Pitfalls and Benefits of Serological Diagnosis of Lyme Borreliosis From a Laboratory Perspective

Lajmska borelioza (LB) je bolest koju u Europi najčešće uzrokuju borelije kompleksa Borrelia burgdorferi sensu lato, dok je u Sjevernoj Americi jedino patogena B.burgdorferi sensu stricto. Kliničke manifestacije LB su polimorfne. Postavljanje dijagnoze temelji se na kliničkoj slici i epidemiološkim podacima o vjerojatnosti kontakta s krpeljima uz primjenu mikrobiološke dijagnostike. Najčešća je rutinska dijagnostika serologija za određivanje i praćenje dinamike specifičnih protutijela IgM i IgG. Nakon primarnog testiranja, rezultate je potrebno potvrditi dodatnim testom visoke specifičnosti. U područjima visoke prevalencije, specifičnost rezultata visoko osjetljivog i specifičnog testa nije obvezno dodatno potvrđivati. I pozitivni i negativni nalazi moraju se interpretirati klinički. Serološka dijagnostika predstavlja dobrobit za prepoznavanje i liječenje bolesnika samo ako se rezultati interpretiraju temeljem poznavanja patogeneze, kliničke slike i imunosnog odgovora kao i karakteristika korištenog testa. Karakteristike samih borelija i prezentacije antigena, izbjegavanje imunosnog odgovora, dostupnost različitih testova kao i Interneta predstavljaju zamke, posebno ako se slijede neprovjerene informacije.Lyme borreliosis (LB) in Europe is most commonly caused by different borrelia of Borrelia burgdorferi sensu lato complex , while in North America the only pathogen is B.burgdorferi sensu stricto. Clinical manifestations of LB are polymorphic. Diagnosis is based on the clinical presentation and epidemiological data on the likelihood of contact with ticks and with the application of microbiological diagnostics. The most common routine diagnosis is serology to determine and monitor the dynamics of specific IgM and IgG antibodies. After primary testing, the results need to be confirmed by an additional high-specificity test. In regions with a high prevalence, the specificity of the results of a highly sensitive and specific test does not need to be further confirmed. Both positive and negative findings must be interpreted clinically. Serological diagnosis is beneficial for the recognition and treatment of patients only if the results are interpreted on the basis of knowledge of the pathogenesis, clinical presentation and immune response as well as the characteristics of the test used. The characteristics of borrelia itself and the presentation of the antigen, the avoidance of the immune response, the availability of various tests as well as the Internet are pitfalls, especially if unverified information is followed

SPECIFICITY OF LYME NEUROBORRELIOSIS DIAGNOSTICS

Lajmska neuroborelioza (LNB) nastaje hematogenim rasapom borelija u središnji živčani sustav (SŽS), a opisan je i prodor putem perifernog živca. Razvija se serozni meningitis sa ili bez pareze kranijalnog živca što je prevladavajuća klinička slika. Najčešće je zahvaćen n. facialis. Za razliku od Sjeverne Amerike, u Europi mogu biti zahvaćeni i drugi kranijalni živci, što se povezuje s prevaliranjem različitih vrsta borelija - u Europi najčešće B. garinii, B. bavariensis i B. afzelii, a u Sjevernoj Americi samo B. burgdorferi sensu stricto. Meningoradikulitis ili Bannwarthov sindrom tipična je slika LNB samo u Europi. Simptomi LNB većinom nisu tipični i mogu sličiti različitim neurološkim bolestima, pa dijagnozu često nije jednostavno definirati. Dijagnostika LNB mora uključivati analizu likvora u kojem je značajan nalaz pleocitoze, što upućuje na serozni meningitis kojem je potrebno dokazati povezanost s borelijama. Mikrobiološka dijagnostika LNB obuhvaća kultivaciju, zahtjevnu i dugotrajnu metodu (9-12 tjedana) koja se radi isključivo u referentnim centrima, te molekularnu (PCR) i serološku dijagnostiku. Zbog malog broja borelija u likvoru kao i relativno male količine likvora koja se šalje za analizu, molekularna je dijagnostika često lažno negativna. Stoga je serološka dijagnostika ključna za dokazivanje LNB. Serologija se radi iz istovremeno uzetih uzoraka seruma i likvora u kojima se određuju specifična protutijela IgM i IgG te ukupni imunoglobulini i/ili albumini. Serum i likvor moraju se analizirati istom metodom u istim uvjetima kako bi se mogla odrediti intratekalna sinteza specifičnih protutijela, tj. izračunati indeks protutijela (antibody index, AI). Specifična protutijela u lajmskoj boreliozi nastaju relativno sporo, a s duljinom trajanja infekcije njihova količina se povećava. U ranoj LNB protutijela u likvoru ne može se uvijek otkriti, iako je prisutna pleocitoza. Kasnu LNB u pravilu prati jaki imunosni odgovor i uz pleocitozu često se nalazi pozitivan AI. Nakon infekcije, vremenom se likvor normalizira i pleocitoza se više ne nalazi, iako specifična protutijela u likvoru mogu ostati dugo prisutna, čak i uz pozitivan AI. Stoga je potrebno pratiti imunosni odgovor u krvi i likvoru od dana kada se bolesnik javi zbog simptoma i zatim nakon npr. jednog, tri, šest i dvanaest mjeseci, radi procjene korelacije nalaza i bolesti. Dijagnoza LNB mora biti u skladu s kliničkim, epidemiološkim i anamnestičkim podatcima te laboratorijskim nalazima, posebno u likvoru. LNB je 1) potvrđena ako uz kliničku sliku postoji pleocitoza i intratekalna sinteza specifičnih protutijela; 2) vjerojatna ako intratekalna sinteza nije potvrđena, a specifična protutijela su prisutna u krvi bolesnika; 3) LNB nije vjerojatna ako nema pleocitoze ili nema analize likvora, iako su prisutna specifična protutijela u krvi bolesnika, ali klinička slika i epidemiološka anamneza nisu karakteristični. CXCL13 je biljeg koji može biti koristan kao dodatni test premda nije specifičan za LNB - u likvoru je povišen i prati akutnu upalu. Ako postoji mogućnost, LNB bi trebalo potvrditi kultivacijom i molekularnom dijagnostikom. Interpretacija laboratorijskih i kliničkih nalaza zahtijeva znanje i iskustvo. Informacije se trebaju sagledati u skladu s okolnostima i specifičnosti bolesnika, tako da je svaki bolesnik poseban dijagnostički izazov.Lyme neuroborreliosis (LNB) is caused by hematogenous spread of Borrelia into the central nervous system (CNS), but entry through a peripheral nerve has also been described. Aseptic meningitis develops with or without cranial nerve palsy, which is the predominant clinical presentation. Facial nerve is most frequently affected. Unlike North America, other cranial nerves can be affected in Europe, which is related to the prevalence of different types of Borrelia. Borrelia (B.) garinii, B. bavariensis, and less frequently B. afzelii are most common in Europe, while B. burgdorferi sensu stricto is the only North American strain. Meningoradiculitis or Bannwarth syndrome is a typical LNB presentation described only in Europe. The symptoms of LNB can resemble various neurological diseases, which makes the diagnosis of LNB difficult. The diagnosis of LNB must include analysis of cerebrospinal fluid (CSF) in which pleocytosis is significant to support aseptic meningitis, and the association with Borrelia must be proven. Microbiological diagnosis of LNB includes cultivation, a demanding and long-term method (9-12 weeks), which is performed exclusively in reference centers, and molecular (polymerase chain reaction, PCR) and serological diagnostics. PCR is often false-negative due to the low number of strands in the CSF. Thus, serological diagnosis remains crucial to confirm LNB. Serology is performed on simultaneously collected serum and CSF samples, from which specific IgM and IgG antibodies, total immunoglobulins and/or albumins need to be determined. Serum and CSF samples must be analyzed by the same method under the same conditions in order to assess the intrathecal synthesis of specific antibodies, i.e., to calculate the antibody index in CSF (antibody index, AI). In patients with Lyme borreliosis, specific antibodies are produced relatively slowly, and their quantity increases with the duration of the infection. In early LNB, antibodies in the CSF are not always detectable while pleocytosis is present. In late LNB, a strong immune response is present in the CSF, as well as pleocytosis, and a positive AI can be determined. Over time, CSF normalizes and pleocytosis is no longer detected, but CSF antibodies can remain present for a long period of time. Therefore, the immune response in the blood and CSF has to be monitored from the day the patient presented with symptoms, and then, for example, at one, three, six and twelve months to assess the correlation of laboratory findings with the disease. The diagnosis of LNB must be in accordance with clinical, epidemiological and history data and laboratory findings, especially in CSF. LNB is confirmed if the clinical picture is accompanied by pleocytosis and intrathecal synthesis of specific antibodies; LNB is probable if intrathecal synthesis is not confirmed while specific antibodies are present in the patient’s blood; and LNB is unlikely if there is no pleocytosis or no CSF analysis, although specific antibodies are present in the patient’s blood but the clinical picture and epidemiological history are not characteristic. If there is a possibility, LNB should be confirmed by culture and molecular diagnostics. CXCL13 is a marker that can be useful as an additional test, even though it is not specific for LNB as it is elevated in CSF and observed during acute inflammation. Interpretation of laboratory and clinical findings in LNB requires knowledge and experience. The findings should be interpreted in accordance with the circumstances and condition of the patient, and therefore each patient represents a special diagnostic challenge

First isolation of Borrelia sp. (Borrelia afzelii) from cerebrospinal fluid in a patient with neuroborreliosis in Croatia

Opisan je bolesnik s lajmskom boreliozom koja se manifestirala eritemom migrans na licu mjesec dana nakon uboda krpelja te poslije jednog mjeseca razvitkom faciopareze po perifernom tipu uz limfocitni meningitis (127 stanica/μL i 78% limfocita). Klinička slika neuroborelioze bila je razmjerno blaga. Bolesnik je liječen parenteralno ceftriaksonom kroz tri tjedna, uz dobar učinak antibiotske terapije te gotovo potpuno povlačenje klijenuti ličnog živca do kraja hospitalizacije. Bolesnik je imao reaktivna protutijela IgG na B. burgdorferi u serumu. Utvrđen je pozitivan indeks intratekalne sinteze protutijela IgM i IgG za borelije (specifičan test IDEIA Lyme Neuroborreliosis Oxoid, Velika Britanija). Imunosne pretrage na krpeljni meningoencefalitis, varicela-zoster virus i herpes simplex bile su negativne u serumu i u likvoru. U Mikrobiološkom institutu Medicinskog fakulteta u Ljubljani obra|en je likvor specifičnim uzgojnim metodama te je kultivirana B. burgdorferi sensu lato. Poslije kultivacije uzročnika izvršena je identifikacija borelijske vrste restrikcijom cjelokupnog borelijskog genoma enzimom MluI čime je utvrđen uzročnik bolesti: Borrelia afzelii. Premda se u Hrvatskoj neuroborelioza dijagnosticira i liječi preko dvadesetak godina, borelija dosada nije bila izolirana iz cerebrospinalnog likvora u naših pacijenata.We describe a patient with lyme borreliosis that manifested with facial erythema migrans one month after tick bite and consequently with peripheral facial paresis with lymphocyte meningitis (127 cells/μL and 78 % lymphocytes). Clinical picture of neuroborreliosis was relatively mild. The patient received ceftriaxone parenterally for three weeks, with beneficial effect of antibiotic therapy and almost complete resolution of facial paresis until discharge from hospital. Reactive IgG antibodies to B. burgdorferi were found in the patient’s serum. A positive index of intrathecal synthesis of IgM and IgG antibodies to borreliae was determined (specific test IDEIA Lyme Neuroborreliosis Oxoid, Great Britain). Immunological examination for detection of tick-borne meningoencephalitis, varicella-zoster virus and herpes simplex proved negative in both serum and cerebrospinal fluid (CSF). B. burgdorferi sensu lato was isolated from CSF using specific culturing techniques at the Institute of Microbiology and Immunology of the Medical Faculty, University of Ljubljana. After cultivation of the pathogen, identification of Borrelia species was performed by using restriction enzyme MluI thus determining the causative agent of neuroborreliosis: Borrelia afzelii. Although neuroborreliosis has been diagnosed and treated for over twenty years in Croatia, so far Borrelia has never been isolated from cerebrospinal fluid in our patients

Guillain-Barre Syndrome in Patients with Seroconversion of IgG Antibodies to Borrelia Burgdorferi sensu lato

A case of polyneuroradiculitis (Guillain-Barre Syndrome) is presented, which was diagnosed in a 62 year-old man after progressive weakness in the legs and arms and double vision, preceded by severe pain in the back. Diagnosis was made on the basis of electromioneurography, a specific finding of cerebrospinal fluid (albumino-citological dissociation), and the clinical course of the disease. Serological analysis of serum included Borellia Burgdorferi sensu lato (BBSL). Positive findings (slowing of conduction velocity of sensor and motor neurones, and marked albumino-citological dissociation), together with the dynamics of these findings on the 33rd, 67th and 101st days and one year and a half after the first clinical signs of disease, indicated the possibility of BBSL infection. Because of the absence of clear clinical and serological signs of other infections it was assumed that BBSL might be the possible trigger for Guillain-Barre Syndrome. The fact that there were no obvious clinical signs of infection with BBSL, only serological, suggests that in the case of unclear aetiology of Guillain-Barre Syndrome BBSL should not be excluded

Prognosis of severity of tick-borne encephalitis based on selected parameters

Svrha našeg rada bila je istražiti može li se u bolesnika s KME na temelju izabranih pokazatelja određenih kod primitka na bolničko liječenje predvidjeti težina tijeka akutne bolesti. Retrospektivnim istraživanjem uključili smo odrasle bolesnike s KME koji su od 1995. do 2005. godine obrađeni u Djelatnosti za infektivne bolesti Opće bolnice u Koprivnici. Sve podatke o pojedinom bolesniku prikupili smo iz povijesti bolesti. Akutna meningoencefalitička (ME) faza klasificirana je kao lagana ili teška, ovisno o prisutnosti meningealnih simptoma, težini znakova encefalitisa i prisutnosti žarišnih znakova središnjeg živčanog sustava (SŽS). Svi su bolesnici uglavnom pregledani i kategorizirani od istog liječnika. Izabrani i analizirani pokazatelji s mogućim učinkom na težinu bolesti uključuju: spol i dob bolesnika, podatak o višekratnim ubodima krpelja, sezonsku raspodjelu, vremensko razdoblje (u danima) od prvih simptoma do prvog pregleda, trajanje asimptomatskog razdoblja (u danima), stanje svijesti, tijek bolesti (bifazni, monofazni), nalaz lumbalnoga likvora i periferne krvi, pridruženu infekciju s Borrelia burgdorferi sensu lato (BBSL). Sa ciljem što bolje i ujednačenije obrade te lakše mogućnosti uspoređivanja, sve podatke o pojedinom bolesniku upisivali smo u posebno pripremljene anketne listiće (upitnike). Akutnu infekciju virusom KME dokazali smo u 133 bolesnika, u dobi od 16 do 76 godina. Prevladava muški spol (83/133, 62,4%). Višekratni ubodi krpelja zabilježeni su u 33 (38,4%) bolesnika, od kojih u 24 (48,0%) s laganim i devetero (25,0%) s teškim ME stadijem bolesti. Klinički se bolest najčešće očituje kao ME (66/49,6%), bifaznog tijeka u 94 (70,7%) bolesnika. Lagani ME prisutan je u 77 (57,8%), a teški u 56 (42,1%) bolesnika. Na početku bolesti samo kratko asimptomatsko razdoblje (P<0,001), poremećaj svijesti (P<0,001), povišena koncentracija ukupnih proteina u lumbalnom likvoru (P=0,009), leukocitoza periferne krvi (P=0,009) i povišena SE (P=0,002) mogući su prediktor nepovoljnog tijeka bolesti. Za ostale istražene pokazatelie nije zabilježena statistički značajna razlika između promatranih skupina. Potrebna su daljnja istraživanja za utvrđivanje dodatnih pouzdanih pokazatelja odgovornih za težinu tijeka KME.The main purpose of our study was to investigate whether the severity and course of acute illness in patients with tick-borne encephalitis can be predicted based on selected parameters determined on admission to hospital. This retrospective study included adult patients with TBE, who were treated at the Department of Infectious Diseases, General Hospital, Koprivnica, Croatia, between 1995 and 2005. Case records of all patients were reviewed. On admission to hospital the acute meningoencephalitic (ME) stage was classified as mild or severe, depending on the presence of meningeal symptoms, the severity of clinical signs of encephalitis and presence of focal central nerves systems (CNS) signs. The patients were generally examined and categorized by the same physician. We analyzed and compared selected parameters determined on admission to hospital including: sex and age, multiple tick bite, seasonal distribution, period of time (days) between the onset of first symptoms of disease and the first examination, duration of asymptomatic interval (days), state of mind, course of illness (biphasic, monophasic), cerebrospinal fluid and peripheral blood findings, concomitant infection with Borrelia burgdorferi sensu lato (BBSL). All data collected from patients were entered into specially prepared questionnaire. Recent infection with TBE was confirmed in 133 patients, 83 (62,4%) males and 50 (37,6%) females, aged 16 to 76. A history of tick-bite was noted in 86 (64,6%) of whom multiple in 33 (38,3%) patients. TBE presented as isolated meningitis in 50 (37,6%), as ME in 66 (49,6%) and as meningoencephalomyelitis (MEM) in 17 (12,8%) patients. A biphasic course of disease occurred in 94 (70,7%) patients. Mild ME stage was noticed in 77 (57,8%) and severe in 56 (42,1%) patients. On admission to hospital only a short period of time between finishing initial stage and beginning of second ME stage (p<0,001), altered consciousness (p<0,001), elevated total protein concentration in CSF (p=0,009), peripheral blood leukocytosis (p=0,009) and elevated ESR (p=0,002) might indicate an unfavorable course of TBE. Other parameters investigated in this study did not correlate with the severity of the illness. Further investigations of more reliable parameters are needed in order to predict the severity of TBE

Additive Effects of Water-Soluble Propolis (Greit 120) and Human Interferon Alfa (HuIFN-αN3) against Influenza Viruses in Vitro

Abstract: Influenza virus affects the respiratory tract in humans causing a range of distinct manifestations including fever, nasal secretions, cough, headaches, muscle pain and pneumonia, which could become violent and severe. It was found that influenza A viruses remain resistant to amantadine and rimantadin with high level of oseltamvir resistance. Therefore, there is a need for constant improvement of drugs active against resistant influenza viruses. Propolis has anti-influenza activity both in vitro and in vivo. Human leukocyte interferon (HuIFN-αN3) is a multi-subtype protein that displays an antiviral activity against influenza virus. In this study we elucidated the anti-influenza activity of the mixes of water-soluble propolis (WSP) (Greit 120) and HuIFN-αN3 at different ratios. Greit 120 polyphenols, total phenol acids and bioflavonoid were characterized by HPLC-UV-ESI-MS504971 and HuIFN-αN3 by reverse-phase high-performance liquid chromatography (RP-HPLC). Influenza A and B viruses were separately added to the LLC-MK2 cells treated with WSP (Greit 120) and HuIFN-αN3 alone or in proportions 1:1, 1:2 and 2:1. Plates were incubated and cytopathic effect was determined. The best results (ID50) were obtained with the mix of 10% WSP and HuIFN-αN3 in proportion 1:2, showing ID50 at 12 ± 0.2 μg/mL and 19 ± 0.6 μg/mL for influenza A and B viruses, respectively. When comparing anti-influenza activity of WSP (Greit 120)/HuIFN-αN3 with that of ribavirin, it was found that 1:2 was the optimal ratio for WSP (Greit 120)/HuIFN-αN3 (0.5 and 0.6 for influenza A and B, respectively). This new formulation of WSP (Greit 120) and HuIFN-αN3, showing better anti-Influenza activity, will definitely improve its application in flu infections

Whole genome sequencing characterization of Slovenian carbapenem-resistant Klebsiella pneumoniae, including OXA-48 and NDM-1 producing outbreak isolates

Objectives The first hospital outbreak of carbapenemase-producing Enterobacteriaceae in Slovenia occurred in 2014-2016. Whole genome sequencing was used to analyse the population of carbapenem-resistant Klebsiella pneumoniae collected in Slovenia in 2014-2017, including OXA-48 and/or NDM-1 producing strains from the outbreak. Methods A total of 32 K. pneumoniae isolates were analysed using short-read sequencing. Multilocus sequence typing and core genome multi-locus sequence typing were used to infer genetic relatedness. Antimicrobial resistance markers, virulence factors, plasmid content and wzi types were determined. Long-read sequencing was used for six isolates for detailed analysis of plasmids and their possible transmission. Results Overall, we detected 10 different sequence types (STs), the most common being ST437 (40.6%). Isolates from the initial outbreak belonged to ST437 (12/16) and ST147 (4/16). A second outbreak of four ST15 isolates was discovered. A new ST (ST3390) and two new wzi types (wzi-556, wzi-559) were identified. blaOXA-48 was found in 17 (53.1%) isolates, blaNDM-1 in five (15.6%), and a combination of blaOXA-48/NDM-1 in seven (21.9%) isolates. Identical plasmids carrying blaOXA-48 were found in outbreak isolates sequenced with long-read sequencing technology. Conclusions Whole genome sequencing of Slovenian carbapenem-resistant K. pneumoniae isolates revealed multiple clusters of STs, two of which were involved in the first hospital outbreak of carbapenem producing K. pneumoniae in Slovenia. Transmission of the plasmid carrying blaOXA-48 between two STs was likely to have occurred. A previously unidentified second outbreak was also discovered, highlighting the importance of whole genome sequencing in detection and/or characterization of hospital outbreaks and surveillance of drug-resistant bacterial clones