Antibiotic Treatment-Resistant Lyme Arthritis

(TRLA)

NIH2/3/04

An Autoimmune Disease?

Clinical Features

Early Lyme Disease

Early Disseminated Lyme Disease

• Neurologic – cranial neuropathy,meningitis, radiculoneuropathy• Joint – Acute, inflammatory largejoint 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

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)

A+/C-A-/C-A-/C+A+/C+

1. unfed tick 3. recently infected host

2. feeding tick, fromgut to salivary gland

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 ExpressionIn vitro vs. In vivo vs. In vivo-Inflamed

Bb, in vitrochamber-grown

Bb, in vivochamber-grown

Flagellin, 41 kD

OspA, 31 kD

OspC, 21 kD

Bb, in vivochamber-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 treatment1

• Increased frequency of HLA-DR4 alleles: HLA-DRB1*0401, 0404 and 0101, 0102 in the affected population2

1.Carlson et al., Arthritis & Rheumatism 42(12) 19992.Steere et al., New Engl Journal of Med.161 1990

Strong T-cell response to OspA: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), 20002. Gross et al. Science 281, 1998

A Shift in Paradigm:

1. Linked T-B recognition of autoantigen (GPI) – RA mouse model1. Linked T-B recognition of autoantigen (GPI) – RA mouse model

2. Ectopic germinal centers in RA synovium2. Ectopic germinal centers in RA synovium

Strong B-cell response to OspAStrong B-cell response to OspA

1.Matsumoto et al.Science 286,19992. 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

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 cellsAkin 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 ArthritisAntibodies in Lyme Arthritis

Isolation of Ig from single B cells

Stepwise introduction of somatic mutations

Patient ID: DCSample ID: 3-1

Rearranged kappa light chain

QGISSY A T T Y CQQLNSYPPGermline (L8)

QDISSY A ---3---- CQQFNMYPP1

QSISSY N 2

R

T

R CQQFNMYPP

CDR1 CDR2 CDR3

--------- -c-g-t-Germline (L8)

CDR1 CDR2 CDR3

----11---- -t-t-g-1

2

- t - g-

- t - c-

- g- g- t -

- g- a- t -

---- 11 ----- c- g- - a- g- c-

Nucleotide Sequence Alignment

- g- c- c- a- g

- g- c- c- a- t

- a- a- t - g- g - t - t - g-

1

2

Amino Acid Sequence Alignment

18

23

L8

--- 3----

Common CDR3

Patient ID: DCSample ID: 2-1

Rearranged gamma chain

GFTFSSYW Y V I Y M N A E CARGermline (3-7)

CVR1

2 CMR

1CDR 2CDR 3CDR

GFSLSI YW

GFSLSI YW

------ 8------

-- a- t - g- --------- - gc-Germline (3 - 7)

1CDR 2CDR 3CDR

-- t - a- t - ---- 13 ---- - gt -1

2

- t -

- g-

- c- t -

- c- t -

-- t - a- t - ---- 13 ---- - at -- g- - c- t -

Nucleotide Sequence Alignment

---

---

---

Amino Acid Sequence Alignment

2

1

3−7

19

20

------ 8------

Patient ID: DCSample ID: 2-1

Rearranged kappa light chain

QSISSW A S S Q T CQQYNSYS

QSIDIW T T S K S CQHYNRDS2

QSIDIW T T N K S CQHYNRDS3a

Germline (L12)

T T N K S CQHYNRDS3b QSIDIW

QSIDIW T T S Q S CQHYNRDS1

CDR1 CDR2 CDR3

L12

1

2

3a 3b

Amino Acid Sequence Alignment

9

10

11 11

OspA vaccine

Is it a problem?

Protein Sequence DR binding

B.b. B31-OspA 165-173 YVLEGTLTA + 6.5

hLFA-1 L332-340 YVIEGTSKQ + 7.3

B. afzelii OspA 165-173 FTLEGKVAN - 1.3

FTK-OspA 165-173 FTLEGKLTA + 0.2position 1 2 3 4 5 6 7 8 9

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

Acknowledgements

Allen C. Steere

B. David Stollar

Jenifer Coburn

Theresa WillettHelena CrowleySrimoyee Ghosh