Seronegative Lyme arthritis caused by Borrelia garinii

A case of a female patient suffering from Lyme arthritis (LA) without elevated antibody levels to Borrelia burgdorferi sensu lato is reported. Seronegative Lyme arthritis was diagnosed based on the classic clinical manifestations and DNA-detected Borrelia garinii in blood and synovial fluid of the patient, after all other possible causes of the disease had been ruled out. The disease was resistant to the first treatment with antibacterial agents. Six months after the therapy, arthritis still persisted and DNA of Borrelia garinii was repeatedly detected in the synovial fluid and the tissue of the patient. At the same time, antigens or parts of spirochaetes were detected by electron microscopy in the synovial fluid, the tissue and the blood of the patient. The patient was then repeatedly treated by antibiotics and synovectomy has been performed. Received: 28 August 2001 / Accepted: 1 January 2002     

Frequencies of Borrelia burgdorferi-reactive T lymphocytes in Lyme arthritis

Summary Using a limiting dilution system, frequencies of Borrelia burgdorferi-reactive T cells were determined in the blood and synovial fluid of four patients with chronic Lyme arthritis (LA), one patient with acrodermatitis chronica atrophicans (ACA), two patients with other inflammatory joint diseases, and two healthy individuals. B. burgdorferi-reactive precursor T cells ranged from 1/750 to 1/8 220 in case of LA and ACA patients and from 1/820 to 1/31 400 in case of controls. In vivo activated B. burgdorferi-reactive T cells were almost absent in control subjects. With one exception, they were detected in LA patients at frequencies ranging from 1/1 300 to 1/15 400. Interestingly, even after successful antibiotic therapy of LA patients, similar frequencies of in vivo activated B. burgdorferi-reactive T cells were observed in the peripheral blood, provided that low cell concentrations were used for culture. At higher cell numbers, the fraction of B. burgdorferi-reactive T cells apparently dropped, suggesting regulatory phenomena.     

Detection of Borrelia burgdorferi by DNA amplification in synovial tissue samples from patients with lyme arthritis

Objective. To compare the detection rates of chromosomal flagellin gene from Borrelia burgdorfen in synovial tissue (ST) and synovial fluid (SF) using polymerase chain reaction (PCR) techniques. Methods. B burgdorferi DNA was sought in SF and ST from 12 consecutive patients with Lyme arthritis and from 29 patients with noninfectious diseases (controls). Results. No DNA amplification was observed in samples obtained from the 29 control patients, whereas B burgdorferi DNA was detected in all ST and/or SF samples from the 12 patients with Lyme arthritis. Results from 1 ST sample were not interpretable because of PCR inhibitors. Among the 11 remaining patients, 10 had positive ST samples, whereas only 4 had positive SF samples (P < 0.05). Conclusion. These data suggest that detection of chromosomal B burgdorferi DNA may be more efficient in ST than SF.     

Intracellular persistence ofBorrelia burgdorferi in human synovial cells

To investigate ifBorrelia burgdorferi can persist in resident joint cells, an infection model using cell cultures of human synovial cells was established and compared to the interaction ofBorrelia burgdorferi and human macrophages.Borrelia burgdorferi were found attached to the cell surface or folded into the cell membrane of synovial cells analysed by transmission electron and confocal laser scanning microscopy. In contrast to macrophages, morphologically intactBorrelia burgdorferi were found in the cytosol of synovial cells without engulfment by cell membrane folds or phagosomes.Borrelia burgdorferi were isolated from parallel cultures. Treatment with ceftriaxone eradicated extracellularBorrelia burgdorferi, but spirochetes were reisolated after lysis of the synovial cells.Borrelia burgdorferi persisted inside synovial cells for at least 8 weeks. These data suggested thatBorrelia burgdorferi might be able to persist within resident joint cells in vivo.     

Host metalloproteinases in Lyme arthritis

Objective

: To assess the role of matrix metalloproteinases (MMPs) in cartilage and bone erosions in Lyme arthritis

Methods

We examined synovial fluid from 10 patients with Lyme arthritis for the presence of MMP‐2, MMP‐3, MMP‐9, and “aggrecanase” activity using gelatinolytic zymography and immunoblot analysis. We developed an in vitro model of Lyme arthritis using cartilage explants and observed changes in cartilage degradation in the presence of Borrelia burgdorferi and/or various protease inhibitors.

Results

Synovial fluid from patients with Lyme arthritis was found to contain at least 3 MMPs: gelatinase A (MMP‐2), stromelysin (MMP‐3), and gelatinase B (MMP‐9). In addition, there was evidence in 2 patients of “aggrecanase” activity not accounted for by the above enzymes. Infection of cartilage explants with B burgdorferi resulted in induction of MMP‐3, MMP‐9, and “aggrecanase” activity. Increased induction of these enzymes by B burgdorferi alone was not sufficient to cause cartilage destruction in the explants as measured by glycosaminoglycan (GAG) and hydroxyproline release. However, addition of plasminogen, which can act as an MMP activator, to cultures resulted in significant GAG and hydroxyproline release in the presence of B burgdorferi. The MMP inhibitor batimastat significantly reduced the GAG release and completely inhibited the collagen degradation.

Conclusion

MMPs are found in synovial fluids from patients with Lyme arthritis and are induced from cartilage tissue by the presence of B burgdorferi. Inhibition of MMP activity prevents B burgdorferi–induced cartilage degradation in vitro.

     

Expression of ICAM-1, ICAM-2, NCAM-1 and VCAM-1 by human synovial cells exposed to Borrelia burgdorferi in vitro

The interaction of resident tissue cells with migratory inflammatory cells is essential for the recruitment of immune effector cells to inflammatory sites. The sustained expression of adhesion molecules in the synovium of patients with chronic Lyme arthritis seems to contribute to this chronic inflammation. Whether cell adhesion molecules influence the early steps of Borreliosis is unclear. Therefore, we examined the expression of ICAM-1, ICAM-2, VCAM-1 and NCAM-1 in synovial cells exposed to two different Borrelia burgdorferi sensu stricto strains Geho and B31. The mRNA expression of ICAM-1, ICAM-2, VCAM-1 and NCAM-1 was not changed in synovial cells exposed to B31. Whereas ICAM-2 and VCAM-1 was upregulated, NCAM-1 mRNA was downregulated and ICAM-1 mRNA was unchanged by strain Geho. The ICAM-1 protein expression on the synovial cell surface was downregulated by both strains. Differential regulation of adhesion molecule mRNA, and subsequent high turnover or elevated shedding from the cell membrane may contribute to early pathogenesis in Lyme arthritis.     

Detection of Borrelia burgdorferi by polymerase chain reaction in synovial membrane, but not in synovial fluid from patients with persisting Lyme arthritis after antibiotic therapy

OBJECTIVES—To identify possible sites of bacterial persistence in patients with treatment resistant Lyme arthritis. It was determined whether Borrelia burgdorferi DNA may be detectable by polymerase chain reaction (PCR) in synovial membrane (SM) when PCR results from synovial fluid (SF) had become negative after antibiotic therapy.
METHODS—Paired SF and SM specimens and urine samples from four patients with ongoing or recurring Lyme arthritis despite previous antibiotic therapy were investigated. A PCR for the detection of B burgdorferi DNA was carried out using primer sets specific for the ospA gene and a p66 gene of B burgdorferi.
RESULTS—In all four cases, PCR with either primer set was negative in SF and urine, but was positive with at least one primer pair in the SM specimens. In all patients arthritis completely resolved after additional antibiotic treatment.
CONCLUSIONS—These data suggest that in patients with treatment resistant Lyme arthritis negative PCR results in SF after antibiotic therapy do not rule out the intraarticular persistence of B burgdorferi DNA. Therefore, in these patients both SF and SM should be analysed for borrelial DNA by PCR as positive results in SM are strongly suggestive of ongoing infection.

Keywords: Lyme arthritis; polymerase chain reaction; synovial membrane; synovial fluid     

High levels of inflammatory chemokines and cytokines in joint fluid and synovial tissue throughout the course of antibiotic‐refractory lyme arthritis

Objective

To investigate the possible role of chemokines and cytokines in the pathogenesis of Lyme arthritis.

Methods

Using cytometric bead array and flow cytometry techniques, chemokine and cytokine levels were determined in 65 synovial fluid (SF) samples and 7 synovial tissue (ST) samples from 17 patients with antibiotic‐responsive Lyme arthritis and 35 patients with antibiotic‐refractory Lyme arthritis seen during the past 18 years. In the ST samples, expression of chemokine receptors was measured using immunohistochemistry.

Results

Before or during antibiotic therapy, when the majority of patients had positive polymerase chain reaction (PCR) results for Borrelia burgdorferi DNA, SF from patients with antibiotic‐refractory arthritis contained exceptionally high levels of Th1 chemoattractants and cytokines, particularly CXCL9 and interferon‐γ (IFNγ). Compared with the patients whose arthritis was responsive to antibiotic treatment, those with antibiotic‐refractory arthritis had significantly higher levels of CXCL9 and CXCL10 (both P ≤ 0.001) and CCL3, CCL4, CXCL8, IFNγ, tumor necrosis factor α, interleukin‐1β (IL‐1β), and IL‐6 (all P ≤ 0.01). During the post‐antibiotic period, when the results of PCR for B burgdorferi DNA in SF and ST were uniformly negative, patients with antibiotic‐refractory arthritis continued to exhibit high SF and ST levels of these chemokines and cytokines. In addition, synovial samples showed marked expression of the receptors for T cell or macrophage chemokines, CXCR3 and CCR5.

Conclusion

Patients with antibiotic‐refractory Lyme arthritis have high synovial fluid levels of proinflammatory chemokines and cytokines, especially CXCL9 and IFNγ, throughout the illness. Thus, even when antibiotic treatment reduces or completely clears the infection in these patients, the inflammatory response in synovium persists.

     

Diagnostik und Therapie der Lyme-Arthritis

These guidelines summarize the current evidence for diagnosis and treatment of Lyme arthritis and the most frequent skin manifestations of Borrelia burgdorferi infections. Lyme arthritis is a monoarticular or oligoarticular form of arthritis that typically involves the knee. A positive enzyme-linked immunosorbent assay (ELISA) for IgG antibodies should be followed by an IgG immunoblot. A positive PCR test from synovial fluid adds increased diagnostic certainty. Serum positivity for antibodies to Borrelia burgdorferi without typical symptoms does not justify antibiotic treatment. Oral antibiotic treatment for erythema migrans is recommended using doxycycline, 200 mg once per day for 10–21 days, alternative choices are amoxicillin, cefuroxime and azithromycin. For children below 8 years of age, amoxicillin is recommended. Lyme arthritis can usually be successfully treated with orally administered antimicrobial agents. Doxycycline, 1?×?200 or 2?×?100 mg for 30 days is the antibiotic agent of choice. Amoxicillin (3?×?500–1000 mg) can be alternatively chosen. Patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy should be treated intravenously. In this situation, ceftriaxone at 2 g per day for 14–21 days is recommended. There is no evidence to recommend long-term and combined treatments.     

Induction of experimental allergic arthritis with outer surface proteins of borrelia burgdorferi

Objective. The arthritogenic potential of the cationic outer surface proteins (Osp) from Borrelia burgdorferi was tested in rats. Methods. Water-soluble Osps were prepared by butanol extraction and were administered by intraarticular injection. Tissue injury was assessed by scintigraphy and histology. Results. A mild arthritis was seen in naive rats. Preimmunized animals had more severe, longer lasting bouts of inflammation. Conclusion. The Osps of Borrelia burgdorferi are potent arthritogens in rats. These immunodominant antigens may play a role in the development of Lyme arthritis in humans.     

Lyme Arthritis in a 12-Year-Old Patient after a Latency Period of 5 Years

Summary Lyme arthritis (LA) may be confused with other rheumatic diseases, particularly in the absence of a history of erythema migrans (EM). We report the case of a 12-year-old patient who developed a large effusion of the tight knee joint. The titer for antinuclear antibodies was 1:80 and the test for rheumatoid factor was negative. – Investigations for antibody response to Borrelia burgdorferi demonstrated remarkable elevation of IgG antibody and no specific IgM response. These results were confirmed by immunoblotting reactivity with the bands p83/100, p58, p43, p41, p39, OspA, p30, OspC, p21, and p17. We subsequently learned that the child had suffered a tick bite followed by an EM 5 years earlier and had been treated with trimethoprim/sulfamethoxazole at that time. The patient now was given intravenous ceftriaxone, 2 g daily for 14 days. In the absence of clinical improvement 3 weeks later a knee joint aspiration was performed which resulted in a positive polymerase chain reaction (PCR) test for B. burgdorferi DNA (OspA) in the synovial fluid. The patient fully recovered 2 months later without further treatment. The case indicates that the latency period between EM and onset of LA may last up to 5 years. In addition to serologic test methods, analysis of synovial fluid using PCR may be decisive for making the final diagnosis of LA. Received: April 19, 1999 · Revision accepted: July 5, 1999     

Chlamydia and Borrelia DNA in synovial fluid of patients with early undifferentiated oligoarthritis: Results of a prospective study

Objective

More than 50% of patients with synovitis involving 1–4 joints remain classified as having undifferentiated oligoarthritis (UOA) after 1 year of disease. The clinical presentation is often similar to that of reactive arthritis (ReA) and other spondylarthropathies or to Lyme arthritis. We therefore determined how often Chlamydia trachomatis (Ct) and Borrelia burgdorferi (Bb) can be identified in patients with UOA, by using an extensive laboratory approach.

Methods

We prospectively studied 52 patients with UOA who presented at an early synovitis clinic in a region highly endemic for Lyme disease. Patients were examined by standardized clinical and immunoserologic procedures. Synovial fluid was screened for the presence of Ct and Bb DNA by polymerase chain reaction (PCR). Urine was tested for Ct DNA by ligase chain reaction, and serum was tested for Ct antibodies by enzyme‐linked immunosorbent assay and Bb antibodies by hemagglutination test and Western blotting. PCR results in the UOA patients were compared with the results in cohorts of patients with definite rheumatoid arthritis (RA), Lyme arthritis, and Chlamydia‐induced arthritis (CIA).

Results

In the synovial fluid of 9 of 52 patients with UOA (17%), we found Ct DNA, and in 6 of the 52 patients (12%), Bb DNA was found. The frequency of bacteria‐specific DNA was 50% (7 of 14) in CIA patients and 69% (11 of 16) in patients with Lyme arthritis. No Bb or Ct DNA was found in the synovial fluid of the 31 RA patients.

Conclusion

With optimized PCR protocols, it is possible to detect considerable levels of Bb and Ct DNA in the synovial fluid of patients with UOA. Although the presence of bacterial DNA does not unequivocally prove its etiologic significance, we suggest that at least one‐third of patients with UOA may have a form of ReA that involves asymptomatic primary infection.

     

Characteristics and clinical outcomes after treatment of a national cohort of PCR-positive Lyme arthritis

ObjectivesTo describe the clinical and microbiological characteristics and outcomes after antibiotic treatment of a national cohort of patients with Lyme arthritis confirmed by PCR testing on synovial fluid and by serology, when available.MethodsUsing the French National Reference Center for Borrelia database, patients with a positive PCR on synovial fluid for Borrelia were identified. Patient clinical and biological characteristics were reviewed from patient records. Long-term outcomes after treatment were studied through a questionnaire and with follow-up data.ResultsAmong 357 synovial fluid testing by PCR between 2010 and 2016, 37 (10.4%) were positive for Borrelia. Patients’ median age was 36 years (range 6–78) with 61% of men and 28% patients under 18. The presentation was monoarticular in 92% and the knee was involved in 97%. Contrary to the Borrelia species repartition in European ticks, B. burgdorferi sensu stricto was the most prevalent species found in synovial fluid (54%) followed by B. azfelii (29%) and B. garinii (17%). Antibiotic treatments were mainly composed of doxycycline (n = 24), ceftriaxone (n = 10) and amoxicillin (n = 6), for a median duration of 4 weeks (range 3–12). Despite a properly conducted treatment, 34% of patients (n = 12) developed persistent synovitis for at least 2 months (median duration 3 months, range 2–16). Among those, 3 developed systemic inflammatory oligo- or polyarthritis in previously unaffected joints with no signs of persistent infection (repeated PCR testing negative), which mandated Disease-Modifying Antirheumatic Drugs (DMARD) introduction, leading to remission.ConclusionIn France and contrary to ticks ecology, Lyme arthritis is mainly caused by B. burgdorferi sensu stricto. Despite proper antibiotic therapy, roughly one third of patients may present persistent inflammatory synovitis and a small proportion may develop systemic arthritis. In such cases, complete remission can be reached using DMARD.     

Western blot band intensity analysis. Application to the diagnosis of lyme arthritis

Objective. To determine the usefulness of quantitative band-intensity analysis of Western blots for the diagnosis of Lyme arthritis. Methods. IgG Western blots for antibodies to Borrelia burgdorferi were performed on sera from 39 patients with Lyme arthritis, 30 patients with syphilis, 50 patients with connective tissue diseases, and 10 healthy individuals. Band positions and band intensities were calculated using a computerized image analysis system. Results. Lyme arthritis patients had more bands and higher-intensity bands than did non-Lyme patients. The presence of at least 2 bands of moderate to high intensity (>40 optical units) or at least 5 bands of lower intensity (>20 optical units) was over 90% sensitive and 100% specific for the diagnosis of Lyme arthritis. A 60-kd band was present in all Lyme arthritis patients. The presence of an 83-, 39-, 21-, or 18-kd band was highly specific for Lyme arthritis. Conclusion. Band intensity analysis increases the objectivity and accuracy of Western blot interpretation for the diagnosis of Lyme arthritis.     

Antibody responses to Borrelia burgdorferi in patients with antibiotic‐refractory,antibiotic‐responsive,or non–antibiotic‐treated lyme arthritis

Objective

To compare the pattern of antibody responses to Borrelia burgdorferi in patients with antibiotic‐refractory, antibiotic‐responsive, or non–antibiotic‐treated Lyme arthritis as an indirect measure of spirochetal persistence or eradication.

Methods

At least 3 serial serum samples from 41 patients with antibiotic‐refractory arthritis and 23 patients with antibiotic‐responsive arthritis, and samples from 10 non–antibiotic‐treated, historical control patients were tested for IgG reactivity with B burgdorferi sonicate and 4 differentially expressed outer surface lipoproteins of the spirochete, by enzyme‐linked immunosorbent assay.

Results

Among non–antibiotic‐treated patients, antibody titers to B burgdorferi antigens remained high throughout a 2–5‐year period of arthritis. In contrast, in patients with antibiotic‐responsive arthritis, in whom joint swelling usually resolved during a 1‐month course of oral antibiotic therapy, the median antibody titers to most of the spirochetal antigens remained steady or decreased during the first 1–3 months after starting antibiotic therapy. In patients with antibiotic‐refractory arthritis, who had persistent joint swelling for a median duration of 10 months despite 2–3 months of oral or intravenous antibiotics, the median titers to most antigens increased slightly during the first 1–3 months. However, by 4–6 months after starting antibiotic therapy, reactivity with all antigens declined similarly in both antibiotic‐treated groups.

Conclusion

Whereas the antibody titers to B burgdorferi remained high in non–antibiotic‐treated patients, the titers declined similarly 4–6 months after starting therapy in patients with antibiotic‐responsive or antibiotic‐refractory arthritis, suggesting that synovial inflammation persisted in patients with antibiotic‐refractory arthritis after the period of infection.

     

LYME PERICARDITIS LEADING TO TAMPONADE

We report the case of a 62-yr-old man who presented with Lymepericarditis leading to cardiac tamponade shortly followed byan arthritis. IgM and IgG antibodies to Borrelia burgdorferiwere demonstrated in serum by indirect immunofluorescence. Borreliaburgdorferi was demonstrated and identified in pericardial fluidby indirect immunofluorescence using serum from a patient withproven Lyme disease and by a monoclonal antibody immuno-goldsilver stain. Spirochetes were also found in synovial biopsiesusing a silver stain. The tamponade was treated with pericardiocentesis;the arthritis was treated with intravenous ceftriaxone (2 gonce daily) for 14 days. The patient recovered completely withindays of commencing treatment. This case report demonstratesthat borrelial infection may lead to pericarditis and cardiactamponade. KEY WORDS: Borrelia burgdorferi infection, Arthritis, Pericarditis, Tamponade     

Local immunoglobulin production in synovial tissue in patients with Lyme borreliosis

A study was made to find out whether immunoglobulins are produced locally in synovial tissue in patients with Lyme borreliosis. Synovial fluid specimens from six patients with Lyme borreliosis were compared with those from 25 patients with rheumatoid arthritis, psoriatic arthritis, unspecified oligoarthritis or arthrosis (control group). Agarose electrophoresis revealed local oligoclonal IgG and IgM bands in the synovial fluid of two patients with Lyme borreliosis, but no local bands were observed in the control group. An index for local synthesis of immunoglobulins in synovial fluid was calculated in analogy with the IgG index for cerebrospinal fluid. The two patients with Lyme borreliosis in whom oligoclonal bands were seen in the synovial fluid showed the highest synovial fluid IgG indices and the highest concentrations of specific IgG antibodies against Borrelia spirochetes in synovial fluid. The presence of local oligoclonal immunoglobulin bands and a high synovial fluid IgG index suggest that immunoglobulins are produced locally within the synovial tissue in some patients with Lyme borreliosis. The increase in immunoglobulins may be a response to a local invasion of Borrelia spirochetes or may represent an immune reaction which continues after the spirochetes no longer are viable.     

The polymerase chain reaction for the detection of borrelia burgdorferi in human body fluids

Objective. To analyze clinical fluids for the presence of Borrelia burgdorferi DNA using the polymerase chain reaction (PCR). Methods. We utilized a modified, nested PCR to detect the presence of Borrelia DNA in 99 samples of serum, urine, cerebrospinal fluid (CSF), or synovial fluid obtained from 44 patients with various stages of Lyme disease and 47 control subjects. Primer specificity was corroborated by examining 2 DNA data banks, testing against DNA from other organisms, and confirming results with a second set of nested primers. Results. Nested PCR was capable of detecting DNA from fewer than 10 organisms in 1 ml of fluid. The specificity of this technique was 96.4%, with a sensitivity of 76.7%. Although the specificity was uniformly high, the sensitivity was dependent upon the body fluid being tested: CSF 100%, urine 100%, synovial fluid 80%, and serum 59%. The rate of false-positive results was 3.6%. Conclusion. These data demonstrate the potential utility of PCR in confirming the clinical diagnosis of Lyme disease as well as providing insight into the pathogenesis of various stages of this disorder.