This represents part of Part II of the RI Tick Borne Diseases Management Plan (April 2002) submitted to the RI TBDS commission by ActionLyme

MARKERS OF PATHOPHYSIOLOGY IN BORRELIOSIS:

Quinolinic Acid

Neopterin

MMPs (nerve degrading enzymes in the spinal fluid)

GFAp (gliosis)

Antiphospholipid Antibodies

Antiglycolipid Antibodies

Dysregulated Cytokines

Dysregulated Monoamines

QEEG (Quantitative Brain Electrophyiological Deficits)

Allegedly “autoreactive” T Cells

Antibodies to Heat Shock Proteins

EMG

Gadolinium–Enhanced MRI (shows meningitis) …

Do the Infectious Diseases Society of America’s Guidelines explicitly state that these rule outs should be performed before diagnosing hypochondria, anxiety, catastrophising, Munchausen’s by Proxy, Delusional Parasitosis, Aporology, Lyme Paranoia, Depression, … ?? Don’t the American Psychiatric Association’s Guidelines state that a person should have medical rule outs before diagnosing a “mental disorder?” Isn’t it a mental disorder for the very people who discovered these markers of illness to be the same people who say we have hypochondria, anxiety, catastrophising, Munchausen’s by Proxy, Delusional Parasitosis, Aporology, Lyme Paranoia, Depression.?

It is, and it is known as psychopathy. But also, scientific fraud.

QUINOLINIC ACID

The noted pathologies associated with chronic neuroborreliosis include quinolinic acid (QUIN) in the cerebrospinal fluid. Lumbar puncture is a safe and common procedure according to Mark Klempner of Tufts (Diseases of Summer Conference, 2001, South County Hospital). QUIN is a marker of immune activation or infection. National Institutes of Mental Health has determined that quinolinic acid, an excitotoxin/neurotoxin, comes from macrophages. The precise source of QUIN in neuroborreliosis patients is unknown.

QUIN’s excitotoxic properties are related to N-methyl –D-aspartate (NMDA) NMDA agonism. QUIN, an intermediate in the tryptophan to dopamine pathway, has oxidative/foreign antigen lytic properties. QUIN has been implicated as a dopamine antagonist and associated with pathology to GABA bearing neurons and thus seizures (25, 26). The known manifestations that possibly correlate with QUIN/NMDA/GABA pathology in borreliosis are myoclonus, complex partial seizures (Neurocognitive abnormalities in children after classic manifestations of Lyme disease Steere, et al, Pediatr Infect Dis J. 1998 Mar;17(3):189-96.), sleep disorders, explosive rage reaction (“Lyme-Rage”), “a schizophrenia-like disorder”, other manifestations of psychosis and dementia. Hypnogogic and other types of hallucinations observed in Lyme neuroborreliosis are of the type more commonly associated with delirium.

In acute neuroborreliosis, QUIN levels are in the range of, 325 +/-96 nM, while in chronic borreliosis encephalopathy, the levels are in the range of, 31 +/4 nM, or about 50% above normal.  The assay was performed with GC and negative ionization mass spectrometry.

Neuroactive kynurenines in Lyme borreliosis., Neurology  1992 Jan;42(1):43-50 ,

Halperin JJ, Heyes MP., Department of Neurology, SUNY, Stony Brook.

“Although neurologic dysfunction occurs frequently in patients with Lyme borreliosis, it is rarely possible to demonstrate the causative organism within the neuraxis. This discordance could arise if neurologic symptoms were actually due to soluble neuromodulators produced in response to

infection. Since immune stimulation is associated with the production of quinolinic acid (QUIN), an excitotoxin and N-methyl-D-aspartate (NMDA) agonist, we measured levels of CSF and serum QUIN, and lymphokines. Samples were obtained from 16 patients with CNS Borrelia burgdorferi infection, eight patients with Lyme encephalopathy (confusion without intra-CNS inflammation), and 45 controls. CSF QUIN was substantially elevated in patients with CNS Lyme and correlated strongly with CSF leukocytosis. In patients with encephalopathy, serum QUIN was elevated with corresponding increments in CSF QUIN. Lymphokine concentrations were not consistently elevated. We conclude that CSF QUIN is significantly elevated in B

burgdorferi infection--dramatically in patients with CNS inflammation, less in encephalopathy. The presence of this known agonist of NMDA synaptic function—a receptor involved in learning, memory, and synaptic plasticity--may contribute to the neurologic and cognitive deficits seen

n many Lyme disease patients.”  PMID: 1531156

NEOPTERIN

There was only one citation found on PubMed for neopterin production in borreliosis. The full text has not been obtained because this is a foreign journal and is not readily available:

It was detected in the cerebrospinal fluid, here:

Neopterin production and tryptophan degradation in acute Lyme neuroborreliosis

versus late Lyme encephalopathy.,   Eur J Clin Chem Clin Biochem  1994 Sep;32(9):685-9

Gasse T, Murr C, Meyersbach P, Schmutzhard E, Wachter H, Fuchs D.

Klinik fur Neurologie, Universitat Innsbruck, Austria.

“Fourteen patients with Borrelia burgdorferi infection were investigated for possible abnormalities of tryptophan and neopterin metabolism. Four patients (2 were investigated before therapy, 2 when therapy had been already started) had acute Lyme neuroborreliosis, and 10 patients were investigated months to years after an acute infection. Increased concentrations of neopterin and of the tryptophan-degradation product, L-kynurenine, were detected in the cerebrospinal fluid of patients with acute Lyme neuroborreliosis; one patient presented with subnormal tryptophan. Similar but less marked changes were seen in the treated patients and in some of the patients with Lyme encephalopathy. No such abnormalities were seen in the serum of the patients. The data indicate a role of the immune system and particularly of endogenously formed cytokines, like interferon-gamma and tumour necrosis factor-alpha, effecting tryptophan and neopterin metabolism in patients with acute Lyme neuroborreliosis.” PMID: 7865624 “

Neopterin and other pterins may be assayed with HPLC.

There is little data available regarding disturbances to brain function associated with this marker.

Biochemical changes in cerebrospinal fluid associated with the neurotoxicaction of HIV-1, [Article in Spanish] Actas Luso Esp Neurol

Psiquiatr Cienc Afines  1996 Jul-Aug;24(4):209-18,  Gomez Alcalde MS, Reyes Martin A., Departamento de Ciencias Sanitarias y Medico

Sociales de la Facultad de Medicina de Alcala de Henares.

“The aim of this study is to evaluate the usefulness of different markers to diagnose neurologic and psychiatric diseases due to HIV-1 infection Increased concentration of quinolenic acid has been implicated in the neurologic deficits and brain atrophy that may accompany infection with

he HIV-1 virus. CFS concentrations of quinolenic acid have been implicated in the pathogenesis of the AIDS dementia complex. Cytokines  liberation are very altered and this factor may be correlated with direct toxicity about central nervous system cells. Also are increased the values

of neopterin. In the different stages of AIDS, the highest values are obtained in dementia omplex. Neopterin, tryptofan and kinorenina, in blood and CFS are directly correlated with neurologic and psychiatry sintomatology. The highest values of soluble intercellular adhesion molecule 1 are found in HIV encephalopathy As well as are important the values, in CSF and blood of beta-2-M, Ag HIV, Ac41, tumor necrosis factor-alpha in the neurologic disease in HIV-1 infection.”

PMID: 8984853

 There may be other pterins associated with a disease process.

MMPs

The matrix-metalloproteinases obviously degrade matrix/connective tissue. The concern of Mark Klempner (27) was, “Since MMPs can digest myelin, basic protein, B. burgdorferi could promote CNS injury indirectly by inducing the expresion of MMPs in neural cells. MMPs also digest at least two proteins of the adult CNS extracellular matrix: the aggregating proteoglycan versican and tenascin.” -- Perides G, Steere AC, Klempner MS, et al, Matrix metalloproteinases in the cerebrospinal fluid of patients with Lyme neuroborreliosis. J Infect Dis. 1998 Feb;177(2):401-8.

There are other reports of identification of MMPs in the CNS of neuroborreliosis, and these are not in complete agreement with Mark Klempner’s findings.  The method above was SDS-PAGE zymography.

The relationship of MMPs to the other markers of CNS degradation in the CSF of neuroborreliosis patients is unknown, nor is it known the full extent of behavioral and cognitive effects of this active marker alone.

GFAp

Glial fibrillary acidic protein in the CSF of borreliosis patients:

Astroglial and neuronal proteins in cerebrospinal fluid as markers of CNS involvement in Lyme neuroborreliosis., Eur J Neurol 1999 Mar;6(2):169-78 , Dotevall L, Hagberg L, Karlsson JE, Rosengren LE., Department of Infectious Diseases, Goteborg University,

Goteborg, Sweden.

“Is Lyme neuroborreliosis, even in its early phase, a parenchymatous disorder in the central nervous system (CNS), and not merely a meningitic process? We quantified cerebrospinal fluid (CSF) levels of four nerve and glial cell marker proteins in Lyme neuroborreliosis patients with

pretreatment durations of 7-240 days. All 23 patients had meningoradiculitis, and six had objective signs of encephalopathy. Glial fibrillary acidic protein (GFAp) pretreatment levels in

CSF, and the light subunit of neurofilament protein (NFL) levels were related to clinical outcome and declined significantly after treatment (P < 0.001 and P < 0.01, respectively). NFL was detectable in 11 out of 22 patients, and pre- and post-treatment NFL levels were associated with the duration of neurological symptoms within 100 days prior to treatment. Neuron-specific enolase (NSE) concentrations also decreased after therapy (P < 0.001), while CSF levels of glial S-100 protein remained unchanged. The pretreatment duration of disease was related to postinfectious sequelae. GFAp, NSE and NFL levels in CSF are unspecific indicators of astroglial and neuronal involvement in CNS disease. The findings in the present study are in agreement with the hypothesis that early and late stages of Lyme neuroborreliosis damage the CNS parenchyma. Copyright 1999 Lippincott Williams & Wilkins.” PMID: 10053229

Increased cerebrospinal fluid levels of glial fibrillary acidic protein (GFAp) in Lyme neuroborreliosis.,  Infection  1996 Mar-Apr;24

(2):125-9, Dotevall L, Rosengren LE, Hagberg L.

Dept. of Infectious Diseases, Ostra University Hospital, Goteborg University, Sweden.

“Glial fibrillary acidic protein (GFAp), the main protein constituent of the intermediate filaments of astrocytes, was analysed in the cerebrospinal fluid (CSF) of 20 patients with Lyme neuroborreliosis as a marker of the astroglial reaction. The mean GFAp level before antibiotic treatment in the study group was significantly elevated (592 pg/ml +/- 596 [SD]) compared to that in 24 healthy controls (121 +/- 87 [SD]) (p < 0.01). The highest CSF-GFAp levels were seen in

the patients with the most severe disease, but the levels were also increased in patients with peripheral paresis, such as facial palsy with no or only minor encephalitic symptoms. This implies that the infection was not limited to radix dorsalis or the meningeal tissues, but affected the

central nervous system as well. Furthermore, the astroglial reaction seemed to occur early in Lyme neuroborreliosis since CSF-GFAp levels were elevated also in patients with recent (< 3 weeks) onset of disease. After antibiotic treatment, the GFAp levels decreased. It is suggested

the CSF-GFAp concentrations might be useful for monitoring CNS involvement in Lyme neuroborreliosis.” PMID: 8740104

GFAp in the CSF is also seen in ALS and Alzheimer’s. Exposure to Bb in ALS patients met statistical significance:

“There appears to be a statistically significant association between ALS and immunoreactivity to B burgdorferi, at least among men living in hyperendemic areas.”— Halperin JJ, Dattwyler, RJ, et al, Immunologic reactivity against Borrelia burgdorferi in patients with motor neuron disease. Arch Neurol. 1990 May;47(5):586-94. PMID: 2334308

Robert T. Schoen, Yale Rheumatology, Annals of Internel Medicine, Vol 132, No 8:

"Other peripheral neuropathies and Lyme meningitis are also seen at this stage. In late-stage disease, the central nervous system may be involved. A new diagnostic test measuring glial fibrillary acidic protein in cerebrospinal fluid may prove to be a useful tool for measuring such involvement (20)."

Robert T. Schoen, Yale Rheumatology, Prevention Magazine:

“While it's especially important at this time of year to be aware of the warning signs of the disease – a skin rash around the site of a tick bite, headache, fever, fatigue and muscle or joint pain – Lyme paranoia, as I call it, is not warranted.”-- The previous text was excerpted from Prevention magazine, published by Rodale Press. Lyme fear prevails more than disease. , The Washington Times, 04-18-1999

GFAp has been assayed by ELISA, Western Blot. This needs further analytical development.

GFAp has been implicated in disturbance to brain function:

Effects of gliosis on dopamine metabolism in rat striatum., Brain Res  1994 Nov 14;663(2):199-205, Wang J, Lieberman D, Tabubo H, Finberg JP, Oldfield EH, Bankiewicz KS., CNS Implantation and Regeneration Unit, NINDS, NIH, Bethesda, MD 20892.

“Neuroimplantation is inevitably accompanied by gliosis. Although graft-induced trophic effects on host neurons may be mediated by glial cells, the effects of gliosis on dopamine (DA) metabolism remains unclear. To examine these effects, basic fibroblast growth factor (bFGF)

was directly infused into the striatum of 12 male rats (250-280 g). One week later, substantial gliosis was demonstrated in the infused striatum by immunochemical staining for glial fibrillary acidic protein (GFAP) and quantified by GFAP Western blot analysis. One week after bFGF infusion, extracellular DA and its metabolites were  measured by in vivo microdialysis using HPLC. Infusion of L-dopa through the dialysis probe resulted in a 60% reduction in the L-dopa-

induced DA peak in the gliotic striatum compared with the normal side. After L-dopa infusion, dihydroxyphenylacetic acid (DOPAC) levels were similar between the gliotic and normal striatum. In contrast, homovanillic acid (HVA) levels were 26% higher in the gliotic striatum.

Enzyme assays demonstrated that aromatic L-amino acid decarboxylase activity was unchanged in the gliotic striatum, but both MAO-A and MAO-B activities increased by 23% and 21%, respectively. These results suggest that the reduced striatal DA peak in the gliotic striatum

after L-dopa administration was due to accelerated DA catabolism through enhanced MAO activity. The bFGF-induced striatal gliosis may serve as a model to study neurotransmitter metabolism in the gliotic brain caused by disease processes, aging, or tissue grafting.” PMID: 7874502

Although GFAp is a a sign of reactive gliosis in Alzheimer’s, MS, and ALS, patients would much rather be told Chronic Lyme is a real disease rather than be told it’s fear, anxiety, and paranoia. It makes more sense for a patient to work with a medical practioner towards resolution of symptoms. It’s difficult to find in Medical Ethics code anywhere, that validating the patient’s person and the patient’s complaints is the first step towards recovery. Perhaps this is because this is common sense and therefore not worthy of philosophical analysis.

ANTIPHOSPHOLIPID ANTIBODIES

Antiphospholipid antibody production in neuroborreliosis patients, as has been identified by Allen Steere, is positively correlated with neurologic symptoms.

“Sera from 28 patients with Lyme disease were tested for the presence of anticardiolipin antibodies (ACLA). Seven serum samples had elevated levels of IgM ACLA, and 4 had elevated levels of IgG ACLA. Higher IgM ACLA positivity tended to be associated with neurologic disease, and IgM ACLA levels correlated with the specific IgM response to the infecting spirochete (P less than 0.01). Absorption experiments indicated that ACLA and antispirochete antibodies are largely separate populations. Thus, ACLA may occur in patients with Lyme disease, particularly in those with neurologic abnormalities, and the production of these antibodies seems to be linked to the specific IgM response.”— Anticardiolipin antibodies in Lyme disease Mackworth-Young CG, Steere AC, et al, Arthritis Rheum 1988 Aug;31(8):1052-6, PMID: 3408508

The analytical methods used there should also be employed as part of patient workup, until further investigations reveal a more sensitive and specific method. Antiphospholipid-negative assay results do not exclude the diagnosis of Lupus. Although the Lupus/MS haplotypes HLA-DQB1*0602 and *1501 have been identified as possible correlates in chronic CNS Lyme disease, it is possible to make a differential diagnosis at least of Lupus. The phospholipids found in borrelia are phosphatidylcholine and phosphatidylglycerol (28).

Adequate assays for antibodies to these are recommended. The VRDL used in Lupus wasnot adequate to detect anticardiolipin antibodies in borreliosis and Steere presented a more sensitive method: radioimmunoassay (RIA). The differential diagnosis of the Antiphospholipid Syndrome, Lupus, and antiphospholipid antibodies from the borrelioses may be a considerable challenge. We haven’t run across any recent developments from L2 Diagnostics.

Antiphospholipid antibodies are implicated in the neuropsychiatric symptoms.

ANTIGLYCOLIPIDS

Antibodies to glycolipids can also be determined. Jorge Benach of SUNY Stony Brook has found that IgM to borrelial gangliosides may result in autoimmune response similar to Guillain Barre, or possible antibody competition for receptors, and clearly, the nodes of Ranvier, which are suspected to result in compromise to nerve conduction.

Although these mechanisms of nerve conduction may be reversible and temporary, animal models of Lyme borreliosis, such as in Rhesus macaques, have shown irreversible nerve damage via immune cell response. Likeliest, these neurological lesions are the result of spirochetal blebbing, or the shedding of antigen and macrophage activity.

Alan Barbour (UC Irvine) and Stephen Bartold (Yale):

“Many researchers believe that the secret to B. burgdorferi's infectivity and inflammatory capacity lies in the interaction of its surface proteins with the host's immunological system. Yale researcher Stephen Barthold, a veterinarian and professor of comparative medicine who developed the first mouse model of Lyme disease, studies the expression of B. burgdorferi surface proteins throughout various stages of the spirochete's life cycle. He finds that during the early stages of infection, B. burgdorferi avoids immune detection by decreasing its expression of surface proteins or cloaking its expressed surface proteins under a layer of slime. "It's using some sort of stealth-bomber-type mechanism," he says. Or, using another diversionary tactic called blebbing, the spirochete can pinch off bits of its membrane in order to release its surface proteins. Explains Barbour: "It's like a bacterial Star Wars defense program," in which released surface proteins might intercept incoming host antibodies, keeping the spirochete safe from immunological attack. “— The Scientist, Vol:10, #14, pg.13, July 8, 1996.

Even when spirochetes are not detected in a borreliosis nerve lesion, it is suspected some spirochetal material blebs) remains:

"Nerve changes. A detailed survey of the central nervous system lesions was carried out, which included 50 sampling sites. The lesions observed are listed in Table 4. Sensory ganglia of the dorsal root and trigeminal ganglia of animals J 831 and K 216 had individual neurons that immunostained positive with anti-Bb 7.5kD lipoprotein mAb (fig 16). These neurons were swollen and were undergoing chromatolysis. The dorsal root ganglia of the thoracic and cervical regions were especially affected. Nerve sheath fibrosis within the spinal cord was limited to the thoracic segment in animal J 831. Positive staining with anti-Bb mAb, accompanied by vacuolization of peripheral nerves, was observed n three of four animals. This change occurred as a radiculoneuropathy of the thoracic segment and peripheral nerves (Fig 17). Animal L 131 had five peripheral nerves affected. When the same nerves were stained for fat, focal vacuolization was observed (Figs 18 and 19).

Focal demyelination  of the cervical cord was limited to J 831.  Lymphocyte infiltration of the affected nerves was mild in extent and confined to perivascular spaces.  In animals L 131 and K 383, Bb could be demonstrated by immunostaining (Fig 20).

“ The pathogenesis of Lyme disease neuropathies is poorly understood...Sensory ganglia involvement has previously been described in human borreliosis (27-28).  In our study,

many of the ganglia positive for Bb by immunstaining were undergoing necrosis.  This staining was seen in two out of five animals and was not accompanied by a cellular infiltrate.

" Nerve tissues with perivascular lymphocyte infiltrate were present in three out of five animals.  This was the only lesions where extracellular Bb could be demonstrated. Peripheral cutaneous nerves were prominantly affected in the early phase of borreliosis of rhesus macaques(20, 28-29). Changes of the nercous system include the full range of changes observed in neuroborreliosis, which suggests a variety of disease mechanisms, including sensitization or mimicry as suggested

by the vacuolization of peripheral nerves and cytokine-mediated destruction of nerves as a result of the infiltrating lymphocytes..." --- Chronic lyme disease in the rhesus monkey , Lab Invest 1995 Feb;72(2):146-60, Roberts, ED, et al.

Experimental immunization with Borrelia burgdorferi induces development of antibodies to gangliosides., Infect Immun  1995 Oct;63(10):4130-7, Garcia-Monco JC, Seidman RJ, Benach JL., Department of Neurology, Hospital de Galdacano, Vizcaya, Spain.

“Patients with neuroborreliosis produce antibodies, mostly of the immunoglobulin M (IgM) class, to gangliosides, particularly to those with Gal(beta 1-3)GalNac terminal sequences. Lewis rats were immunized with a nonpathogenic strain of Borrelia burgdorferi and with a chloroform-methanol extract (nonprotein) of this organism (CM) to determine whether antibodies to B. burgdorferi also recognized gangliosides. Rats were also immunized with asialo-GM1 to determine whether the elicited antibodies recognized antigens in B. burgdorferi. Rats immunized with B. burgdorferi produced low levels of IgM antibodies that cross-reacted with asialo-GM1 and GM1. Rats immunized with CM had marked IgM reactivity to asialo-GM1 and GM1. Immunization with asialo-GM1 resulted in antibodies that cross-reacted with B. burgdorferi antigens. Although antibodies to B. burgdorferi were of both the IgM and IgG classes, those to CM and to asialo-GM1 and GM1 were predominantly in the IgM fraction. Reactivity of the IgM antibodies decreased after adsorption with the heterologous and the homologous antigens,

indicating bidirectional cross-reactivity between CM, asialo-GM1, and GM1 and that immunization with one produces antibodies to the other. There was no in vivo deposition of Ig in peripheral nerves, nor was there nerve pathology as a result of immunizations, but IgM antibodies

to asialo-GM1 and CM recognized homologous antigens in the nodes of Ranvier of peripheral nerves from nonimmunized rats. This immunization model suggests that antibodies to

gangliosides in Lyme disease have a microbial origin and are potentially relevant in pathogenesis.” PMID: 7558329

Reactivity of neuroborreliosis patients (Lyme disease) to cardiolipin and gangliosides.

J Neurol Sci  1993 Jul;117(1-2):206-14, Garcia Monco JC, Wheeler CM, Benach JL, Furie RA, Lukehart SA, Stanek G, Steere AC., Department of Pathology, SUNY, Stony Brook 11794.

“A subset of patients (50%) with neuroborreliosis (Lyme disease) showed IgG reactivity to cardiolipin in solid phase ELISA. In addition, a subset of patients with neuroborreliosis (29%) and syphilis (59%) had IgM reactivity to gangliosides with a Gal(beta 1-3) GalNac terminal

sequence (GM1, GD1b, and asialo GM1). Anti-ganglioside IgM antibodies were significantly more frequent in these two groups of patients compared to patients with cutaneous and articular

Lyme disease, primary antiphospholipid syndrome, systemic lupus erythematosus and normal controls. Correlative evidence and adsorption experiments indicated that antibodies to cardiolipin had separate specificities from those directed against the gangliosides. IgM antibodies to

Gal(beta 1-3) GalNac gangliosides appeared to have similar specificities since these were positively correlated and inhibitable by cross adsorption assays. Given the clinical associations of patients with neuroborreliosis and syphilis with IgM reactivity to gangliosides sharing

the Gal(beta 1-3) GalNac terminus, we suggest that these antibodies could represent a response to injury in neurological disease or a cross reactive event caused by spirochetes.” PMID: 8410057

 In, Role of the cerebrosides and a galactodiglyceride in the antigenic cross-reaction between nerve tissue and treponema., J Immunol. 1972 Jul;109(1):146-53., Dupouey P. writes:

“This cross reaction between the GDG [galactodiglyceride] contained in certain species of treponema and cerebrosides of the cerebral tissue poses a problem of pathogenesis, Similar problems have been discussed in a recent review of the role of microorganisms in autoimmune response (13). With regard to this subject it should, however, be noted: 1) That the central nervous system is infected in syphilis and yet T. pallidum does not seem to contain any GDG (8). 2) That the anti-erebroside and anti-GDG studied here are circulating antibodies. Antibodies of this type are considered to be proof of, not the agents of, autoimmune response. 3) That certain infectious or traumatic diseases liable to liberate cerebral constituents within the organism should be able to give rise to anti-cerebroside antibodies which are therefore GDG. 4) That these anti-GDG antibodies are sometimes encountered at high titers in human subjects who are in apparent perfect health.”

Abstract from the same publication:“Various authors have demonstrated an antigenic identity between various nervous tissue and treponema.  This report shows that this antigenic diversity is due to the presence in the treponema extracts of a galactodiglyceride hapten: i.e., 2, 3-di-O-acyl-1-O-(b -D-galactopyranosyl)-D-glycerol.  This hapten shows a cross reaction with the cerebrosides; moreover, the the nervous tissue contains a lipid which, on deacylation, liberates a O-(b-D-galactosyl_-1-1’-glycerol (11).  The part palyed by each of the constituents as well

as the possible consequences of this antigenic community are discussed.”

It was recognized long ago that anti-nerve antibodies might possibly be coming from cross reaction, or they may be coming from degradation of host tissue, which, upon injury of some sort, becomes autoantigenic.  Thirty years ago, scientists looked at these questions in spirochetal illnesses.  In 1988 and later, Steere looked at anti-nerve antibodies in borreliosis patients and found them.  Yet these markers of illness are not only not addressed in management of patients --not only are they are not routinely looked for-- but the lay media are instead told patients have “some psychiatric illness”, there are no adverse outcomes in Lyme disease, Lyme is curable, and there is no such thing as Chronic Lyme. The Post-Lyme syndrome is “ill-defined”, according to the Infectious Diseases Society of America: “Clinical Infectious Diseases    2000;31:1-14, GUIDELINES FROM THE INFECTIOUS DISEASES SOCIETY OF AMERICA, Practice Guidelines for the Treatment of Lyme Disease, Gary P. Wormser, Robert B. Nadelman,

Raymond J. Dattwyler, David T. Dennis, Eugene D. Shapiro, Allen C. Steere, Thomas J. Rush, Daniel W. Rahn, Patricia K. Coyle, David H. Persing, Durland Fish, and Benjamin J. Luft.”

Many of the above authors are the very people who were involved in the development and discovery of methods and markers of chronic illness in Chronic Lyme disease.

It is not known if IgM antibodies to nerve cell components would be present in the absence of spirochetes.  That condition, 100% spirochete clearance, has never been proven in any animal model.

A recent public relations Lyme prevention announcement:

“Once a dog is infected, it is infected for life.” –American Lyme Disease Foundation, Somers, New York, PR Newswire, United Business Media, April, 2002

AUTOREACTIVE T CELLS, NEUROLOGICAL

Very little concrete data to support autoreactive T cells in Lyme borreliosis exists. However, there remain the genetic correlates in Klempner’s and Martin’s MHC Class II antigen-presenting molecules to be explained. Whether Class II should be considered alone, and outside the dynamic of Class I and B cell contribution to the association of Class II to an autoimmune disease with a known etiology such as a permanent spirochetal infection, will probably be played out in the NIH and CDC funding competition arena.

The data are:

AUDIO TRANSCRIPT: Mark Klempner, Tufts Unibversity. South County Hospital Diseases of Summer Conference, July 2001, regarding his treatment study of borreliosis, reported July 12, 2001, NEJM.

“Um, There, these patients obviously, are very, very much interested in that question, as we are, and I just want to highlight a preliminary piece of data of where we think we’re going from here, unpublished*, and not for large, uh, dissemination, but here is the preliminary data. And, that is, that when you look for the possibility of an autoimmune disease, the best way to look is to see if there is any genetic clustering in HLA haplotypes. The reason for that is the way antigens get presented in the context of who you are, that is, your HLA haplotype. And we can talk in some detail about that. Those diseases that I think everybody would agree are so called Autoimmune :lupus, rheumatoid arthritis, type 1 diabetes, and perhaps MS, have some clear genetic clustering that leads us to believe that these are indeed autoimmune diseases, although we do not satisfy so-called Koch’s Postulates of autoimmune disease that we’ve written[?-KMD] about. And the odds ratio for your having that particular HLA type, in the case of R.A, a DR4, or a DQB0602 to protect you from type 1 diabetes, are on the order of 3 to 6. One of the ones that is probably highest, of course, is B27, in patients with alkyloiding spondolytis and the like. It turns out that if you look at the first 51 patients with post-treatment chronic Lyme disease, the patient population that participated in our study, there was a very high incidence of DQB0602 with an odds ratio of 770%. So it may well be that exposure to THAT organism with THAT background of HLA haplotype may lead you to develop chronic symptoms. That is a hypothesis that needs to be tested. It would obviously lead to an entirely new form and approach to therapy.”

Borrelia burgdorferi--specific and autoreactive T-cell lines from cerebrospinal fluid in Lyme radiculomyelitis. Ann Neurol 1988 Oct;24(4):509-16
Martin R, Ortlauf J, Sticht-Groh V, Bogdahn U, Goldmann SF, Mertens HG.
Department of Neurology, University of Wurzburg, FRG.

In 3 patients with Lyme radiculomyelitis, cellular immune reactions of cerebrospinal fluid (CSF) lymphocytes were analyzed. Phenotypic analysis of CSF cells demonstrated that the majority were T cells (CD3+) of the helper/inducer subset (CD4+). These T cells were directly expanded from the CSF by limiting dilution. A total of 505 T-cell lines were tested for Borrelia burgdorferi (Bb)-specific proliferation and also partly tested for reactivity to a panel of central and peripheral nervous system antigens. Proliferative assays revealed 33 of them to be Bb specific, 16 to be specific for myelin basic protein, 16 to be specific for peripheral myelin, 1 to be specific for cardiolipin, and 2 to be specific for galactocerebrosides. The antigen-specific proliferation was restricted by autologous human leukocyte antigen (HLA) class II molecules. The majority of CSF-derived T-cell lines stained positively for CD3, CD4, and HLA class II antigens and negatively for CD8 (cytotoxic/suppressor subset). One T-cell line provided help for the production of specific IgG by autologous B cells and secreted gamma-interferon upon stimulation with Bb antigen in the presence of autologous antigen-presenting cells. These data show that in patients with severe neurological manifestations of late Lyme disease, not only Bb-specific T-cell lines but also T cells reactive to central or peripheral nervous system autoantigens can be found.
PMID: 3266455 [PubMed - indexed for MEDLINE]

Identification of candidate T-cell epitopes and molecular mimics in chronic Lymedisease., Nat Med  1999 Dec;5(12):1375-82, Hemmer B, Gran B, Zhao Y, Marques A, Pascal J, Tzou A, Kondo T, Cortese I, Bielekova B, Straus SE, McFarland HF, Houghten R,

Simon R, Pinilla C, Martin R., Neuroimmunology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Building 10, Room 5B-16, 10 Center DR MSC 1400, Bethesda, Maryland 20892-1400, USA.

“Elucidating the cellular immune response to infectious agents is a prerequisite for understanding disease pathogenesis and designing effective vaccines. In the identification of microbial T-cell epitopes, the availability of purified or recombinant bacterial proteins has been a chief limiting factor. In chronic infectious diseases such as Lyme disease, immune-mediated damage may add to the effects of direct infection by means of molecular mimicry to tissue autoantigens. Here, we describe a new method to effectively identify both microbial epitopes and candidate autoantigens. The approach combines data acquisition by positional scanning peptide combinatorial libraries and biometric data analysis by generation of scoring matrices. In a patient with chronic neuroborreliosis, we show that this strategy leads to the identification of potentially relevant T-cell targets derived from both Borrelia burgdorferi and the host. We also found that the antigen

specificity of a single T-cell clone can be degenerate and yet the clone can preferentially recognize different peptides derived from the same organism, thus demonstrating that flexibility in T-cell recognition does not preclude specificity. This approach has potential applications

in the identification of ligands in infectious diseases, tumors and autoimmune diseases. “PMID: 10581079

The above patient had HLA-DRB1*1501.

A trial of glatiramer actetate for putative T cell autoimmunity in Lyme disease failed:

Mechanisms of immunomodulation by glatiramer acetate., Neurology  2000 Dec 12;55(11):1704-14, Gran B, Tranquill LR, Chen M, Bielekova B, Zhou W, Dhib-Jalbut S, Martin R. Cellular Immunology Section, Neuroimmunology Branch, NINDS, NIH, Bethesda, MD 20892, USA.

OBJECTIVE: To define the mechanism of action of glatiramer acetate (GA; formerly known as copolymer-1) as an immunomodulatory treatment for MS. BACKGROUND: The proposed mechanisms of action of GA include 1) functional inhibition of myelin-reactive T cells

by human leukocyte antigen (HLA) blocking, 2) T-cell receptor (TCR) antagonism, and 3) induction of T helper 2 (Th2) immunomodulatory cells. In this report, the authors examined the effects of GA on the functional activation of human T-cell clones (TCC) specific for myelin basic protein (MBP) and for foreign antigens. Several questions were addressed: Is the inhibitory effect of GA specific for autoantigens? Is it mediated by blocking the interaction between peptide and HLA molecule? Is GA a partial agonist or TCR antagonist, or does it induce anergy? Does it induce Th2 modulatory T cells? METHODS: The effects of GA on antigen-induced activation of human TCC specific for MBP, influenza virus hemagglutinin, and Borrelia burgdorferi were studied by proliferation and cytokine measurements, TCR downmodulation, and anergy assays. GA-specific TCC were generated in vitro from the peripheral blood of patients and healthy controls by limiting dilution. RESULTS: GA more strongly inhibited the proliferation of MBP, as

compared with foreign antigen-specific TCC; in some MBP-specific TCC, the production of Th1-type cytokines was preferentially inhibited. In addition to HLA competition, the induction of anergy, but not direct TCR antagonism, was observed. Numerous GA-specific TCC were generated from the peripheral blood of both MS patients and normal controls, and a fraction of these showed a Th2 phenotype. CONCLUSIONS: This study confirms a preferential inhibitory effect of GA on autoreactive TCC. With respect to cellular mechanisms, although HLA

competition appears to play the most important role in functional inhibition in vitro, a direct effect on the TCR may be involved at least in some autoreactive T cells as shown by anergy induction.  Although not confirmed at the clonal level, it is demonstrated further that GA

induces T cells that crossreact with myelin proteins. GA-specific, Th2-modulatory cells may play an important role in mediating the effect of the drug in vivo.  PMID: 11113226

DETECTING MENINGITIS

Gadolinium Contrast MRI was used to look for spirochetal meningitis the nonhuman primate model:

Inoculation of nonhuman primates with the N40 strain of Borrelia burgdorferi leads to a model of Lyme neuroborreliosis faithful to the human disease., Neurology  1995 Jan;45(1):165-72, Pachner AR, Delaney E, O'Neill T, Major E., Department of Neurology, Georgetown University Medical Center, Washington, DC.

“We injected rhesus macaques with a highly infective strain of Borrelia burgdorferi to assess whether experimentally inoculated nonhuman primates (NHPs) could serve as models of human Lyme neuroborreliosis (LNB). The animals developed biopsy-confirmed erythema migrans in the area of the inoculations. ELISA testing of sera revealed strong antibody reactivity to B burgdorferi antigens, and Western

blotting showed that 16-, 22-, 31-, 34-, and 41-kd proteins of the spirochete were major antigens recognized by antibody. Culture and polymerase chain reaction (PCR) testing of serial CSF specimens revealed that chronic infection of the CNS occurred in all NHPs injected.

CSF pleocytosis occurred concurrently with CNS infection. Brain MRI revealed intense meningeal inflammation in one NHP as manifested by gadolinium uptake by the dura at the base of the temporal lobes. All animals had measurable antibody in the CSF after invasion. These studies are the first to demonstrate that experimental LNB in NHPs is a reliable model faithful to the human disease, with spirochetal invasion of the subarachnoid space. This also is the first report of CSF samples positive by culture in experimental LNB.  Inflammation in the CNS as manifested by CSF pleocytosis and MRI findings was also correlated with the presence of spirochetal DNA detected by PCR. These data support the hypothesis that the pathogenesis of LNB is associated with direct spirochetal invasion, and provide evidence that CNS involvement is more common than heretofore thought.” PMID: 7824109

Note that the monkeys only had one of CDC’s specific bands, and if these were all IgG, none would have been a reportable case.  This is evidence of faithfulness to human disease.  These monkeys would have been classified as “Unconfirmed Lyme” in the SKB LymeRIX trial.  “Unconfirmed Lyme” data was not included in analysis of safety and efficacy of the vaccine. Less than 5 bands-Lyme data was simply discarded.  (OspA and B were excluded in CDC’s IgG.)

Gad-MRI has been used in humans to detect spirochetal meningitis.

Contrast enhancement of the cerebrospinal fluid on MRI in two cases of spirochaetal meningitis., Good CD, Jager HR., Lysholm Radiological Department, National Hospital for Neurology and Neurosurgery, London, UK.,

“We report two patients with meningitis due to spirochaetal infection, both of whom showed diffusely enhancing meninges around the brain and spinal cord. In addition, there was enhancement of the cerebrospinal fluid after intravenous administration of Gd-DTPA.”

PMID: 10929307

It is not known why this is method not used more commonly.  It seems that this might be more economical and specific than a neuropsychiatric evaluation.

EEG

Changes in electroencephalography, consistent with delirium, were identified in Lyme patients:

QEEG and evoked potentials in central nervous system Lyme disease., Chabot RJ, Sigal LH., Clin Electroencephalogr. 1995 Jul;26(3):137-45.

 “Quantitative EEG, flash visual evoked potentials, auditory evoked potentials to common and rare tones, and median nerve somatosensory evoked potentials were obtained from 12 patients with active CNS Lyme disease and from 11 patients previously treated for active CNS Lyme disease. Abnormal QEEG and/or EPs were found in 75% of the active Lyme disease patients and in 54% of the post CNS Lyme disease atients. Three different types of neurophysiological abnormality were observed in these patients including QEEG slowing, possible signs of cortical hyperexcitability, and focal patterns indicating disturbed interhemispheric relationships. In patients tested before and after treatment QEEG and EP normalization was associated with clinical improvement.” PMID: 7554300

Compare to:

The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome. Arthritis Rheum  2000 Nov;43(11):2493-500, Hassett AL, Cone JD, Patella SJ, Sigal LH.,

Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903, USA.

“OBJECTIVE: Although 2 recent studies have found associations between catastrophizing and poor medical outcomes in patients with fibromyalgia syndrome (FMS), neither assessed these findings in comparison with a similar group of patients with chronic pain. Our study examined the complex relationships between depression, catastrophizing, and the multidimensional aspects of pain in women with FMS and compared these relationships with those in women with rheumatoid arthritis (RA). METHODS: Sixty-four FMS patients and 30 RA patients completed

the Coping Strategies Questionnaire (CSQ), the Beck Depression Inventory II (BDI-II), and the McGill Pain Questionnaire. RESULTS: Compared with subjects with RA, FMS subjects scored significantly higher on the catastrophizing subscale of the CSQ. FMS patients also earned higher scores on overall depression and on the cognitive subscale of the BDI-II.  Furthermore, the

relationship between catastrophizing and depression was significant in the FMS group only. Regression analyses revealed that in FMS, catastrophizing as a measure of coping predicted patients' perception of pain better than demographic variables such as age, duration of illness, and education. CONCLUSION: Cognitive factors, such as catastrophizing and depressive self-statements, have a more pronounced role in the self-reported pain of patients with FMS than in patients with RA.  Clinically, this indicates that treating pain and depression in FMS by adding cognitive therapy and coping skills components to a comprehensive treatment program may

improve the outcomes obtained with pharmacologic interventions.” PMID: 11083273

The above two examples show the inconsistent and non-systematic use of objective measures, in addition to non-validated-by-physiology subjective measures, deployed in service of Managed Care financial goals.

Leonard Sigal: Chapter 8, page 145, Rahn and Evans’ book, “Lyme Disease, ACP Key Diseases Series”, 1998

“Lyme Anxiety

Lyme anxiety is common in and near areas endemic for Lyme disease. There is widespread concern that Lyme disease is incurable and that this infection can only be brought into temporary remission and will continue to flare. With widespread anxiety about Lyme disease has come Munchausen syndrome and Munchausen by Proxy in those concerned about Lyme disease. The psychologic and financial costs of the misdiagnosis of “chronic” Lyme disease are staggering but have not been considered in most discussions of the public burden of the mismanagement of Lyme disease.”

DYSREGULATION OF CSF MONOAMINES AND CYTOKINES

Cytokines

IL-6 in the CSF is associated with physical and emotional depression. The downstream effect of increased IL-6 in the CNS on neurotransmission needs further study.

Interleukin-6 is expressed at high levels in the CNS in Lyme neuroborreliosis., Neurology  1997 Jul;49(1):147-52, Pachner AR, Amemiya K, Delaney E, O'Neill T, Hughes CA, Zhang WF., Department of Neurology, Georgetown University School of Medicine, Washington,

DC 20007, USA.

In patients with Lyme neuroborreliosis, inflammation and symptoms of fatigue and malaise occur out of proportion to the relatively low number of spirochetes present. Previous studies have identified interleukin-6 (IL-6) as a candidate molecule for amplification of CNS inflammation in this disease. We pursued this possibility by measuring cytokine gene expression by reverse-transcriptase polymerase chain reaction (RT-PCR) in the brain of rhesus macaques actively

infected with Borrelia burgdorferi. Samples of brain tissue were screened for IL-6 and interferon gamma using RT-PCR-ELISA, a technique that uses RT-PCR, subsequent hybridization of the PCR product with a biotinylated probe, and capture and ELISA readout of hybridization product. The number of copies in positive samples was then quantitated using qRT-PCR-ELISA, in which

wild-type cytokine cDNA competes with recombinant competitor DNA in the PCR. Elevated

levels of IL-6 cDNA and, to a lesser extent, interferon gamma were detected in three of three nonhuman primates with persistent infection with B burgdorferi, whereas the brains of three uninfected animals and undetectable levels of gene expression of these cytokines. These data support the hypothesis that cytokines such as IL-6 are important amplification molecules for CNS inflammation in Lyme neuroborreliosis.PMID: 9222183

IL-10

The following excerpt was taken from the results section of a report of an experiment ex vivo.  No data was been published as per a search of MEDLINE for the query parameters: “borrelia and CSF and IL-10”. It is not known the influence of IL-10 on cognitive changes.  It is suspected that IL-10 plays a role in the persistence of the spirochete.

OspA appears to exert an effect on IL-10 expression and might play a role in vaccine adverse events (Haupl T, Landgraf S, et al, FEMS Immunol Med Microbiol 1997 Sep;19(1):15-23: “ High induction of IL-10 by L-OspA further suggested a negative feedback on monocyte activation by the lipidated form.” Activation of monocytes by three OspA vaccine candidates: lipoprotein OspA is a potent stimulator of monokines.).

Modulation of cytokine release in ex vivo-stimulated blood from borreliosis patients. Infect Immun 2001 Feb;69(2):687-94, Diterich I, Harter L, Hassler D, Wendel A, Hartung T., Biochemical Pharmacology, Department of Biology, University of Konstanz, D-78457 Konstanz, Germany.

(From the Results Section):

“To compare the patterns of cytokine release induced by LPS and Borrelia lysate, the oncentrations of endotoxin from fourdifferent LPS preparations were adjusted to induce the same levelsof TNF- release as seen with 10 µg of protein per ml of Borrelialysate. The release of the cytokines TNF-, IFN-, G-CSF, andIL-10 induced by endotoxins from S. enterica serovar Abortusequi(200 pg/ml), E. coli (10 ng/ml), K. pneumoniae (100 pg/ml), andS. enterica serovar Enteritidis (50 pg/ml) was uniform in bloodfrom healthy volunteers (Fig. 3), suggesting that different endotoxinsshare a leukocyte activation principle. However, a pronounceddifference was seen between the four LPS preparations and theBorrelia lysate: at concentrations which induced the same TNF-release as 10 µg of protein per ml of Borrelia lysate, endotoxinsinduced much more IFN- than Borrelia lysate did. Instead, Borrelialysate induced a 5- to 10-fold-higher release of the anti-inflammatorycytokines IL-10 and G-CSF than the LPS preparations did. The lysatesfrom otherBorrelia species, i.e., B. afzelii and B. garinii,induced the same cytokine pattern as did those from B. burgdorferi(data not shown). These findings show that LPS induces the releasepredominantly of the proinflammatory cytokine IFN- while Borrelialysate is a

stronger inducer of the anti-inflammatory cytokinesIL-10 and G-CSF. Such an inverse cytokine induction pattern demonstratesthat the immunostimulatory components of B. burgdorferi differfrom those of endotoxins.”

IL-10 has not been reported found in the CSF of borreliosis patients in MEDLINE. This may be a failure of search strategy.

There is other cytokine dysregulation in borreliosis. These were only a sampling. It needs to be looked at systematically and probably put into a database. Different combinations of TBDs may have different effects. Note that the above two examples were controlled studies of infecting monkeys with Bb alone.

Monoamines

Neurotransmitters and their metabolites in the CSF of post-meningitis patients have not been extensively studied. Evidence of immune activation such as quinolinic acid in HIV and neuroborreliosis and behavioral effects suggest that there may be evidence of dysregulation, which can be correlated. MMPs are related to neurologic sequelae in childhood meningitis with degree of damage a function of concentration dependence. Monoamine dysregulation in the CSF of autistic children has been studied. MMR vaccination in childhood has been implicated in the development of autism, particularly since many of these children experience normal development until approximately 18 months of age, the recommended age to administer MMR. This is not to say that MMR vaccination results in autism, this is to say, does a strong immune response from an immunogen result in permanent or temporary changes to receptor profiles, neurotransmitters and their degradants concentration that can be detected in CSF, or evidence of abnormal differentiation of brain cells that can be detected via monoamine assay?

Vaccination effects other than autism, due to MHC capacities, are now being studied, but from the reverse standpoint.

Scientists are now looking at targeting vaccines towards people predisposed to autoimmune disease by HLA identification.

ANTIBODIES TO HEAT SHOCK PROTEINS

Antibodies to heat shock proteins (sometimes considered part of “common antigens”) are considered possible cross-reacting antibodies, since microbial and mammalian heat shock proteins are similar. There are times when mammalian heat shock proteins are surface-expressed. Bb contains at least 12 heat shock proteins. This is not surprising, since it has multiple hosts, including the tick, which often survives near zero C temperatures. Bb itself survives freezing, as the spirochete has been recovered from frozen banked blood. Lyme patients are prohibited from donating blood to the Red Cross.

Heat shock proteins (HSPs) of Bb expressed in humans have apparent molecular weights of 60, 62, 72, 74 kilodaltons. P66, one of at least three pore-forming antigens of Bb (others: P28, P45) has qualities of heat shock proteins and may bind heat shock protein antibodies. HSPs are not always detectable via antibody. They are not as immunogenic in some people as they are in others. When they show up in neurologically impaired patients, one might expect an MS-like syndrome. HSPs obviously have less specificity than Bb-specific lipoproteins, but do not exclude illness symptoms.

Characterization of the heat shock response and identification of heat shock protein antigens of Borrelia burgdorferi., Infect Immun  1990 Jul;58(7):2186-91, Carreiro MM, Laux DC, Nelson DR., Department of Microbiology, University of Rhode Island, Kingston 02881.

“The heat shock response of Borrelia burgdorferi B31 cells was characterized with regard to the heat shock proteins (Hsps) produced. Five to seven Hsps were detected by sodium dodecyl sulfate-gel electrophoresis and fluorography of proteins from cells labeled with [35S]methionine after shifts from 33 degrees C to 37 or 40 degrees C or from 20 degrees C to 33, 37, or 40 degrees C. Analysis of [35S]methionine-labeled Hsps by two-dimensional electrophoresis and

autoradiography revealed 12 Hsps. Western immunoblot analysis with antisera to highly conserved Escherichia coli and Mycobacterium tuberculosis Hsps revealed a single 72-kilodalton (kDa) protein band that reacted with antibodies to E. coli DnaK and with antibodies to the M. tuberculosis 71-kDa Hsp homolog of E. coli DnaK. Two proteins with apparent molecular masses of 66 and 60 kDa reacted with antibodies against the M. tuberculosis 65-kDa Hsp homolog of E. coli GroEL. Human immune sera collected from patients with Lyme disease reacted with both

the 66-kDa Hsp and the 60-kDa Hsp but failed to react with the 72-kDa Hsp. These data are discussed with regard to the possibility that host recognition of highly conserved epitopes of GroEL homologs of B. burgdorferi may result in autoimmune reactions causing arthritis

nd other pathologies.” PMID: 2194963

Anti-alpha B-crystallin immunoreactivity in inflammatory nervous systemdiseases., J Neurol  2000 Dec;247(12):935-9, Celet B, Akman-Demir G, Serdaroglu P, Yentur SP, Tasci B, van Noort JM, Eraksoy M, Saruhan-Direskeneli G., Department of Physiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.

alpha B-Crystallin, a small heat shock protein, is an immunodominant antigen with increased tissue expression in demyelination. To investigate the humoral response against alpha B-crystallin, the sera and CSF samples of patients with multiple sclerosis (MS), Guillain-Barre syndrome (GBS), neuro-Behcet's disease (NBD) and other non-inflammatory neurological diseases (NIND) were screened by enzyme-linked immunosorbent assay for anti-alpha B-crystallin IgG and IgM antibodies. Serum and CSF IgG antibody responses to alpha B-crystallin were significantly elevated only in NBD patients (serum IgG, NBD 1.29 +/- 0.49 vs. NIND 0.95 +/- 0.39, P = 0.01; CSF IgG, NBD 1.22 +/- 0.64 vs. NIND 0.81 +/- 0.35, P = 0.01). Similarly, high serum IgM antibody titres were also detected in NBD (1.83 +/- 0.72 vs. 1.16 +/- 0.49, P = 0.0005) and in MS (1.57 +/- 1.07, P = 0.046), whereas elevated CSF IgM responses were observed only in GBS (2.09 +/- 1.09 vs. 1.41 +/- 0.7, P = 0.007). Humoral responses against alpha B-crystallin are increased in NBD and GBS, which may implicate this central nervous system antigen in the causation and pathogenesis of these inflammatory nervous system

disorders.  PMID: 11200685

Molecular mimicry in Lyme disease: monoclonal antibody H9724 to B. burgdorferi flagellin specifically detects chaperonin-HSP60., Biochim Biophys Acta  1993 Mar 24;1181(1):97-100

Dai Z, Lackland H, Stein S, Li Q, Radziewicz R, Williams S, Sigal LH.  Center for Advanced Biotechnology and Medicine, Piscataway, NJ.

“A monoclonal antibody (H9724), specific for the 41-kDa flagellar protein of the Lyme disease pathogen Borrelia burgdorferi, cross-reacts with human axons and detects one major protein in human neuroblastoma cell extracts. The homologous cross-reacting protein has now been isolated from calf adrenal and identified as chaperonin-HSP60 by N-terminal sequencing.” PMID: 8096152

This citation demonstrates the need for a formal physician education program in Rhode Island.  In 2000, South County Hospital invited Dr. Sigal to come and speak about Fibromyalgia at their Annual “Diseases of Summer” Conference.  Fibromyalgia is not a disease of summer, nor is it associated with antibodies to heat shock proteins, particularly.The 60-62 kD Bb heat shock protein is not a CDC antigen.  That an antibody to a heat shock protein from Bb sonicate shows up in a patient with suspected TBDs implies simply that:  The patient has a heat shock protein antibody that they are reacting to, not necessarily from Bb, possibly cross-reactive.  The patient may have neurologic symptoms, as a consequence.

Some people exposed to bacterial HSPs develop autoimmune disorders. As a result, research in vaccines is heading

in this direction. It is thought that exposure to bacterial HSPs before involution of the thymus may protect against autoimmune disease. HSPs as vaccines is a direction of research in development of vaccines against MS (a search of the patent database will best reveal the research). Children tend to have better outcomes from Bb exposure. Some children with congenital Lyme exposure and persisting antibodies have no illness symptoms. They may have thus become immune tolerant. Others clearly do not fair as well, as is seen also in congenital syphilis.

It makes no sense to make proclaimations whatsoever about Lyme and long term illness, or Lyme and pregnancy when in 100 years, we still know so little about spirochetes. Again, currently used detection methods and case criteria are not only poor, but negligent. The variables are not under control, as we learn from other autoimmune diseases.

QUALIFYING PATIENT PRESENTATION

The current state of the art in analysis of the psychological condition of TBDs patients is that many of the neuropsychiatric testing instruments typically employed have not been validated against the presence of the biophysical markers of disease state. Neuroborreliosis patients present with psychiatric symptoms ranging from mild depression to psychosis, but essentially fall within the scope of a mild Delirium, as described by the Comprehensive Textbook of Psychiatry, 2002. The following is an older, but adequate description:

DELIRIUM-Diagnostic Criteria

· Reduced ability to maintain attention to external stimuli and to appropriately shift attention to new external stimuli. Thus at least 1 of:

o Questions had to be repeated because attention wandered

o Perseverated answers to previous questions

· Disorganized thinking

· Confusion developed over a short period of time

· Fluctuating level of confusion

· At least 2 out of 6 of:

o Reduced level of consciousness

o Perceptual disturbances

o Disturbance of sleep-wake cycle

o Increased or decreased psychomotor activity

o Disorientation to time, place, or person

o Memory impairment

· Either of the following:

o Evidence that an organic factor initiated and maintained this confusion

o Confusion cannot be accounted for by any nonorganic mental disorder

Associated Features

· Learning Problem

· Dysarthria/Involuntary Movement

· Hypoactivity

· Psychotic

· Euphoric Mood

· Depressed Mood

· Somatic/Sexual Dysfunction

· Hyperactivity

· Addiction

· Sexually Deviant Behavior

Differential Diagnosis

Schizophrenia; Schizophreniform Disorder; and other psychotic disorders; Dementia; Factitious Disorder with

Psychological Symptoms.

Inasmuch as biopsychiatry relies on pharmacological treatment of a brain disease, primarily within the framework of neurotransmitter imbalance, Lyme as a brain disease as not been similarly probed. This is unsurprising, since delirium is more commonly associated with an organic problem, such as CNS infection; such as in Lyme disease That Steere suggests Lyme patients have “some psychiatric disorder” is true, as shown above. However, the other publicly proclaimed terms of endearment of Lyme patients have included “Irrational”, Munchausens, and Paranoia. One would think such statements would require proof in the form of demonstrating the neurotransmitter imbalance criteria of biopsychiatry, the DSM-IV, and criteria for the development of the targeted psychopharmaceuticals.

Stigmatizing Lyme disease in this way also works in reverse. Dr. Leonard Sigal has “studied” Fibromyalgia and determined that “catastrophizing” plays an important role. Also, he suggests that Lyme patients’ demonstrate “Illness behavior” (Millar vs. Kenny and Glenn, SUPERIOR COURT OF NEW JERSEY LAW DIVISION-OCEAN COUNTY DOCKET NO. L 2148-94). for which behavior modification is indicated, and that Lyme disease patients have Fibromyalgia instead of Lyme disease when they don’t have 5 of 10 bands. Sigal was also the principle investigator in a vaccine trial, Connaught’s, in which the Dressler criteria was also employed, and both trials were started using this standard, before the standard was in place (CDC’s Dearborn Conference).

We fear that such statements about the mental disorder of Lyme borreliosis might have an adverse effect on the social consequences to patients with other mental illnesses. If illness behavior is mental illness, then mental illness is illness behavior, and persons demonstrating signs of mental illness might receive behavior modification therapy instead of psychopharmacotherapy, which may only exacerbate their mental illness and related suffering. Conversely, anyone with a new medical complaint who demonstrates illness behavior might be sent for sychopharmacotherapy instead of a proper medical evaluation.

The Evidence-Based Medicine Spin Engine (EBMSE) is a risk to all populations. Tick bites are random. It cannot be said otherwise. If next we are to hear that chronic Lyme patients had a pre-existing mental illness, via the EBMSE, we would not be surprised. The same favor was granted Gulf War Veterans and CFIDS patients. Fibromyalgia patients just plain exaggerate, according to Sigal, but how much closer do these “studies” bring us to symptom relief? Are we getting what we paid for as taxpayers? If we truly want decreased cost of healthcare, we need to stop wasting money by spinning diseases, only to have to repeat the studies later because the empirical evidence, reality, keeps showing up. Meanwhile, patients linger miserably in the MD Pinball Zone, continually driving new medical claims. The burden of decreasing healthcare expenses therefore falls on the shoulders of US government. They must excise this EBMSE tumor. It can be found originating at the CDC under the misnomer “Agency for Healthcare Research and Quality”.

In order to avoid misdiagnosis of TBDs patients based on their suspected psychiatric symptoms, RI needs a database of patient/pathological objective status. Psychological analyses of suspected TBDS patients are not recommended until the psychological testing methods have been validated against the pathophysiology present. For example, if 80% of neuroborreliosis patients present with abnormal levels of matrix-metalloproteinases and IL-6 in their cerebrospinal fluid, psychiatric instruments such as the Beck Depression inventory or MMPIs need to be validated in patients who have these markers of pathophysiology. The hazards of misuse of psychological testing are misdiagnosis and thus inadequate treatment and prolonged mental and physical discomfort.

A 4.8 million dollar research program is currently underway at Columbia to discover at least the correlates in neurocognitive testing results in known infected borreliosis patients, and effects of long term treatment, inasmuch as CDC IgG criteria could be valid for current infection (it is not). PCR-positive patients are also eligible for enrollment, although these patients are rare. At the conclusion of that study, we will at least be certain of some of the elements of the neurocognitive presentation of the PCR positive patients, if any such patients are to be found with Mayo’s Bb primers. Exposure to Bb, via CDC diagnostic criteria, plus neurocognitive esults will contribute to a database. We will see what the presence of Lyme arthritis IgG antibodies means in Chronic Neurologic Lyme disease to the extent that the neurocognitive testing is valid.

Patients with preexisting neuropsychiatric presentation are excluded from the Columbia study and therefore this is a realm and patient set for future discovery. It has been found by Dr. Klempner of Tufts a high prevalence of HLA-DQB1*0602 patients in the seronegative Lyme cohort of his 4.7 million dollar retreatment study of Chronic Lyme patients. These *0602 patients have a tendency for low immune competence.

“We demonstrated that HLA-DQB1*0605 was associated with a possible increased risk of susceptibility to infection in African Americans and that DQB1*0602 was associated with a possible increased risk of infection in Caucasians.”-- Achord AP, et al, HLA-DQB1 markers associated with human immunodeficiency virus type I disease progression. Pathobiology. 1997;65(4):210-5. PMID: 9396045

Since *0602 is associated with Lupus, MS, and narcolepsy as well, it must be noted that there are recognized psychiatric manifestations. There may be infectious etiologies of mental illnesses. Yale University recently undertook study of the treatment of children with a susceptibility to Staphylococcus infection and the noted resultant development of Obsessive Compulsive Disorder (Pediatric Autoimmune Neuropsychiatric Diseases Disorder Associated With Group A Streptococcal Infection (PANDAS) and performed a clinical trial of treating these patients with prophylactic antibiotics.

Higher prevalence of antibodies to Borrelia burgdorferi in psychiatric patients than in healthy subjects., Am J Psychiatry  2002 Feb;159(2):297-301, Hajek T, Paskova B, Janovska D, Bahbouh R, Hajek P, Libiger J, Hoschl C., Prague Psychiatric Center,

Department of Epidemiology, Charles University, Third Faculty of Medicine, Czech Republic

“OBJECTIVE: Borrelia burgdorferi infection can affect the CNS and mimic psychiatric disorders. It is not known whether Borrelia burgdorferi contributes to overall psychiatric morbidity. The authors compared the prevalence of antibodies to Borrelia burgdorferi

 in groups of psychiatric patients and healthy subjects to find out whether there is an association between this infection and psychiatric morbidity. METHOD: Between 1995 and 1999 the authors screened for antibodies to Borrelia burgdorferi in 926 psychiatric patients consecutively admitted to Prague Psychiatric Center. They compared the results of this screening with findings from 884 consecutive healthy subjects who took part in an epidemiological survey of antibodies to Borrelia burgdorferi in the general population of the Czech Republic. Sera were tested by means of enzyme-linked immunosorbent assay. Circulating immune complexes were isolated by polyethylene glycol precipitation. To control for potential confounders, the two groups of patients and healthy subjects were matched according to gender and age. Results were obtained in a sample of 499 matched pairs. RESULTS: Among the matched pairs, 166 (33%)

of the psychiatric patients and 94 (19%) of the healthy comparison subjects were seropositive in at least one of the four assays.  CONCLUSIONS: These findings support the hypothesis that there is an association between Borrelia burgdorferi infection and psychiatric morbidity. In countries where this infection is endemic, a proportion of psychiatric inpatients may be suffering from neuropathogenic effects of Borrelia burgdorferi.” PMID: 11823274

Not only do we want to know if there is an infectious etiology of psychiatric diseases, such that they might perhaps be treated and perhaps recover, this is a place to mine HLA data for developing concepts in prevention of neurologic autoimmune diseases.  A characteristic of mental illnesses would be lack of ability to communicate, or even the desire, to make medical complaints.  This report is clear evidence that illness behavior is not mental illness and mental illness is not illness behavior.  These patients were first in a psychiatric hospital, and then someone decided to look to see if they were exposed.  These were not patients who went to went

to a non-psychiatric hospital with hypochondriacal or exaggerated complaints.  Clearly there is a spectrum in symptom reporting habits in mental illnesses.  Factitious disorders are uncommon and the current Managed Care contributions to the understanding and treatment of Lyme disease would not satisfy the goal of a factitious disorder such as Munchausens’:  getting medical attention.

Studies such as the one above should be performed in the US, but not with the CDC’s HLA-DR4, or Lyme arthritis-related antibody scheme, because there is a negative association between rheumatoid arthritis and schizophrenia.  There is a negative association between HLA-DR4 and schizophrenia:

At issue: schizophrenia and rheumatoid arthritis: the negative association revisited., Schizophr Bull  1999;25(4):625-38, Oken RJ, Schulzer M., New York State Institute for Basic Research in Developmental Disabilities, Staten Island, USA.

“A strong negative association between schizophrenia and rheumatoid arthritis (RA), implying low comorbidity, has been found in 12 of 14 previous studies, which we review. To this literature we add two recently acquired data sets encompassing 28,953 schizophrenia patients, only 31 of whom had comorbid RA. Integrating our new data into those of the previous nine studies, which

stratified their populations according to psychiatric diagnosis, we obtain a median frequency of RA in schizophrenia populations of 0.09 percent and a mean frequency of 0.66 percent, well below the expected range of 1 percent. These data robustly support prior studies. We also present a meta-analysis evaluating the association between the two diseases by integrating information derived from nine data sets, each furnishing an estimate of the relative risk of RA in schizophrenia patients versus that in other psychiatric patients. We find that the estimated rate of RA among schizophrenia patients is only 29 percent of the corresponding rate in other psychiatric patients. Further, the relative risk of RA in schizophrenia patients versus that in the general population is even less than 29 percent and could be as low as one-third of this value. We present a new hypothesis involving the platelet activating factor system in an effort to account for this negative association and review the suggestions of other investigators toward this end. Finally, we consider the glutamatergic system dysfunction hypothesis of schizophrenia and suggest a possible common pharmacological approach that may ameliorate some of the symptomatology of both schizophrenia and RA.”  PMID: 10667736

HLA-DR4 and Lyme Arthritis:

Association of treatment-resistant chronic Lyme arthritis with HLA-DR4 and antibody reactivity to OspA and OspB of Borrelia burgdorferi., Infect Immun  1993 Jul;61(7):2774-9, Kalish RA, Leong JM, Steere AC, Division of Rheumatology/Immunology, New

England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111.

“Chronic Lyme arthritis that is unresponsive to antibiotic therapy is associated with an increased frequency of the HLA-DR4 specificity. To determine whether the immune response to a particular polypeptide of Borrelia burgdorferi may be associated with treatment-resistant

chronic Lyme arthritis, we correlated the clinical courses and HLA-DR specificities of 128 patients with Lyme disease with their antibody responses to spirochetal polypeptides. Antibody reactivity was determined by Western blotting (immunoblotting) with sonicated hole B. burgdorferi and recombinant forms of its outer surface proteins, OspA and OspB, as the antigen preparations. Of 15 patients monitored for 4 to 12 years, 11 (73%) developed strong immunoglobulin G responses to both OspA and OspB near the beginning of prolonged episodes of arthritis, from 5 months to 7 years after disease onset. When single serum samples from 80 patients with Lyme arthritis, were tested, 57 (71%) showed antibody reactivity to recombinant Osp proteins; in contrast, none of 43 patients who had erythema migrans or Lyme meningitis (P < 0.00001) and 1 of 5 patients who had chronic

 neuroborreliosis but who never had arthritis (P = 0.03) showed antibody reactivity to these proteins. Among the 60 antibiotic-treated patients with Lyme arthritis, those with the HLA-DR4 specificity and Osp reactivity had arthritis for a significantly longer time after treatment than those who lacked Osp reactivity (median duration, 9.5 versus 4 months; P = 0.009); a similar trend was found for the HLA-DR2 specificity. For other HLA-DR specificities, arthritis resolved within a median duration of 2 months in both Osp-reactive and nonreactive patients. We conclude

that the combination of the HLA-DR4 specificity and OspA or OspB reactivity is associated with chronic arthritis and the lack of a response to antibiotic therapy.PMID: 7685738

Rheumatoid Arthritis and HLA-DR4

Rheumatoid arthritis (RA)-associated HLA-DR alleles form less stable complexes with class II-associated invariant chain peptide than non-RA-associated HLA-DR alleles., J Immunol  2001 Dec 15;167(12):7157-68, Patil NS, Pashine A, Belmares MP, Liu W, Kaneshiro B, Rabinowitz J, McConnell H, Mellins ED., Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, CA 94305, USA. npatil@genencor.com

“Certain HLA-DR alleles confer strong susceptibility to the autoimmune disease rheumatoid arthritis (RA). We compared RA-associated alleles, HLA-DR*0401, HLA-DR*0404, and HLA-DR*0405, with closely related, non-RA-associated alleles, HLA-DR*0402 and HLA-

DR*0403, to determine whether they differ in their interactions with the class II chaperone, invariant chain (Ii). Ii binds to class II molecules in the endoplasmic reticulum, inhibits binding of other ligands, and directs class II-Ii complexes to endosomes, where Ii is degraded to class II-associated Ii peptide (CLIP). To evaluate the interaction of Ii and CLIP with these DR4 alleles, we introduced HLA-DR*0401,  *0402, and *0404 alleles into a human B cell line that lacked endogenous HLA-DR or HLA-DM molecules. In a similar experiment, we  introduced HLA-DR*0403 and *0405 into an HLA-DM-expressing B cell line, 8.1.6, and its DM-negative derivative, 9.5.3.  Surface abundance of DR4-CLIP peptide complexes and their susceptibility to SDS-induced denaturation suggested that the different DR4-CLIP complexes had different stabilities. Pulse-chase experiments showed CLIP dissociated more rapidly from RA-associated DR molecules in B cell lines. In vitro assays using soluble rDR4 molecules showed that DR-CLIP complexes of DR*0401 and DR*0404 were less stable than complexes of DR*0402. Using CLIP peptide variants, we mapped the reduced CLIP interaction of RA-associated alleles to the

shared epitope region. The reduced interaction of RA-associated HLA-DR4 molecules with CLIP may contribute to the pathophysiology of autoimmunity in RA.”  PMID: 11739539

If autoimmune phenomena are generally thought to occur post-infection, then Dr. Klempner has surely found a neuroautoimmune haplotype in great frequency in the seronegative borreliosis patients, which, if it had been reported, would have lent credibility to patient complaints of chronic illness. Instead, the public relations’ focus announced, far and wide, that patients should not be given “long term” antibiotic treatment. The degree of

political ferocity behind these machinations, is evidenced by Klempner’s suggestion to NEJM editors, that his “results” be “Early Released” in June instead of July, 2001, at the beginning of tick-infection season. Very important data regarding the neuroautoimmune association with markers of pathophysiology found in Chronic Lyme patients (MMPs and *0602) was not reported last summer in the NEJM, but Dr. Klempner mentioned these findings at the South County Hospital “Diseases of Summer Conference”, 2001.

The simplest and most economical approach to managing a patient who, in a Lyme endemic area, complains of a chronic fatiguing illness, chronic muscular and perhaps joint paint, and a memory problem, would be to find out why, using diagnostic laboratory analyses. If the patient demonstrates illness behavior, they might have: Illness?

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SUMMARY OF RI TBDs MANAGEMENT OBJECTIVES

A statewide physician education program is clearly necessary to patient management.

Improved surveillance for known and new TBDs, i.e., The development of a sentinel TBDs identification database and DNA ident/sequencing.

Immediate testing improvement measures via the discontinuation of the use of labs that fail to report correctly or use even the current US recommended stains. The development of a patient/pathology database to identify cohorts of patients who would be eligible for neuroprotective regimens such as MMP inhibition, therapeutic kynurenines, or whatever is on the horizon in new antibiotic trials, blood brain barrier, physical, and cognitive rehabilitation after resolution of infections, when or if that becomes possible.

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