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FACULTÉ de
MÉDECINE
de STRASBOURG
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Lyme borreliosis
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from bench Lto bedside
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Jaulhac
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National reference center for Borrelia
Laboratoire de Bactériologie
Strasbourg
EA 7290 Groupe borréliose de Lyme
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Commercial relationships disclosure
• Siemens
• BioMérieux
• Virbac
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• BD, Copan
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Lyme borreliosis: an arthropod-borne disease
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Taxonomy of ticks
Chelicerata
Sous-phylum
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Arachnida
Class
Sous-class
Super-order
With courtesy of F. Schramm
Acari
Parasitiformes
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Order
Super-family
Family
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Arthropoda
Phylum
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Ixodida
Ixodoidea (ticks)
Argasidae
(soft ticks)
Nuttalliellidae
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Ixodidae
(hard ticks)
Ixodinae
Family
Sous-family
Genus
Taxonomy of ticks
Chelicerata
Sous-phylum
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Arachnida
Class
Sous-class
Super-order
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Super-family
Genus
With courtesy of F. Schramm
Acari
Parasitiformes
Order
Family
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Arthropoda
Phylum
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Ixodida
Ixodoidea (ticks)
Argasidae
(soft ticks)
Ornithodoros
Nuttalliellidae
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Ixodidae
(hard ticks)
Ixodinae
Ixodes
Family
Sous-family
Genus
Ixodes
ricinus
Taxonomy of Borrelia species
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Borrelia species involved in Lyme borreliosis
With courtesy of F. Schramm
Borrelia species involved in Lyme
borreliosis
Ixodes
pacificus
Ixodes
scapularis
Ixodes persulcatus
Ixodes
ricinus B. afzelii
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B. burgdorferi sensu stricto
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B. garinii
B. burgdorferi sensu stricto
B. spielmanii
B. valaisiana
B. lusitaniae
B. bavariensis
B. bissettii
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Lyme borreliosis incidence
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65 000 cases/year
30 000 cases/year
CDC data
2003-2012
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Algeria
Marocco
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Gordillo-Perez G et coll,
Emerg Infect Dis 2007
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France - Germany
40 / 100 000 hab.
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Austria - Slovenia
130 / 100 000 hab.
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3 500 cases/year
Hubálek Z, Curr Probl
Dermatol 2009
Portugal - Italy
< 1 / 100 000 hab.
Tunisia
Mayne PJ, Clin Cosm
Investig Dermatol 2012
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Natural history of Lyme borreliosis
Infected tick bite
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Early disseminated
phase
Late disseminated
phase
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Localized phase
No transmision
Aborted infection
Transmission
Lyme borreliosis
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Erythema migrans
neurologic articular
Lymphocytoma
Acrodermatitis
Chronicum
Atrophicans
cardiac
Chronic
manifestations
ocular
Skin and Lyme borreliosis
Skin
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Brisson et al., PlosOne 2011
- Skin : a key Interface by its immunity ?
- Immunoprivileged site for Borrelia (Fibroblasts) ?
- Filter for the selection of virulent strains of Borrelia ?
- Role of the tick in the transmission ?
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Tick saliva and skin
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HOVIUS J., J. Invest Derm.,, 2009;
J. Hovius, 2011
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Marchal et al., J Invest Derm, 2009
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Tick saliva and skin
Mouse host
collagen
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Feeding pit
Tick biting
pieces
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L. Bockenstedt, 2012
Radolf, 2012
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Tick saliva and resident skin cells
In vitro models
1- Keratinocytes (epidermis)
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Inhibition of antimicrobial peptide secretion and of
danger signals (antialarmin effect)
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Marchal et al., Infection and Immunity, 2011
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2- Fibroblasts (dermis)
0h
24h
Lytic effect of SGE -> induction of a lesion in the
skin within Borrelia is inoculated ? (feeding pit)
Murine model
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C3H/HeN
Kinetic of skin inflammation :
5h, 24h, 3d, 5d, 7d, 15 and 30d
Detection by qRT-PCR : TNF-, defensins, cathelicidin…
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Immunosuppressive effect of tick saliva
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AMPs : Cramp (cathelicidin), mBD3 et mBD14 (defensins)
Kern et al., Vector Borne and Zoonotic diseases, 2011
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Borrelia infection in Europe
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Lyme borreliosis
95%
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84%
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(H. Fahrer et al., 1998)
5%
2%
14%
Localized infection
(EM, LCB)
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Bite by infected tick (1% - 25%)
Aborted course infection
Seroconversion only
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Stage I
8%
92%
Disseminated manifestations
Stage II
99%
Recovery
Recovery
< 0,5%
Stage III
< 0,5%
Chronic manifestations
(P. Oschmann et al, 1999)
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Diagnostic and biological tools
 Culture :
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 specific medium, slow growth (2 to 8 weeks…),
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need for a dark-field microscope and trained
observer
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 Sensitivity : 50-80% (EM biopsies), <20 % (CSF,
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 PCR :
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ACA biopsies) (Lebech, 2000)
EM and CSF : same sensitivity as culture (Aguero-
Rosenfeld, 2005, Lebech 2000), easier and quicker
Lyme arthritis, ACA : sensitivity ++ (50-90%)
(Nocton, 1994, Jaulhac, 1996, Schmidt, 1997)
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Diagnostic and biological tools
Indirect Methods mainly :
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 Usually two-tier testing with a sensitive first tier (ELISA ++)
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 if EIA (+) or (±) -> immunoblots as confirmation only,
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 IgG IB (+) ≤ 6 weeks for
disseminated manifestations
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Two-tier testingD
using 2 ELISA as effective ?
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for IgG and/or IgM (Stanek, 2013)
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(Wormser 2013)
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Diagnostic and biological tools
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 IgM (+) ≠ recent or active infection
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 Detection of intrathecal production of Bbsl antibodies :
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best biological marker for neuroborreliosis (Blanc, 2007 ; Mygland,
2010)
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Alternative
methods:
T-lympho
proliferation, Ag detection, CD57
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 CSF/serum antibody index

(Stanek, 2012 ; Dessau, 2014)
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About good tu
use
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of laboratory
tests
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Case 1: use on patients of a population
with high seroprevalence (10%)
Specificity = 95 %
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Test +
9.8
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- Sensitivity = 98 % - Seroprevalence = 10%
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Prevalence = 1% n = 1000
Disease
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No Disease
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Total
59.3
Test -
0.2
940.5
940.7
Total
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990
1000
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NPV = 99.97 %
PPV = 16.5%
 Need for judicious use to ensure a high PPV of the test
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Case 2 : use on patients of a population
with mild seroprevalence (2 %)
Specificity = 95 %
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Sensitivity = 98 %
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seroprevalence = 2% Prevalence = 0.2%
Disease
Test +
1.96
Test -
0.04
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Disease
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49,9
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Total
51.86
O 948,1
948.14
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Total
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998
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1000
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b-> NPV = 99.99 % and PPV = 3.78% …
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So, what to do?
Stop serological testing …
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Improve the analytical quality of the tests :
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Sp ≥ 0.99 et Se : 0.98 -> research is necessary
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Improve practical use of the tests :
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compatibleIclinical
: need for case definition
D pictures
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criteria
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Improve pre-test value of the tests by testing only
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Clinical case definitions for diagnosis of Lyme
borreliosis in Europe
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EUCALB group :
11 participants
(clinicians-biologists-entomologists-epidemiologists)
8 countries (A, D, DK, F, Ir, S, Slo, UK)
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Recommendations based on literature analysis
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(G. Stanek et al. CMI 2011)
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Lyme borreliosis: diagnostic criteria
Clinical
manifestation
compatible with
Serological evidence as essential
Erythema
migrans
None
Acrodermatitis
chronicum
atrophicans
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Borrelial
lymphocytoma
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Seroconversion or serology (+)
Hign level of specific (WB) IgG
antibodies
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Laboratory evidence as
supporting
PCR and/or culture on skin
biopsy for atypical lesions
- PCR and/or culture on skin
biopsy for atypical lesions
- Histology
- PCR and/or culture on skin
biopsy for atypical lesions
- Histology
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Lyme borreliosis: diagnostic criteria
Clinical
manifestation
compatible with
Neuroborreliosi
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Serological evidence as essential
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Pleocytosis
AND
intrathecal synthesis (may fail in
the first weeks)
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Laboratory evidence as
supporting
- EM concomitant or recent
EM
- PCR and/or culture on CSF
- Intrathecal synthesis of
total IgG, IgM or IgA
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Lyme borreliosis: diagnostic criteria
Clinical manifestation
compatible with
Lyme arthritis
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(High) level of specific (WB) IgG
antibodies
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Ocular
manifestations
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Specific (WB) IgG antibodies
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Serological evidence as essential
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Laboratory evidence as
supporting
- PCR and/or culture on
synovial fluid and/or tissue
- Inflammatory synovial fluid
- EM concomitant or recent
EM
- PCR and/or culture of
ocular fluid and/or CSF
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Borrelia miyamotoi infection
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First cases (n=46) reported in 2011 (AE Platonov, EID, 2011)
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- Viral-like illness in late spring-summer : fever > 39°C, headache,
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fatigue, ± chills,± myalgias, ± arthralgias, ± nausea
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- Febrile relapse in 11% of cases - Specific PCR on blood (+),
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- EM in 9% (co-infection?)
- B burgdorferi sl IgM serology (+) (co-infection?)
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- Jarisch-Herxheimer reaction in 15%
HGA-like disease : fever > 39°C, headache, fatigue, myalgias,
arthralgias.
No febrile relapse. (Krause, NEJM, 2013).
Treatment : doxycycline < ceftriaxone? (HR Chowdri, 2013)
Specific PCR on blood (+),
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Borrelia miyamotoi neuro-infection
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Two case reports of severely immunocompromised patients
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Meningo-encephalitis with progressive cognitive
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decline, walking impairment
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(J Hovius, Lancet, 2013 and JL Gugliotta, NEJM, 2013)
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Borrelia miyamotoi neuro-infection
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Two case reports of severely immunocompromised patients
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Meningo-encephalitis with progressive cognitive
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decline, walking impairment
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Pleocytosis, elevated protein values in CSF
Dark-field examination of CSF (+), culture (-)
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Specific PCR on CSF (+)
B. burgdorferi sl serology negative
(J Hovius, Lancet, 2013 and JL Gugliotta, NEJM, 2013)
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