# Presentation: 341670

## Antibiotic Treatment-Resistant Lyme Arthritis 

**(TRLA)**

**NIH**
**2/3/04**

- 	**An** **Autoimmune Disease?**

## Clinical Features

**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**

***Ixodes *****tick**

***Borrelia burgdorferi***
***(Bb)***

**Arthritic knee**
**(Single joint)**

***Erythema migrans***

** **
-  Erythema migrans
-   (localized and multiple)
-  Flu-like illness

**Notes:**
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)

## Acute Inflammatory vs. Chronic Arthritis

-  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

-  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)

**Treatment Resistant Lyme Arthritis**
**(TRLA)**

**Notes:**
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 

## Osp Expression during Transmission

**Osp Expression during Transmission**

## Evidence for OspA Upregulation In Vivo

**Later in the course of infection, patients **
**develop strong spiking titers of  OspA antibodies **
**coinciding with periods of arthritis (Kalish 1995).**

***Bb***** transmitted to the host express little or no OspA.**

**If these responses indicate OspA upregulation, **
**then are inflammatory cues stimulating OspA **
**expression by *****Bb*****?**

## Western Blot Analysis of Osp Expression

***In vitro***** vs. *****In vivo *****vs. *****In vivo*****-Inflamed**

***Bb*****, *****in vivo***
**chamber-grown,**
**zymosan-induced **
**inflammation**

## 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**

## Autoimmune basis for TRLA

**Synovial  samples are PCR-negative for *****B.burgdorferi***** DNA after antibiotic treatment****1**
**Increased frequency of HLA-DR4 alleles: HLA-DRB1*0401, 0404 and 0101, 0102 in the affected population****2**

- 1.Carlson et al., *Arthritis & Rheumatism* 42(12) 1999
- 2.Steere et al., *New Engl Journal of Med.*161 1990

**Notes:**
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

## 	Strong T-cell response to OspA:
	1. OspA-reactive T-cells in synovial fluid1
	2. Human LFA-1 candidate T-cell autoantigen2

- 	1. OspA-reactive T-cells in synovial fluid1
- 	2. Human LFA-1 candidate T-cell autoantigen2

**Molecular mimicry with OspA?**

- 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

**Strong B-cell response to OspA**

- 1.Matsumoto et al.*Science *286,1999
- 2. Kim et al. *J Immunol.* 162(5), 1999

## Model

**B**

**T**

**Generation of a strong OspA response**

**Pathogenic Antibodies**

**Molecular Mimicry**

**Structurally related**

**Chronic arthritis**

**OspA**

**B**

**T**

**Antibiotics**

**Notes:**
-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

## 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 
 2222222
 Tightly intermixed B-& T-cells

 Follicular dendritic cells

 Activated germinal center B-cells

 Plasma cells

**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**** **
** ****2222222**
-  **Tightly intermixed B-& T-cells**
** ****Follicular dendritic cells**
** ****Activated germinal center B-cells**
** ****Plasma cells**

- Akin et al., *Infection and Immunity*, 67(1),1998

- Kalish et al., *Infection and Immunity* 61(7), 1993

- Steere et al., *Arthritis and Rheumatism*, .31 (4), 1988

**Antibodies in Lyme Arthritis**

**Notes:**
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

## Isolation of Ig from single B cells

_**Stepwise**_** introduction of somatic mutations**

## Patient ID: DCSample ID: 3-1Rearranged kappa light chain

**Common CDR3**

**Notes:**
Common CDR3

## Patient ID: DCSample ID: 2-1Rearranged gamma chain

## Patient ID: DCSample ID: 2-1Rearranged kappa light chain

**Notes:**
SS subs close to cdr2 and QT sus close to cdr3

## OspA vaccine

- Is it a problem?

## Modification of Main OspA T cell Epitope:  Minimize Binding to HLA-DRB1*0401

**	****	****	**** ****	**
*  ****B.b.***** B31-OspA ****165-173** 	**YVLEGTLTA****	**	    + **6.5**
-   **hLFA-1******** ****L332-340**    		**YV****I****EGT****SKQ****	**	    + **7.3**
*  ****B. afzelii *****OspA ****165-173**	**FT****LEG****KVAN**	    - **1.3**
**  ****FTK-OspA ****165-173** 		**FT****LEG****K****LTA**		    + **0.2**
- 			position   1  2 3 4 5 6 7 8 9

## Acknowledgements

- Allen C. Steere
- B. David Stollar
- Jenifer Coburn

**Theresa Willett**
**Helena Crowley**
**Srimoyee Ghosh**