Dr. Sam T. Donta
is
helping IDSA remember what "We-Don't-Know
Disease" is.
Med Clin North Am. 86:341-9, 2002
LATE AND CHRONIC LYME DISEASE
-
Sam T. Donta, MD* (Scroll
down for the full text of the article-
See his assessment of Chronic Lyme, and
the failure rate of CDC's testing
criteria.)
Sam T.
Donta is an infectious diseases and
bacterial toxins expert. See
MEDLINE for his 80 publications,
including Gulf War Illness studies.
Dr.
Donta's US Patent for Borrelia
burgdorferi Neurotoxin
http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=6,667,038.PN.&OS=PN/6,667,038&RS=PN/6,667,038
Donta:
BbTox1 BB0755:
http://www.sciencenews.org/sn_arc99/6_12_99/note4ref.htm
Donta: Comparison : Lyme,
Fibromyalgia, Chronic Fatigue Syndrome,
Gulf War Illness
Lyme
Foundation Conference Abstract, 1999:
http://www.lyme.org/conferences/99_abstract.html
Mark J. Cartwright, Ph.D.
Boston University Medical Center
Boston VA Medical Center
88 East Newton Street, E-639
Boston, MA 02118
A Novel Toxin (Bb Tox 1) of
Borrelia burgdorferi
Mark J. Cartwright, Ph.D.*, Suzanne E.
Martin, Ph.D. and Sam T. Donta, M.D.
The mechanisms responsible
for many of the symptoms of Lyme disease
remain to be delineated. Because many of
the symptoms involve the nervous system,
we postulated that the Lyme spirochetes
produce a toxin that interferes with
normal neurophysiological function. We
have identified and cloned a gene of B.
burgdorferi which encodes a protein that
is a neurotoxin.
Initially, degenerate
primers were designed to highly
conserved regions within various toxin
groups. These primers were used for
amplification of DNA extracted from B.
burgdorferi strain 2591 to identify
genes that express proteins analogous to
existing toxins. Degenerate primers
designed to the highly conserved
catalytic domains of diphtheria and
pertussis toxins yielded an
amplification product. The product was
cloned, sequenced, and subsequently
identified in The Institute of Genomic
Research (TIGR) database as BB0755, a 37
kD protein of unknown function. The full
length gene for BB0755 was cloned,
expressed and purified using epitope
tags in the pET30a expression system,
and the resultant recombinant protein
renamed Bbtox1. Using the synthetic
target agmantine, Bbtox1 exhibited ADP-ribosyltransferase
activity. No ADP-ribosyltransferase
activity was detected using elongation
factor 2 as the target. In tissue
culture, Bbtox1 affected the morphology
(rounding) of Y1 mouse adrenal cells and
C6 rat glial cells. Bbtox1 induced cell
death in both Y1 and C6 cells. C6 glial
cells responded to Bbtox1 in a dose and
time dependent manner. Brefeldin A, an
inhibitor of the trans-golgi network,
accelerated the onset of action of
Bbtox1 an Y1 adrenal cells.
The effects of Bbtox1 are
consistent with a mechanism of action
similar to that of botulinum C2 and
other cytoskeletal toxins. Studies are
underway to identify the cellular target
of Bbtox1 and its role in Lyme Disease.
In addition, a homologous gene in
Treponema pallidum of undefined function
is being analyzed to determine if it
codes for a toxin similar to Bbtox1.
----------------
Med Clin North Am. 86:341-9, 2002
LATE AND CHRONIC LYME DISEASE
Sam T. Donta, MD*
* Professor of Medicine, Divisions of
Infectious Disease and BioMolecular
Medicine, Director, Lyme Disease Unit
Boston University Medical Center,
Boston, Massachusetts
Corresponding author for proof and
reprints:
Sam T Donta MD, Boston Medical Center,
650 Albany Street-8th floor, Boston MA
02118, (617) 638-6017, (617) 638-6009
(fax)
page 1
INTRODUCTION
Following the introduction of Borrelia burgdorferi into the skin
by an infected tick,
the organisms begin to spread both
locally and systemically. Several
days typically elapse before the
appearance of the first sign of
infection, i.e. erythema chronicum
migrans (ECM), or other less typical
rashes (29). The rash occurs in
fewer than 50% of patients with Lyme
Disease (8,10), but the true incidence
of Lyme Disease in the absence of a rash
is unknown.
The occurence of multiple rashes is
indicative of systemic spread of the
organisms. Multiple rashes usually
do not occur until 2-4 weeks following
the initial tick bite. This is the
same time period during which the
organisms are being disseminated to
their target tissues and cells.
The incidence of multiple rashes was
initially reported to occur in as many
as 50% of cases, but has been much less
common in the last two decades, probably
because of frequent use of antibiotics.
Approximately 4-6 weeks following the
tick bite, the first systemic symptoms
(other than multiple rashes) occur in
some patients, usually in the form of
"flu" (15). These symptoms include sore
throat, severe headaches and neck aches,
and severe fatigue. Rhinitis,
sinusitis, and cough are not usually
present, distinguishing this "flu" from
other influenza-like illnesses.
While the Lyme-flu symptoms can
spontaneously resolve, patients can
experience recurrent "flu".
Soon after the onset of Lyme-flu,
fatigue, arthralgias and/or myalgias may
begin. The arthralgias appear to
primarily involve the large joints (i.e.
knees, elbows, hips, shoulders),
although smaller joints (e.g. wrists,
hands, fingers, toes) may be involved
(29). Some patients
page 2
may have actual arthritis, often
oligoarticular, more frequently in men
than in women. Earlier estimates
were that 50-75% of patients who
developed late Lyme Disease had
arthritis, but more recent analyses
suggest that the incidence of actual
arthritis in patients with late or
chronic disease is closer to 25% (33).
Neck stiffness is common. The pains are
described as severe, jumping from joint
to joint, and may be present for only
short periods of time. Pain in the teeth
or in the temporal-mandibular joints is
not uncommon. Rib and chest pains
occur frequently, leading some patients
to seek care in emergency rooms and
urgent care centers for evaluation of
possible cardiac disease.
Frequently as well are paresthesias such
as burning, numbness and tingling, and
itching. Some patients experience
crawling sensations, vibrations, or
electric shock-like sensations.
Rarely is there any actual palsy of the
affected areas, making this much more of
a neurosensory, rather than a motor,
disease.
In addition to paresthesias, purely
neurological symptoms and signs include
headaches, an aseptic meningitis, facial
nerve (Bell's) palsy, and encephalitis
or encephalopathy that may be manifested
by cognitive dysfunction, especially
short-term memory loss, and psychiatric
symptoms such as panic, anxiety, or
depression (14). The aseptic
meningitis and Bell's palsy tend to
occur within the first few months
following the tick bite, but may also
occur as part of reactivation disease
(9).
Other symptoms may include fevers
(usually low grade, but may be high),
sweats (which may be severe), visual
dysfunction (described primarily as
blurriness, but can include optic
neuritis or uveitis), tinnitus,
sensitivity to sounds, or hearing loss.
Shortness of breath, palpitations and/or
tachycardia, abdominal pains, diarrhea
or irritable bowel, testicular or pelvic
page 3
pain, urinary frequency or urgency,
dysequilibrium, and tremors are also
common symptoms. Some of the
dysautonomia symptoms can be disabling.
Rarer symptoms may relate to
panniculitis and hepatitis. Rarely
as well are congenital and intrautero
infection; when this occurs, it appears
to be similar to toxoplasmosis and
rubella, i.e. a primary infection during
the first trimester. The
occurrence of optic neuritis or uveitis
raises other possibilities such as
multiple sclerosis, but can be part of
Lyme Disease.
The course of the disease can best be
described as persistent, but with
periods of worsening symptoms, often
cyclical every few weeks or monthly.
Especially disconcerting are persistent
symptoms such as headaches and fatigue
that can be exhausting. Some
patients are more symptomatic than are
others, which may reflect
genetically-determined differences in
responsiveness or extent of infection.
The disease does not appear to be
progressive or destructive, as with
cancer, nor is it fatal, but can be very
debilitating.
The incidence of asymptomatic infection
has not been adequately delineated.
There appear to be substantial numbers
of patients who remain asymptomatic, but
reactivate their disease a number of
months or years later, following trauma,
pregnancy, a medical illness for which
an antibiotic is prescribed, or other
stresses, including psychological
stresses (9). The Lyme OspA
vaccine has appeared to reactivate Lyme
Disease in a number of individuals who
knew, but some who did not know, they
had prior Lyme Disease (11). The
mechanisms responsible for the
reactivation of the disease have not
been defined, but may include both
molecular mimicry and underlying
infection.
page 4
PATHOGENESIS
The pathogenesis of Lyme Disease remains
to be defined. From the available
studies, it
would appear that the organisms are
trophic for either the endothelial cells
of the blood vessels that serve the
nervous system or for the glial or
neural cells themselves (4,24,26,31).
Accumulating evidence supports the
hypothesis of a persistent infection as
the cause of the persisting or relapsing
symptoms (26,31). Whether
molecular mimicry is involved in the
pathogenesis of some of the symptoms
remains more speculative (18). Although
arthritis can occur in Lyme Disease, the
organisms can only rarely be found in
synovial tissue. And as many of
the arthralgias that occur in the
disease do not respond well to
antiinflammatory agents, the
disease is more of an infectious
neuropathy than an actual invasion of
synovial or bursal tissues.
DIAGNOSIS
The diagnosis rests heavily on the
clinical symptomatology. When
there are clinical signs, e.g. rash,
aseptic meningitis, optic neuritis,
arthritis, an appropriate differential
diagnosis must be pursued. On a
clinical basis, "chronic fatigue
syndrome" or "fibromyalgia" cannot be
readily distinguished from chronic Lyme
Disease. Indeed, accumulating
experience suggests that Lyme Disease
may be a frequent cause of fibromyalgia
or chronic fatigue (8,12). Other
microbes have been proposed as causative
agents of multisymptom disorders that
are being termed chronic fatigue and
fibromyalgia, especially more recently
recognized mycoplasma species such as M.fermentans and M.genitalium,
but definitive proof of cause and effect
has not yet been
page 5
established (6, 23).
There has been an attempt to separate
“late” Lyme Disease from “chronic” Lyme
Disease, the former being manifested by
objective signs of arthritis or
neurological disease (32). Some have
denied the existence of chronic disease,
inferring that these patients suffer
from psychiatric disorders; some have
used the term “chronic” to mean
post-treatment disease (“post-Lyme”),
assuming that the infection has been
treated, and the remaining symptoms are
in the same realm as those patients who
have “fibromyalgia” or “chronic fatigue”
(27, 30). These assertions are
speculative and remain unproven.
That chronic Lyme Disease actually
exists, and is likely the most common
form of the disease, is supported by
epidemiologic studies demonstrating that
30-50-% of treated and untreated
patients go on to develop a multisymptom
disorder typical of, and
indistinguishable from, fibromyalgia and
chronic fatigue (1, 28). As with other
multisymptom disorders, chronic Lyme
Disease is a clinical syndrome
consisting of fatigue, arthralgias and
myalgias, and other nervous system
dysfunction (7). Furthermore, the
results of treatment studies appear to
support the hypothesis that persistent
infection is responsible for the chronic
symptoms. It is likely that Lyme
Disease will serve as a useful model for
other chronic multisymptom disorders.
Whether the pathogenesis of “late” Lyme
Disease differs from that of the chronic
form of the disease remains to be
established.
Routine laboratory tests are usually
normal in Lyme Disease. The ESR is most
often normal, distinguishing it from
some of the inflammatory disorders such
as rheumatoid arthritis or lupus.
Culture of the borrelia is possible
early in the disease, usually from
biopsies of the erythema migrans rash;
however, most laboratories are not
capable of culturing the organisms.
page 6
The only currently available useful
laboratory tests are the immunologically-based
ELISA and Western blot assays. The
recommendation was made in 1994 to have
a two-tiered testing system in which the
Western Blot would only be done on
ELISA-positive samples (5). The
recommendation was based primarily on
the results obtained from patients with
arthritis (13), did not take into
account the chronic form of the disease,
and was made despite the lack of
consistent reproducibility of results
between various laboratories (2, 16).
The ELISA has been shown to be an
unreliable test in many patients with
Lyme Disease, both in early infection
and later disease (8, 10). Part of
the reason for the lack of sensitivity
of the ELISA is the use of whole
organisms, resulting in a high amount of
background absorbance. After
correction for the high background, only
a small percentage of positives can be
detected. Because Western blots separate
the proteins of the borrelia, specific
reactions can be visualized, and more
accurate interpretations of the results
made. Over 75% of patients with
chronic Lyme Disease are negative by
ELISA, while positive by Western blot
(8, 10). Patients with
oligoarticular arthritis may be more
likely to have robust IgG responses and
positive ELISA tests and IgG Western
Blots (13).
By Western blot analyses, the first
immunologic reactions in Lyme Disease
are to the 41kd flagellar protein, and
the 23kd OspC protein. Typically, at the
time of the ECM rash, there will be an
IgM reaction against the 23kd and 41kd
proteins, and no IgG reactions.
Within the next few weeks, the IgM
reactions persist, sometimes accompanied
by less specific reactions against 60kd
and 66kd proteins, and IgG reactions are
now visible against the 23kd and 41kd
proteins. Thus, in the presence of
an appropriate clinical picture, the
immunoreactivity against the 23kd and
41kd proteins appear to be diagnostic of
Lyme Disease.
page 7
Whereas the 41kd protein is not unique
to B. burgdorferi, the 23kd
protein appears to be unique. Also
apparently unique proteins of B.burgdorferi are the 31kd (Osp A)
and 34kd (Osp B) outer membrane
proteins, and the 35kd, 37kd, 39kd, and
83/93kd proteins. Reactions to the
31kd proteins are not usually seen until
after a year or more following the onset
of disease. Not all patients with
symptoms for more than one year,
however, display reactions to the outer
membrane proteins.
Most symptomatic patients have specific
reactions on IgM Western blots (8,10).
With resolution of the symptoms, the IgM
reactions disappear or attenuate.
IgG reactivity may
continue to be present with resolution
of symptoms, but it typically also
disappears or attenuates with successful
therapy. There are some patients
(20%) who have symptoms, but whose
Western blots are negative (8,10).
If the borrelial organisms remain
intracellular, with no extracellular
reemergence once established, this could
explain the absence of additional or
persistent immune responses.
PCR (Polymerase Chain Reaction) is a
highly sensitive means to detect
microbial DNA or RNA, and it was hoped
that this technique would find an
important role in the diagnosis of Lyme
Disease. Thus far, however,
despite the specificity of this method,
borrelial DNA or RNA has not been
reliably detected in the blood, urine,
or spinal fluid of patients with early
or later forms of Lyme Disease, findings
again supportive of an intracellular
reservoir for the borrelia.
It should be possible to develop a
better, highly specific ELISA for Lyme
Disease, using recombinant 41kd, 23kd,
31kd and/or 34kd (and perhaps other B.burgdorferi-specific) proteins.
Currently, however, the Western blot
assay is the most reliable immunologic
test.
page 8
TREATMENT
In vitro,
B. burgdorferi is sensitive to
several antibiotics (20,25). This
assumption is complicated, however,
because of the long incubation times
needed to determine minimum inhibitory
concentrations (MIC), as the borrelia
have doubling times of 20-24 hrs.
With these limitations, the results of a
few studies show minimum bactericidal
concentrations (MBC) to
penicillin of 8ug/ml, ampicillin:
2ug/ml, tetracycline: 1-2ug/ml,
doxycycline: 2ug/ml, ceftriaxone:
0.5ug/ml, cefotaxime: 0.5ug/ml,
cefuroxime: 1-2ug/ml, cefixime: 8ug/ml,
erythromycin: 0.5ug/ml, clarithromycin:
0.5ug/ml, azithromycin: 0.5ug/ml, and
ciprofloxacin: 4ug/ml.
At the time of the first rash, any one
of several antibiotics appear to be
effective, if given for 2 weeks,
according to several published studies.
However, a number of patients so treated
developed subsequent symptoms of
arthralgias, fatigue, and paresthesias,
with positive Western blots, who were
then successfully treated with longer
courses of antibiotics (8, 10).
The recommendation at this time,
therefore, is that tetracycline,
doxycycline, or amoxicillin be used for
1 month if ECM is the only symptom of
Lyme Disease.
Once any other symptoms appear, the
treatment of Lyme Disease for only 2-4
weeks is associated with frequent
failures and relapses (8, 10). Our
initial experience suggested that a 3
month course of tetracycline was
associated with a higher success rate
(8). In patients with symptoms
present for more than six months, the
treatment course may need to be more
prolonged, or a retreatment course of
varying length may be needed. In
patients with symptoms for more than a
year, 12-18 months may be needed for
complete resolution of symptoms.
The rationale for a longer treatment
course is based on extensive
observations (8,10), plus the analogy
page 9
to the longer treatment courses required
for tuberculosis, leprosy, Q fever, and
certain fungal
diseases. With Lyme Disease, the
slow growth rate and metabolic activity
of the borrelia would seem to correlate
with the need for longer treatment
periods.
Once treatment is initiated for patients
beyond the earliest signs of infection,
their symptoms frequently increase
during the first several days, or even
for the first several weeks of
therapy. For patients with
preexisting symptoms of more than a few
months, relief of any of
their symptoms may not occur until after
4-6 weeks of therapy (8, 10).
Typically, there are short periods of
relief, followed by relapsing or
migrating symptoms; with continued
therapy there are longer symptom-free
periods. Some arthralgias may
require 3 months or more to resolve, and
fatigue may be the last symptom to
disappear.
The preference for tetracycline evolved
because of the large number of failures
that were noted in patients who had been
on ampicillin and doxycycline. Patients
generally had some response to
doxycycline, but it was usually not
complete, nor long-lasting.
Tetracycline may be more effective than
doxycycline simply because of the
greater dose, i.e., 100mg of doxycycline
twice daily is not equivalent to 500mg
of tetracycline three times daily; also,
doxycycline is highly protein-bound,
compared to tetracycline, which could
limit the availability of free drug to
diffuse into tissues and cells.
Some physicians use doxycycline at doses
of 300-400mg daily to try to achieve a
successful result. A strict
comparison between doxycycline and
tetracycline has not yet been made.
Minocycline has also been used by some
physicians, with varying success, but
faces the same issues of dosage and
protein binding.
Of the beta lactams used for the
treatment of Lyme Disease, the most
efficacious appears to be ceftriaxone.
In limited comparitive trials,
cefotaxime appears to be equally
efficacious, and
page 10
high-dose IV penicillin may also be
effective. In early Lyme Disease,
oral amoxicillin is as
effective as doxycycline. In later
disease, many failures are noted,
despite the use of up to 3 grams of
amoxicillin daily, with probenicid.
Cefixime would also not appear to be
effective therapy. Cefuroxime
axetil has been evaluated only in the
treatment of early Lyme Disease, and
appears comparable to doxycycline.
Limited reports of its use in later Lyme
Disease have not shown it to be
efficacious.
The role of the newer macrolides in the
treatment of Lyme Disease needs further
assessment. Erythromycin has been
regarded as ineffective, despite its
good in vitro sensitivities.
Azithromycin has been reported to be
less effective in the treatment of early
Lyme Disease than amoxicillin (21).
Some physicians use clarithromycin and
azithromycin in higher dosages and for
longer periods of time, but there have
been no reports of greater success with
these drugs than with the tetracyclines
or beta-lactams. In our
experience, all macrolides are effective
when combined with a lysosomotropic
agent, especially hydroxychloroquine
(see below) (10).
In evaluating the possible factors, it
would appear that antibiotics that can
achieve intracellular concentrations and
activity are the most efficacious drugs.
The results of studies in Klempner’s
laboratory using a tissue culture model
of borrelia infection demonstrated that
ceftriaxone was incapable of eradicating
intracellular organisms (17); similar
experiments in Raoult’s laboratory using
an endothelial cell model demonstrated
that tetracycline and erythromycin were
effective, but beta lactam antibiotics
were not (3). These results
are in line with our experience that the
tetracyclines and macrolides achieve the
greatest success. In contrast to
beta lactams, antibiotics of the
tetracycline and macrolide classes are
capable of good intracellular
penetration. Experience with the
macrolide antibiotics has been
disappointing,
page 11
however, when compared with its in vitro
activities against the Lyme borreliae,
and with the
established efficacy of macrolides
against other intracellular parasites
such as chlamydia, legionella,
mycobacterium-avium intracellulare, and
toxoplasma. If, though, the Lyme
borreliae reside in intracellular
vesicles that are acidic, the macrolides’
activity would be sharply decreased at
the lower pH. This is in contrast
to the tetracyclines, which are active
at acid pH; even so, the activity of
doxycycline was shown to be further
increased by increasing the pH. In
a tissue culture model of ehrlichia
infection, the use of lysosomotropic
agents such as amantidine, NH4Cl, and
chloroquine increased the killing of
intracellular organisms by doxycycline
(22). Based on those studies, and
the hypothesis that late Lyme Disease
symptoms are due to persisting
intracellular infection, we have been
successfully treating patients using the
combination of a macrolide and
hydroxychloroquine (10).
As regards "CNS" disease, there is no
evidence that ceftriaxone is more
successful than either the tetracyclines
or the combination of macrolide and
hydroxychloroquine; if our presumption
that the pathogenesis of the disease
involves the localization of the
borrelia to the endothelial cells of the
blood vessels serving the nervous system
or to glial or neural cells is correct,
then one would not need to have a drug
that can cross the blood-brain barrier
to be effective. Indeed, the
tetracyclines can cross the blood-brain
barrier to some extent, and were used
when initially introduced into clinical
medicine for the treatment of
meningitis, with some success.
Macrolide antibiotics do not cross the
blood-brain barrier, but have been
effective in treating other CNS
infections (eg toxoplasmosis), and in
our experience have been effective in
reversing the neuropsychiatric symptoms
and signs (eg SPECT scans) of Lyme
Disease (10). With regard to the
issue of bactericidal vs
bacteristatic effects, any such effect
in vivo has not
page 12
been demonstrated. Finally, there
have been no reports showing any change
in antibiotic
resistance patterns during the course of
treatment. Ultimately, the
determination of efficacy of therapy
depends on the clinical response.
FUTURE DIRECTIONS
The diagnosis and treatment of Lyme
Disease have been hampered by less than
adequate diagnostic tests and inadequate
comparisons of antibiotic regimens.
Specific antigen-based ELISA tests
should result in greater specificity,
but sensitivity of any tests based on
measurements of the host immune response
might still be of limited value if the
borrelia remain intracellular. Most
useful would be the development of tests
that can determine the presence and
extent of any residual borreliosis.
In the therapy of Lyme Disease,
double-blind, placebo-controlled and
comparitive trials are needed to answer
the questions relating to duration and
class of antibiotic therapy. The
apparent failure of a regimen of one
month of IV ceftriaxone, followed by two
months or oral doxycyline, to improve
the outcomes of patients with chronic
Lyme Disease (19) was not surprising,
based on prior observations that neither
regimen used for a limited duration was
capable of yielding patient improvement
(8,10,33). Additional trials are
needed to evaluate whether longer
durations of treatment, using
tetracycline itself, or the novel
combination of macrolide and
lysosomotropic agent, would be proven
effective treatments.
page 13
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10.. Donta ST. Treatment of chronic Lyme
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