016.globalchange.gov/low/ClimateHealth2016_05_Vector_small.pdf, Figure 3. Larvae and nymphs acquire B. burgdorferi by feeding on small mammals and birds in spring and summer, carry infection for life10 Adult ticks feed mainly during cold months; nymphs in warm months10
9. Geographical Distribution Climate change and increasing temperatures causing expansion of tick habitat and higher transmission of disease10 Photo: modified from bewareofthebugs.com/diseases/lyme-disease
10. The Tick Bite Step 1. Questing – Ticks climb vegetation and wait with limbs outstretched3,11 Photo: blog.kittykono.com/2011/05/hard-questing-tick.html
11. The Tick Bite Step 2. Attachment – Ticks detect animals´ breath, body odours, body heat, moisture, and vibrations, latch on when host brushes by3 Photos: blog.kittykono.com/2011/05/hard-questing-tick.html, dreamstime.com
12. The Tick Bite Step 3. Feeding – Occurs within 10 minutes to 2 hours after attachment3 – Grasps the skin, cuts into the surface, and inserts feeding tube3 Photos: blog.kittykono.com/2011/05/hard-questing-tick.html, dreamstime.com, kuusinc.com/be-ticked-off-lyme-disease-is-preventable
13. The Tick Bite “Feeding tube” – hypostome and chelicerae Photos: emlab.uconn.edu/gallery/head-of-a-deer-tick, "Mouth Parts 50x, Ixodes scapularis (Deer Tick)" © Mark Smith, Daniel Saftner, and Annette Evans from Macroscopic Solutions, LLC on flickr.com I. scapularis head I. scapularis feeding tube
14. B. burgdorferi Infection Tick acquires infection from small mammal host, commonly mice12 Bacteria population maintained in the tick midgut, disseminates throughout tick body12 Photos: mammals.carnegiemnh.org/pa-mammals/white-footed-mouse-peromyscus-leucopus, modified from Šimo et al., 2017, Figure 1., Edwards et al., 2009, Step 9. White-footed mouse (Peromyscus leucopus) Tick midgut (Amblyomma maculatum)
15. B. burgdorferi Infection Environmental changes in pH and temperature induce bacteria to differentially express >19 adhesive outer surface proteins that assist in infection7,12 – Bind to host cells, complement system regulatory factors, or aid in vascular and tissue colonization12 Photo: Modified from Šimo et al., 2017, Figure 1. Mammal Host7: Temperature regulated at 37–39°C pH = neutral Tick Host7: Temperature varies with environment pH = basic
16. B. burgdorferi Infection After 24–48 hours of feeding, bacteria migrate to the salivary glands and enter new host7,13 – Saliva acts as a vasodilator, anticoagulant, anti-inflammatory, and immunosuppressive, facilitating the flow of blood14 Photos: Modified from Šimo et al., 2017, Figure 1., Edwards et al. 2009, Step 8. Tick salivary glands (Amblyomma maculatum) Tick salivary glands (Amblyomma maculatum)
17. B. burgdorferi Infection Bacteria disseminate via bloodstream using “drag” and “tether” interactions with blood vessel endothelia12 Bind host molecules that mediate endothelial interactions: – Fibronectin and integrins15 Photo: Modified from Niddam et al., 2017, Figure 1.a.
18. Stage 1: Localized Disease Symptoms occur within 1–28 days following tick bite3,4 – Erythema migrans develops in 60%-80% of patients4,16 – Muscle pain, neck stiffness, paralysis – Low-grade fever, fatigue, and flu-like symptoms Photos: aad.org/public/diseases/a-z/lyme-disease-signs, medicalnewstoday.com/articles/323457 Classic cases of erythema migrans (bull’s-eye rash)
19. Stage 2: Disseminated Disease Develops 3–12 weeks after the initial infection3,4 Symptoms may last 12–20 weeks3,4,17 – Damage to central nervous system in 20% of patients4 – Joint inflammation, pain and swelling, muscle pain3,4 – Carditis (inflammation of the heart) in 3–4% of patients17 MRI showing damage to bilateral cranial nerve Tissue sample from a patient who died of Lyme carditis3 Photos: Blackwell, 2017, Figure 2., cdc.gov/lyme/treatment/lymecarditis.html
20. Stage 3: Late Disease Symptoms can develop months/years after initial infection and last for years3,4: – Poor cognition, persistent fatigue, seizures, mental illness18 – Meningitis, Bell’s palsy, dysesthesias, fibromyalgia-like symptoms3,4 – Arthritis, especially in the knees3,4 Photos: modified from prepareformedicalexams.blogspot.com/2017/06/regarding-bells-palsy.html, ayurbethaniya.org/images/multiplescelorosis.jpg, cdc.gov/lyme/treatment/LymeArthritis.html Bell’s palsy Arthritis Fibromyalgia
21. Spirochaetes can permeate tissue to reach immunoprivileged sites with less immune activity19 Evidence of biofilm formation, allowing adhesion to tissues20, 21, 22 Immune Evasion Photo: modfied from asbmb.org/asbmb-today/science/100320/viruses-that-come-to-stay, Sapi et al., 2012, Figure 1.a-b. Borrelia burgdorferi aggregates in vitro21 Immunoprivileged sites
22. Immune Evasion Borrelia produces cell surface proteins that allow evasion from the complement cascade, including12: – BBK32 – binds part of C1, inhibits attack complex formation – CspA – interacts with C7 and C9, inhibits attack complex formation – ErpP – interacts with other proteins to inactivate C3b Complement pathways Photo: Stone and Brissette, 2017, Figure 2.a.
23. Immune Evasion Has high number of genes encoding virulence factors, including: – ospC – expression required for host colonization and resistance to innate immunity7, 23 – vlsE – antigenic variation system whereby variable surface lipoproteins are expressed to resist adaptive immunity and to establish persistent infection7, 23, 24 Variable expression of vlsE Photos: innate-pharma.com/science/innate-immunity-nk-cells, Stone and Brissette, 2017, Figure 2.a
24. Diagnosis Serology: standard two- tiered testing16, 25: IgM antibodies raised against B. Burgdorferi can be detected within 2-4 weeks of initial infection; IgG at 4-6 weeks13,26 Photos: modified from APHL, 2021 Figure 1., Lecture "Lyme Disease Serologic Testing" by Centers for Disease Control and Prevention (CDC) from https://www.youtube.com/watch?v=Dei-8na9wZU
25. Diagnosis Serology: standard two- tiered testing16, 25: The 1st tier test uses an enzyme- linked immunosorbent assay (ELISA) to screen for infection Photos: modified from APHL, 2021 Figure 1., immunology.org/public-information/bitesized-immunology/experimental-techniques/enzyme-linked-immunosorbent-assay Whole-cell preparation of B. burgdorferi or recombinant antigens25
26. Diagnosis Serology: standard two- tiered testing16, 25: The 2nd tier test uses a more specific western blot to confirm a positive or inconclusive 1st tier test result Photos: modified from APHL, 2021 Figure 1., "Researcher Checks Western Blots" by NIAID on commons.wikimedia.org
27. Diagnosis Serology: standard two- tiered testing16, 25: + Clinical symptoms: – Erythema migrans rash Patient History: – Time spent in endemic areas Photos: modified from APHL, 2021 Figure 1., "Doctor and Patient Illustration" by Chris Cherry on dribble.com
28. Problems with Diagnosis Detection of early Lyme prone to false negatives16 Recovery from disease is not trackable using antibody tests – IgM antibodies can persist after infection is cleared27 Dispute over the frequency of false positives due to cross-reactivity of antigens26 Organs may be infected even if antibody tests are negative28 Photo: lymescience.org/lyme-disease-tests-science/sensitivity-of-lyme-tests-waddell/
29. Problems with Diagnosis Koch’s Postulates: – Used to prove a microbe causes a disease29 – Isolated microbe in culture should produce the same disease in new host, and be the same microbe when re- cultured29 B. burgdorferi does not fit this paradigm: – Difficult and time consuming to culture30 Photo: modified from Neville et al., 2018, Figure 1.
30. Xenodiagnosis Testing the vector for presence of pathogens to indicate exposure in host31,32 – PCR used to detect Borellia DNA in Ixodes tick Already used in Lyme research to prove a host’s infection status31,32 Not currently used in clinical diagnoses, but clinical trial using tick larvae on humans completed on May 4, 2022 (NCT01143558)32 Photos: danielcameronmd.com/test-lyme-disease-using-tick, Marques et al., 2014, Figure 1.
31. Post-Treatment Lyme Disease Syndrome (PTLDS) Clinical definition endorsed by the CDC and NIH: unresolved symptoms lasting >6 months following antibiotic treatment3, 33, 34 Develops in 10–20% of patients treated for Lyme disease35 Treated with 3–4 weeks of additional antibiotic therapy33 Hypothesized causes35,36: – Persistance of antimicrobial-resistant B. burgdorferi – Reactivity with components of dead B. burgdorferi – Co-infections such as Anaplasma phagocytophilum and Babesia microti – Dysfunctional immune response
32. Chronic Lyme A more casual term lacking consistent clinical definition37, 34 – Includes patients with negative serology for B. Burgdorferi Considerable contention between patients/advocacy groups and medical authorities over legitimacy of condition Demonstrators at Worldwide Lyme Disease Awareness Protests, 2013 Photos: worldwidelymediseaseprotest.blogspot.com/
33. Contention – Both overuse of antibiotics and untreated Lyme are dangerous3 – Complicated disease progression and diverse presentation of symptoms can complicate and delay diagnosis38, 39 – Testing methods may not be sensitive enough for reliable diagnosis and cannot track disease recovery27, 40, 41, 42 – Lack of information can allow pseudoscience to take advantage43 – These factors can foster distrust between physicians and patients who believe they could have Lyme disease
34. Contending Perspectives Two general schools of thought about diagnosis and treatment of Lyme: – 1.) Methodology-centered – focusing on standardization of diagnostic tests and treatment to prevent misuse of antibiotics and false insurance claims – 2.) Patient-centered – focusing on patient interest in well-being and recovery from illness, especially where serological tests can be unreliable and disease progression is not fully understood
35. – Methodology-centered – Does’nt recognize chronic Lyme disease41, 43 – Localized to well-defined areas of the world41 – Lyme is hard to catch and easy to cure with short course of antibiotics41 – Discourages tick-testing43 – Laboratory diagnosis is accurate43 – Encourages prophylaxis43 – Patient-centered – Recognizes chronic Lyme disease39 – Unpredictably distributed world- wide41 – Illness is not rare, requires longer courses of antibiotics41, 39 – Considers tick-testing39 – Laboratory diagnosis is inaccurate39 – Discourages prophylaxis39 Contending Organizations
36. Erythema migrans: oral antibiotic therapy with doxycycline for 10 days, or amoxicillin or cefuroxime axetil for 14 days[Lantos] Neurological symptoms: intravenous ceftriaxone, cefotaxime, penicillin G, or oral doxycycline for 14–21 days[Lantos] Lyme arthritis: oral antibiotic therapy with doxycycline, amoxicillin, cefuroxime axetil, or azithromycin for 28 days[Lantos] Prophylaxis: single dose of oral doxycycline within 72 hours of tick removal, 200 mg for adults and 4.4 mg/kg for children [Lantos] Treatment Failure: no additional antibiotics, referral to rheumatologist[Lantos] Symptom Treatment guidelines (2020)43: Erythema migrans Oral antibiotic therapy with doxycycline for 10 days, or amoxicillin or cefuroxime axetil for 14 days Neurological symptoms Intravenous ceftriaxone, cefotaxime, penicillin G, or oral doxycycline for 14–21 days Lyme arthritis Oral antibiotic therapy with doxycycline, amoxicillin, cefuroxime axetil, or azithromycin for 28 days Prophylaxis Single dose of oral doxycycline within 72 hours of tick removal, 200 mg for adults and 4.4 mg/kg for children Treatment failure No additional antibiotics, referral to rheumatologist + +
37. Symptom Treatment guidelines (2014)39: Erythema migrans Minimum of 4-6 weeks of doxycycline, amoxicillin or cefuroxime, or a minimum of 21 days of azithromycin Neurological symptoms No explicit recommendation Lyme arthritis No explicit recommendation Prophylaxis 100–200 mg of doxycycline twice daily for 20 days for tick bite with evidence that feeding occurred Treatment failure Additional 4-6 weeks of antibiotics, then no further treatment
38. – Located in UK – Emphasizes communication between patient and healthcare professionals, including difficulty of diagnosis44 – Advocates early recognition of Lyme for earlier treatment44 Happy Medium?
39. NICE Guidelines[Cruickshank] Erythema migrans: Neurological symptoms: Lyme arthritis: Prophylaxis: Additional antibiotic therapy after treatment failure Symptom Treatment guidelines (2018)38, 44: Erythema migrans Oral antibiotics: 200 mg doxycycline per day for 21 days; amoxicillin: 1 g 3 times per day for 21 days; azithromycin: 500 mg daily for 17 days Neurological symptoms Oral doxycycline: 200-400 mg per day for 21 days Intravenous ceftriaxone: 4 g per day for 21 days Lyme arthritis Oral doxycycline: 200 mg per day for 28 days Oral amoxicillin: 3 g per day for 28 days Intravenous ceftriaxone: 2 g per day for 28 days Prophylaxis No explicit recommendation Treatment failure After 2 courses of antibiotics, no further treatment, referral to a specialist appropriate to the patient’s symptoms
40. More Research is Needed Without reliable tools to diagnose and monitor Lyme, consensus can tend towards the personal and political rather than the scientific Photo: fs.blog/elephant
41. Objectivity? In 2007, science writer Kris Newby sent an information request under the Freedom of Information Act to the CDC to obtain emails and resumes from three employees45, 46, 47 – The CDC took >5 years to fulfil request; legally, request should take ≈1 month47 – 3,000 pages of emails were provided, ≈1,200 pages were whited out47 – Within the FOIA emails, Lyme patients and their treating physicians were called “loonies” and “quacks”48 Photo: camdenarknews.com
42. Safe stewardship of antibiotics less contentious for other diseases, including: – Acne: < 6 months49 – Tuberculosis: 6 months50 – Recurring UTI: > 6 months51 – Rheumatic fever: prophylaxis for 5 years to entire life52 Objectivity? Photos: pinimg.com, acne.org/whats-the-best-treatment-for-cystic-acne.html, ethnomed.org/wp-content/uploads/2020/04/ethnomed-tb-treatment-meds.jpg Common antibiotics for acne Common antibiotics for TB
43. Objectivity? Predatory lab testing: – Money made by taking advantage of weaknesses in current diagnostic tools and patient discomfort – Tests often involve unproven methods53 Photo: lymescience.org
44. Objectivity? Predatory pseudoscience: – Money made from unproven and even dangerous cures Photos: sciencebasedmedicine.org/miracle-mineral-supplement-as-a-cure-all, https://www.fda.gov/news-events/press-announcements MMS, sold as a Lyme disease cure43
45. Consensus ≠ Removing Dissent The Scientific Method: – Create hypothesis – Test hypothesis by trying to disprove it – When hypothesis can’t be disproven after vigorous testing, consider true until proven otherwise Conflicting paradigms of Lyme disease suggest incomplete hypothesis testing Lack of consensus suggests new research questions are needed
46. Prevention is Key Always check for ticks after being in grassy or wooded areas – Check nightly in endemic areas13 Consider use of insect repellents3: – 0.5% permethrin on clothing and gear – Oil of Lemon Eucalyptus and para-menthane-diol (found in Corymbia citriodora) – Picaridin (found in black pepper) – 2-undecanone (found in bananas, cloves, ginger, and Houttuynia cordata) Photo: modified from hikingthemidwest.com
47. Prevention is Key Remove attached ticks immediately and monitor for symptoms Photo: modified from [cdc]
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