Biomarkers of REAL DISEASE



http://www.actionlyme.org/BIOMARKERS.htm

This represents part of Part II of the RI Tick Borne Diseases
Management Plan (2002)

(Caution: Do not say these big words in front of a psychiatrist.)


MARKERS OF PATHOPHYSIOLOGY

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 four different LPS
preparations were adjusted to induce the same levels of TNF-alpha
release as seen with 10 µg of protein per ml of Borrelia lysate. The
release of the cytokines TNF-alpha , IFN-gamma , G-CSF, and IL-10
induced by endotoxins from S. enterica serovar Abortusequi (200 pg/ml),
E. coli (10 ng/ml), K. pneumoniae (100 pg/ml), and S. enterica serovar
Enteritidis (50 pg/ml) was uniform in blood from healthy volunteers
(Fig. 3), suggesting that different endotoxins share a leukocyte
activation principle. However, a pronounced difference was seen between
the four LPS preparations and the Borrelia lysate: at concentrations
which induced the same TNF-alpha release as 10 µg of protein per ml
of Borrelia lysate, endotoxins induced much more IFN-gamma than
Borrelia lysate did. Instead, Borrelia lysate induced a 5- to
10-fold-higher release of the anti-inflammatory cytokines IL-10 and
G-CSF than the LPS preparations did. The lysates from 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 release predominantly of the
proinflammatory cytokine IFN-gamma while Borrelia lysate is a

stronger inducer of the anti-inflammatory cytokines IL-10 and G-CSF.
Such an inverse cytokine induction pattern demonstrates that the
immunostimulatory components of B. burgdorferi differ from 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.

Internet Mental Health (www.mentalhealth.com) copyright © 1995-2000 by
Phillip W. Long, M.D.



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@xxxxxxxxxxxx



"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?



---
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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