Disparity between serological reactivity to Borrelia burgdorferi and evidence of past disease in a high-risk group.

A prevalence study of past Lyme borreliosis in persons with outdoor occupations was done. Consenting individuals (n = 302) were administered a questionnaire eliciting demographic and occupational data and a clinical history, and were asked to donate a serum specimen for detection of antibodies to Borrelia burgdorferi by enzyme-linked immunosorbent assay (ELISA), immunoblotting, and borrelia inhibition assays, and for detection of potentially cross-reactive antibodies. Of 302 individuals, 77 (25%) had reactive antibodies detected by ELISA. Of these 302 individuals, 44 (15%) met the criteria of the Centers for Disease Control and Prevention for serological reactivity as evidenced by immunoblotting, and 70 (23%) had inhibitory activity. Through the clinical criteria employed, only 11 individuals with serological reactivity had prior illness compatible with Lyme borreliosis. Higher ELISA absorbances were positively correlated with age and duration of outdoor occupation. The results from three serological assays and the lack of reactivity to potentially cross-reactive infectious agents indicate that serological reactivity was due to exposure to B. burgdorferi. The disparity between serological reactivity and the clinical evidence of Lyme borreliosis suggests cumulative exposure to a nonpathogenic form of B. burgdorferi.

Lyme borreliosis: laboratory considerations.

The laboratory is frequently the primary source for making the diagnosis of Lyme borreliosis when the symptoms are vague and the clinical hallmarks are missing. However, the temptation to interpret the laboratory results out of context from the clinical history and presentation should be avoided since the laboratory tests for evidence of B. burgdorferi infection can also be problematic. These problems have included sensitivity/specificity problems, lack of standardization of both methology and interpretation, and lack of routine direct evidence (ie culture) testing. These problems are discussed as well as possible solutions. It should be noted that meaningful results can usually be obtained from these tests if caution is used in their interpretation and the clinical symptomatology, history, and examination are integrated with the laboratory results.

Occurrence of antibodies to Borrelia burgdorferi in patients with nonspirochetal subacute bacterial endocarditis.

OBJECTIVE: To determine the prevalence and specificity of antibodies to Borrelia burgdorferi in patients with nonspirochetal subacute bacterial endocarditis and assess whether increased levels of antibodies to B. burgdorferi were attributable to rheumatoid factor. DESIGN: Retrospective case-control study. SETTING: Urban referral center in an area devoid of infected ticks as a source of endocarditis sera. PATIENTS: Sera from 30 consecutive patients with culture-proven subacute endocarditis between 1979 and 1981 were compared with 30 control sera collected between 1989 and 1990. In addition, sera from 20 consecutive patients with rheumatoid arthritis who were positive for rheumatoid factor were collected between 1991 and 1992. Sera were compared with a convenience sample from 15 patients who met the criteria for Lyme disease. MEASUREMENTS: Antibodies to B. burgdorferi were assessed by enzyme-linked immunosorbent assay (ELISA) and immunoblot analysis. IgM rheumatoid factor was quantified using solid-phase radioimmunoassay or latex agglutination techniques. RESULTS: Thirteen of 30 patients with endocarditis (43%) compared with 3 of 30 normal controls (10%) had increased levels of antibodies to B. burgdorferi (P < 0.01). Of these 13 patients, only 1 had an immunoblot consistent with previous infection. The others had nonspecific immunoblots: 5 showed isolated 60-kd reactivity; 1 patient had isolated 41-kd reactivity; and 6 had no bands of reactivity. Immunoblots of the 3 controls with increased antibodies showed only isolated 41-kd reactivity. Thus, the specificity of the B. burgdorferi antibody test in patients with endocarditis was only 60% (95% CI, 42% to 78%), compared with 90% (CI, 79% to 100%) in controls. No correlation was noted between IgM rheumatoid factor and antibodies to B. burgdorferi in patients with endocarditis (r = 0.2; P > 0.2). Only 1 of 20 patients with rheumatoid arthritis without known bacterial infections had antibodies to B. burgdorferi. CONCLUSIONS: Although a positive ELISA test for B. burgdorferi may be a "true positive," a positive serologic test alone does not ensure that the clinical problem is due to Lyme borreliosis. Cross-reactive antibodies to shared epitopes between B. burgdorferi and the endocarditis organism may account for the high false-positive results.

An acute form of T gamma lymphoproliferative disease presenting with massive splenomegaly--importance of immunophenotyping for diagnosis.

We describe a case of T gamma lymphoproliferative disease (T gamma LPD) which presented in an uncustomary acute onset in an adult with massive splenomegaly. Morphologically the cells represented monocytic leukemia. Karyotyping and equivocol special stain results suggested hairy cell leukemia. Gene rearrangement indicated a T lymphocytic malignancy. Immunocytochemistry stains were not definitive. Immunophenotyping by flow cytometry defined the cells as consistent with T gamma LPD (CD45+, CD56+, CD2+, CD3+, CD11b+, and CD38+; some cells CD8+; and CD57-). Although the cells did not have spontaneous activity, which is often the situation for most cases of T gamma LPD, the cells could be partially induced with exogenous interleukin 2 to exhibit in vitro cytotoxicity against a natural killer lymphocyte-susceptible target cell line (K562) but not a lymphocyte-activated killer target cell line (HEPG2). This report hopefully continues to increase the awareness of T gamma LPD as well as demonstrates an unusual acute form which could have been misdiagnosed unless a multidisciplinary approach, especially including flow cytometric immunophenotyping, was used to evaluate the patient.

Nonprotein antigens of Borrelia burgdorferi.

Preparative thin-layer chromatograms of chloroform-methanol extracts of Borrelia burgdorferi (B31) sonicates showed four fractions (Rf values of 0.84, 0.81, 0.66 and 0.61) that stained with iodine vapors, orcinol, or phospray, suggesting the presence of lipid-, carbohydrate-, and phosphorus-containing compounds. Sera from patients with Lyme disease showed IgM or IgG antibody reactivity to hydrophobic fractions, designated F1 and F2, in both early and late stages of the disease. Lack of constitutive amino acids in these fractions was shown by protein, amino acid, and peptide detection analyses. Sera from patients with syphilis, systemic lupus erythematosus, and antiphospholipid syndrome reacted to one or both of the fractions. Adsorption of sera from Lyme disease patients with intact B. burgdorferi resulted in significantly different pre- and postadsorption patterns of reactivity by whole cell ELISA, whereas adsorption with F1 and F2 resulted in similar pre- and postadsorption patterns. These fractions may not be present in aqueous whole cell or whole cell lysate ELISA antigens or in immunoblots.

In vitro enhancement of natural cytotoxicity by atrial natriuretic peptide fragment 4-28.

The presence of atrial natriuretic peptide (ANP) binding sites in the thymic cortex, medulla, and splenic white pulp suggests that this peptide may have immunoregulatory activity. We examined the effect of ANP on human natural killer (NK) cell activity. ANP significantly augmented NK cell cytotoxicity after twenty-four hours of incubation but had no effect on NK activity after short-term incubations of one hour. In addition, atrial natriuretic peptide did not effect the expression of natural killer or T cell surface markers. This study demonstrates that atrial natriuretic fragment 4-28 enhances natural killer cell activity.

Cerebrospinal fluid immune complexes in patients exposed to Borrelia burgdorferi: detection of Borrelia-specific and -nonspecific complexes.

We analyzed cerebrospinal fluid (CSF) from 32 patients with neurological symptoms and evidence of Borrelia burgdorferi infection (29 were seropositive as determined by enzyme-linked immunosorbent assay, 2 were cell-mediated immune positive, and 1 had been seropositive as shown by enzyme-linked immunosorbent assay 9 months previously). CSF immune complexes were found in 22 (69%) of 32 patients; in 18, there was sufficient sample to isolate immune complexes. By enzyme-linked immunosorbent assay, isolated immune complexes from 10 of these 18 patients contained antibody specific for B. burgdorferi antigens. The isotypes were IgG (n = 8), IgM (n = 3), and IgA (n = 2). By immunoblot, these antibodies were directed against B. burgdorferi 41-kDa antigen and occasionally against the 33- and 17-kDa antigens. Anti-B. burgdorferi IgM was present in patients with acute neurological symptoms, was predominantly complexed rather than free, and decreased with clinical recovery in the one serial study. Three patients were nonreactive for free CSF antibodies, but had complexed antibodies to the organism. The preliminary finding of specific B. burgdorferi components in immune complexes in CSF suggests an active process triggered by the organism, even in the absence of other CSF abnormalities.

Lyme borreliosis-associated encephalopathy.

Borrelia burgdorferi infection (Lyme disease) is frequently accompanied by CNS dysfunction. Particularly common is a mild confusional state, the mechanism of which is unknown. Since CNS infection with B burgdorferi is usually accompanied by intrathecal synthesis of specific antibody, we studied CSF in 73 patients referred for presumed CNS Lyme, manifested primarily as this confusional state. Of 30 seropositive patients evaluated, only 5 had intrathecal antibody production. Seven seronegative patients had positive cell-mediated immune responses to B burgdorferi in the peripheral blood; none had antibody production in the CSF. Of the remaining 36 patients referred with this diagnosis despite negative serologic studies, none had compelling evidence of CNS infection by this criterion. We conclude that CNS infection with B burgdorferi does occur in a small proportion of seropositive patients with this confusional state but is extremely uncommon among seronegative individuals with this clinical presentation.

Sequestration of antibody to Borrelia burgdorferi in immune complexes in seronegative Lyme disease.

To find out whether apparent seronegativity in patients strongly suspected of having Lyme disease can be due to sequestration of antibodies in immune complexes, such complexes were isolated and tested for antibody to Borrelia burgdorferi. In a blinded analysis the antibody was detected in all 10 seronegative Lyme disease patients with erythema chronicum migrans (ECM), in none of 19 patients with other diseases, and in 4 of 12 seronegative patients who probably had Lyme disease but had no ECM. These findings were confirmed by western blot, which also showed that immune complex dissociation liberated mainly antibody reactive to the 41 kD antigen and sometimes antibody to an approximate 30 kD antigen. Complexed B burgdorferi antibody was also found in 21 of 22 (95%) of seropositive patients with active disease, 3 additional seronegative but cell mediated immune reactive patients, and 3 other seronegative patients who eventually became seropositive. Apparent B burgdorferi seronegativity in serum immune complexes may thus be due to sequestration of antibody in immune complexes.

Natural killer lymphocyte blast crisis of chronic myelogenous leukemia.

We describe for the first time a case report documenting a chronic myelogenous leukemia (CML) patient who developed a blast crisis of natural killer (NK) lymphocytes. Many of the blasts exhibited large granular lymphocytic (LGL) morphology. Single parameter immunophenotyping results determined that the granulated as well as the agranulated blast cells were NK lymphocytes (CD45, NKH1, CD2, LEU 17, and CD16 positive; CD3, CD8, and LEU 7 negative). Dual parameter flow cytometric testing also determined that some of the blasts expressed the CD11b and CD11c markers as reported for some types of NK lymphocytes. Approximately 10% of the cells were in the S phase of the cell cycle as determined by a modified Vindelov DNA content analysis test and may theoretically reflect some of those cells expressing CD11b and CD11c. The cells did not express in vitro NK lymphocyte functional activity against a K562 target and therefore similar to other reported cases of presumably immature NK lymphocytic leukemias. The NK lymphocyte blast crisis was successfully treated with vincristine and prednisone. The patient's disease eventually relapsed and transformed to a progenitor stem cell before she died (CD45, 13, CD38, and CD34 positive). The flow cytometric immunophenotyping results contributed significantly as an important adjunct in determining the appropriate diagnosis, helping to select the type of therapy, and monitoring the patient with this unusual type of blast crisis.

Inverted T helper/T suppressor lymphocyte ratio is not a reliable indicator of coexistent HIV infection in the presence of carcinoma: report of a patient with ovarian carcinoma and inverted TH/TS ratio.

Patients with non-HIV (Human Immunodeficiency Virus) related cancers may also have HIV infection. Inverted peripheral blood lymphocyte T helper/T suppressor ratios with selective loss of T helper cells may be used as a clinical screening test for HIV infection in these patients since they may be seronegative for retrovirus infection early in the course of infection. We describe a case in which carcinoma alone appeared to induce systemic changes that resembled coexistent HIV infection. Many of these abnormalities, including inverted TH/TS ratio with selective loss of T helper cells, improved in the immediate postoperative period, indicating that HIV infection was not present. We conclude then, that diagnosis of HIV infection should not be made without more definitive evidence of its presence than an inverted TH/TS ratio in a patient with carcinoma.

Seronegative Lyme disease. Dissociation of specific T- and B-lymphocyte responses to Borrelia burgdorferi.

The diagnosis of Lyme disease often depends on the measurement of serum antibodies to Borrelia burgdorferi, the spirochete that causes this disorder. Although prompt treatment with antibiotics may abrogate the antibody response to the infection, symptoms persist in some patients. We studied 17 patients who had presented with acute Lyme disease and received prompt treatment with oral antibiotics, but in whom chronic Lyme disease subsequently developed. Although these patients had clinically active disease, none had diagnostic levels of antibodies to B. burgdorferi on either a standard enzyme-linked immunosorbent assay or immunofluorescence assay. On Western blot analysis, the level of immunoglobulin reactivity against B. burgdorferi in serum from these patients was no greater than that in serum from normal controls. The patients had a vigorous T-cell proliferative response to whole B. burgdorferi, with a mean ( +/- SEM) stimulation index of 17.8 +/- 3.3, similar to that (15.8 +/- 3.2) in 18 patients with chronic Lyme disease who had detectable antibodies. The T-cell response of both groups was greater than that of a control group of healthy subjects (3.1 +/- 0.5; P less than 0.001). We conclude that the presence of chronic Lyme disease cannot be excluded by the absence of antibodies against B. burgdorferi and that a specific T-cell blastogenic response to B. burgdorferi is evidence of infection in seronegative patients with clinical indications of chronic Lyme disease.

A murine IgM monoclonal antibody binds an antigenic determinant in outer surface protein A, an immunodominant basic protein of the Lyme disease spirochete.

A hybridoma cell line formed by the fusion of the P3x63-Ag8.653 myeloma cell line with splenocytes from BALB/c mice immunized with Borrelia burgdorferi produced an IgM monoclonal antibody (mAb-11G1) with kappa-light chains which detected an antigenic determinant in a major spirochetal protein of m.w. approximately 31,000, also known as outer surface protein A (OSP-A). Apparent saturation was reached in approximately 35 min with 34 ng of mAb-11G1 binding to 5 X 10(7) spirochetes giving an estimated 4.8 X 10(2) IgM molecules per spirochete and thus a minimum of 480 binding sites per organism. Enzymatic digestion studies suggest that the antigenic determinant to mAb-11G1 is contained within the peptide chain of OSP-A as binding could be eliminated by treatment of the spirochetes with proteinase K, Pronase and pepsin (100 to 200 micrograms/ml of enzyme) but not by trypsin or bromelain treatment. Periodate oxidation as well as mixed and endoglycosidase treatment of the spirochetes did not alter the binding of mAb-11G1. Two-dimensional gel electrophoresis of whole spirochetal cell lysates disclosed that OSP-A is a heterogeneously charged basic protein with an apparent isoelectric point range from 8.5 to 9.0. Amino acid analysis of OSP-A showed a 10% lysine component which could provide the basic nature to the protein. OSP-A with the intact antigenic determinant for mAb-11G1 can be found in the urine of hamsters experimentally infected with B. burgdorferi.

Cellular immune response in Lyme disease: the response to mitogens, live Borrelia burgdorferi, NK cell function and lymphocyte subsets.

Although some manifestations of Lyme disease may be secondary to the presence of B. burgdorferi, the immune system appears to play a significant role in the clinical manifestations of the disease. The humoral response is well characterized, however the cellular response remains poorly defined. To further define cellular immunity in Lyme disease, the responses of lymphocytes from patients with active Lyme disease were assessed to Con a, PHA, PWM, tetanus toxoid, and whole live B. burgdorferi. In addition, the natural killer cell (NK) function of these patients was assayed. As compared to the controls the lymphocyte response to Con A was reduced and the response to PHA was increased. There was a significant proliferative response to B. burgdorferi in all patients with no response in the controls. The responses to PWM and tetanus toxoid were not different in the two groups. NK cell function in the patients with active disease was reduced as compared to the normal controls and patient's who were not clinically active. We conclude that there is a significant alteration in cellular immunity in active LD consistent with a defect in the induction of suppressor cells leading to a vigorous humoral response.

An IgE response to spirochete antigen in patients with Lyme disease.

Most but not all Lyme disease patients produce specific IgE antibodies to Borrelia burgdorferi. Development of IgE antibodies paralleled that of other immunologic classes and appeared to be directed against a polypeptide with a molecular weight of 41,000. Total serum IgE levels in Lyme disease patients were usually within the normal range in all stages of the disease. However, highly elevated total serum IgE in certain patients were not correlated to any particular disease stage nor to specific antibody titers. Spirochetes and spirochetal sonicates in high concentration induced release of histamine from basophils derived from both patients and controls. At lower antigen concentrations, histamine release could be induced only from basophils derived from patients. Synovial fluids from patients with Lyme arthritis contained IgE but only negligible amounts of histamine.

Selective inhibition of natural killer activity by the monoclonal antibodies OKT10 and VEP10 at the single cell level.

The monoclonal antibodies, VEP10 and OKT10, which have been shown to recognize determinants on human natural killer (NK) cells, inhibit large granular lymphocyte (LGL) NK activity against K562, MOLT4, and CEM tumor target cells in the single cell conjugate agarose assay. Inhibition of NK activity by monoclonal antibodies was expressed independently of effector-target cell binding, as inhibitory activity could be demonstrated when the monoclonal antibodies VEP10 and OKT10 were added to preformed conjugates or to the LGLs and targets prior to the binding event. In addition, this inhibition was exerted on the effector cell and not the target cell since VEP10 and OKT10 did not react with determinants on K562 target cells. Furthermore, the 4F2 monoclonal antibody, which reacted with determinants on the LGL and all of the targets used, effected no inhibition of NK activity. Inhibition of killing by OKT10 and VEP10 was specific to endogenous NK activity since the same antibodies did not inhibit antibody-dependent cellular cytotoxicity (ADCC), mixed lymphocyte-generated NK, or cytotoxic T lymphocyte (CTL) activities.

Potentiation of the cytolytic activity of peripheral blood monocytes by lymphokines and interferon.

Human peripheral blood monocytes obtained by EDTA-reversible adherence to plastic surfaces precoated with autologous serum can rapidly lyse a variety of tumor cells. That the effector cells in this system are indeed monocytes has been demonstrated (1). Using a short-term (3 to 4 hr) 51Cr-release assay and the single cell conjugate cytotoxic assay, we studied the effects of lymphokine-rich supernatants containing gamma-interferon and partially purified fibroblast interferon on the monocyte cytolytic activity. Overnight incubation of the monocytes in fetal bovine serum-containing medium resulted in a relatively small decrease in cytotoxic activity compared to the one obtained with monocytes incubated in autologous serum. The addition of lymphokines or interferon under both incubation conditions resulted in augmented activity as measured in the 51Cr-release assay. However, the proportions of binding and cytotoxic monocytes, determined in the single cell conjugate assay, did not increase. These results suggest that augmented activity is not due to recruitment of inactive cells. Kinetics studies of tumor cell lysis indicate the increase in killing efficiency is probably due to both an increase in the rate of killing and in the recycling ability of the cytotoxic cells. Using the conjugate/agarose technique, we also demonstrated that excess tumor cells could impair the lytic machinery of freshly isolated monocytes, whereas monocytes treated with lymphokines or interferon partially lost their sensitivity to this inhibitory effect. The ability of tumor cells to impair the lytic machinery of monocytes could be one of the mechanisms by which tumors escape immunosurveillance.