1. Antibiotic Treatment-Resistant Lyme Arthritis
(TRLA)
An Autoimmune Disease?
NIH
2/3/04

2. Clinical Features Arthritic knee Late Lyme Disease
(Single joint)
Ixodes tick
Borrelia burgdorferi
(Bb)
Erythema migrans
Erythema migrans
(localized and multiple)
Flu-like illness
Early Lyme Disease
Early Disseminated Lyme Disease
Neurologic – cranial neuropathy,
meningitis, radiculoneuropathy
Joint – Acute, inflammatory large
joint arthritis
Carditis
Late Lyme Disease
Neurologic – peripheral
neuropathy,
encephalopathy
Chronic arthritis
LD progresses thru distinct clinical phases – early lyme disease (EM and flu like illness)  early dissemnated lyme disease (systemic toxicity like fever, chills, secondary skin lesions, cardiac, neurological and joint involvement) late lyme diseasethis is just in genetically susceptible indiv. (chronic inflammation of jts, as well as nervous system)

3. Acute Inflammatory vs. Chronic Arthritis
Develops after a prolonged period of
latency/minimally symptomatic disease
Defined as one year or more of persistent
joint inflammation, usually the knee
Does not subside in response to antibiotic
therapy
Correlates with the development of a strong
immune response to OspA (Outer Surface
Protein A)
Early attacks - within weeks to a few
months after disease onset
Sudden pain, swelling with massive
effusions
Mostly intermittent
Remits after a few days/weeks
sometimes without antibiotic therapy
Experience recurrent attacks in same joint. 3 or fewer joints involved overall. In minority of patients, infection can be controlled by host immune response. Majority are cured by antibiotics. But in a minority of patients, the illness becomes chronic
Treatment Resistant Lyme Arthritis
(TRLA)

4. Osp Expression during Transmission
1. unfed tick
2. feeding tick, from
gut to salivary gland
3. recently infected
host
A+/C-
A-/C-
A-/C+
A+/C+

5. Evidence for OspA Upregulation In Vivo
Bb transmitted to the host express little or no OspA.
Later in the course of infection, patients
develop strong spiking titers of OspA antibodies
coinciding with periods of arthritis (Kalish 1995).
If these responses indicate OspA upregulation,
then are inflammatory cues stimulating OspA
expression by Bb?

6. Western Blot Analysis of Osp Expression
In vitro vs. In vivo vs. In vivo-Inflamed
Bb, in vivo
chamber-grown,
zymosan-induced
inflammation
Bb, in vitro
chamber-grown
Bb, in vivo
chamber-grown
Flagellin, 41 kD
OspA, 31 kD
OspC, 21 kD

7. Prolonged Bb infection for the development of TRLA
Antibiotic treatment in the first couple of weeks after exposure eliminates development of TRLA
Antibiotic treatment later on has no effect
=> Initial exposure to spirochetes required

8. Autoimmune basis for TRLA
Synovial samples are PCR-negative for B.burgdorferi DNA after antibiotic treatment1
Increased frequency of HLA-DR4 alleles: HLA-DRB1*0401, 0404 and 0101, 0102 in the affected population2
Bb rarely cultured from SF/tissue, DNA readily detected. Oral/iv/both antibiotics for a median of 8 weeks. Median of 7 mo from therapy to surgery. All patients had some kind of knee swelling. Pcrs done on both tissue and fluid. Can detect 1-10 bb in spiked samples, but not in real ones. [OspA & OspB: plasmid encoded; Flagellar protein: chromosome
encoded]
1. Joint inflammation may persist after the apparent eradication of spirochetes with therapy
2. Within a HLA-DR4 population, Osp-reactive patients had a significantly longer duration of arthritis, post-treatment, than Osp non-reactive patients
3. Esp in dr4 patients. So a dr4 patient who’s seropositive for ospA has a significantly ihgher arthritis duration than a sero-neg patient of same haplo.
Say – historically, the first correlation with the shift was made wrt to dev of the response
1.Carlson et al., Arthritis & Rheumatism 42(12) 1999
2.Steere et al., New Engl Journal of Med

9. Molecular mimicry with OspA?
Strong T-cell response to OspA:
1. OspA-reactive T-cells in synovial fluid1
2. Human LFA-1 candidate T-cell autoantigen2
1.Meyer et al. PNAS 97(21), 2000
2. Gross et al. Science 281, 1998
A Shift in Paradigm:
1. Linked T-B recognition of autoantigen (GPI) – RA mouse model
2. Ectopic germinal centers in RA synovium
1.Matsumoto et al.Science 286,1999
2. Kim et al. J Immunol. 162(5), 1999
Strong B-cell response to OspA

10. Generation of a strong OspA response Pathogenic Antibodies
Model
Generation of a strong OspA response
Antibiotics B T
OspA
Structurally related
-migration  development of a strong innate response to Bb, the adaptive response picks up  spirochetal clearance.
OspA response develops late in the course of disease. Most people treated with antibiotics will go on to clear disease. However, subset of patients, the arthritis persists after apparent clearance of the pathogen.
We hypo. That b-T cells that got activated activated during the original inflammatory insult persist in the lesions, receive inappropriate activatation signals from autoantigen.
Favorite model is the linked B-T recogntion of a molecular mimic of OspA  pathogenic antibodies  mediate joint damage
Tihs model would be the closest to the mathis model; also would explain both the ospA ab titers as well as the hla-dr restirction of trla
Molecular Mimicry B T
Pathogenic Antibodies
Chronic arthritis

11. Antibodies in Lyme Arthritis
1. Increased Titers of OspA antibodies
IgG response to OspA develops later in the course of infection
High titers of OspA antibodies coincide with periods of maximal arthritis
Mark the transition from episodic to chronic arthritis
Persist after treatment
2. Germinal centers in inflamed synovium
Tightly intermixed B-& T-cells
Follicular dendritic cells
Activated germinal center B-cells
Plasma cells
In LD lit., historically, antibody reactivity to various bb proteins during the disease and attempted to make correlations with the clinical course and outcome. Historically, most of the early studies followed antibody reactivity to various bb proteins during the disease and attempted to make correlations with the clinical course and outcome. Observation that Hla-dr specificity same as RA and the prevailing view that chronic arthritides are mainly t-cell mediated. Most work, esp in lab focussed on charac t-cell responses to ospA and linkage with autoimmunity, molecularly mimicry etc. at the t-cell level. Like RA, trla is a chronic arthritic disease -
C1q binding used as marker for active disease – essentially a read-out for levels of complement fixing immune complexes.
Gradual shift/accumulation of this activity in SF, as arth more chronic – makes sense given that bb has tropism for the joints and initiates a local immune response
Kalish et al., Infection and Immunity 61(7), 1993
Akin et al., Infection and Immunity, 67(1),1998
Steere et al., Arthritis and Rheumatism, .31 (4), 1988

12. Isolation of Ig from single B cells
Stepwise introduction of somatic mutations

13. Patient ID: DC Sample ID: 3-1 Rearranged kappa light chain
Common CDR3
Common CDR3

14. Patient ID: DC Sample ID: 2-1 Rearranged gamma chain

15. Patient ID: DC Sample ID: 2-1 Rearranged kappa light chain
SS subs close to cdr2 and QT sus close to cdr3

16. OspA vaccine
Is it a problem?

17. Modification of Main OspA T cell Epitope: Minimize Binding to HLA-DRB1
Protein Sequence DR binding
B.b. B31-OspA YVLEGTLTA
hLFA-1a L YVIEGTSKQ
B. afzelii OspA FTLEGKVAN
FTK-OspA FTLEGKLTA
position

18. Allen C. Steere B. David Stollar Jenifer Coburn
Acknowledgements
Theresa Willett
Helena Crowley
Srimoyee Ghosh
Allen C. Steere
B. David Stollar
Jenifer Coburn