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Infectious Diseases and Therapy

, Volume 8, Issue 1, pp 5–22 | Cite as

Biologic Markers of Antibiotic-Refractory Lyme Arthritis in Human: A Systematic Review

  • Alaa BadawiEmail author
  • Paul Arora
  • Darren Brenner
Open Access
Review

Abstract

Introduction

Lyme disease—also known as Lyme borreliosis (LB)—is the most common vector-borne disease in North America and Europe. It may result in substantial morbidity, primarily from persistent Lyme arthritis (LA) that—although treatable—can develop into antibiotic-refractory LA (A-RLA). The aim of this study is to systematically review and evaluate a range of biomarkers for their potential predictive value in the development of A-RLA.

Methods

We conducted a systematic review of studies examining biomarkers among patients with A-RLA from MEDLINE via OVID, EMBASE and Web of Science databases and identified a total of 26 studies for qualitative analysis.

Results

All studies were of patient populations from the USA, with the exception of one from Europe. We identified an array of biomarkers that are commonly modulated in the A-RLA compared with subjects with antibiotic-responsive LA. These included a range of inflammatory markers (IL-6, IL-8, IL-10, IL-1β, IL-23, IL-17F, TNFα, IFNγ, CXCL9, CXCL10, CCL2, CCL3 and CCL4, CRP), factors along the innate and adaptive immune response pathways (e.g., CD4+ T cells, GITR receptors, OX40 receptors, IL-4+CD4+Th2 cells, IL-17+CD4+ T cells) and an array of miRNA species (e.g., miR-142, miR-17, miR-20a, let-7c and miR-30fam).

Conclusion

The evidence base of biologic markers for A-RLA is limited. However, a range of promising biomarkers have been identified. Cytokines and chemokines related to Th17 pathway together with a number of miRNAs species (miR-146a, miR-155 and let-7a) may be promising candidates in the prediction of A-RLA. A panel of multiple biomarkers may yield clinically relevant prediction of the possible resistance at the time of LA first diagnosis.

Funding

Public Health Agency of Canada.

Keywords

Antibiotic-refractory Lyme arthritis Biomarkers Human Inflammation Systematic review 

Introduction

Lyme disease or Lyme borreliosis (LB) is caused in humans by at least three genospecies of the Borrelia burgdorferi sensu lato complex: B. burgdorferi, B. garinii and B. afzelii. A bite from an infected Ixodes scapularis and Ixodes pacificus blacklegged ticks initiates this bacterial infection that leads to LB. The early stage of the disease can develop later to a number of long-term complications such as Lyme arthritis (LA) and Lyme carditis [1]. In North America and Europe, LB presently is the most common vector-borne disease [1] with > 30,000 cases reported annually in the USA [2]. However, the actual prevalence estimates are thought to be up to ten times as high because of the underreporting [3]. Moreover, approximately sixfold increased incidence in LB was noted in Canada between 2009 (128 cases) and 2015 (707 cases) [4].

Early symptoms of LB usually start 1–2 weeks following the tick bite with a proportion of the infected subjects developing the characteristic erythema migrans (EM) rash. EM can last for a period of 4 weeks or more. Symptoms such as headache, myalgia, fever, malaise, fatigue and chills may also accompany this stage. If untreated, systemic dissemination of the bacteria may occur via the lymphatic system or blood to the cardiovascular system, nervous system and joints. Weeks to months after the tick bite, early disseminated LB may emerge with symptoms such as Lyme-associated facial nerve palsy and an array of cardiac conditions such as palpitations, shortness of breath or chest pain [5]. A range of inflammatory processes may occur about 6 months after infection as suggested by the development of joint pain and swelling and synovial fluid findings. Months to years after the initial tick bite, the disease can progress to the late disseminated stage. This stage may lead to substantial morbidity, primarily from persistent arthritis (LA) that may occur in ~ 60% of untreated patients [5], rendering it as one of the most common long-term consequences of the late disseminated LB stage. In this case, LA clinically manifests as intermittent or persistent arthritis in the joints for several years.

Current recommendations for treatment of LA patients include initial oral doxycycline (100 mg twice daily) or amoxicillin (500 mg thrice daily) for 30 days. In patients who are unable to take either of these agents, cefuroxime axetil (500 mg twice daily) may be used as an alternative [6]. In patients with antibiotic-refractory LA (A-RLA) treated with antibiotics, PCR testing for B. burgdorferi DNA in the affected joint fluid is usually negative, which suggests that the A-RLA persists despite near or total eradication of the pathogen from the joint [7]. One of the major clinical and public health challenges related to A-RLA is the lack of ability to determine which LB patients may develop A-RLA [8]. This is particularly true given the possible post-treatment eradication of the pathogen [9]. Biologic markers evaluated prior to or at the time of treatment may be useful in the prediction of those individuals who may be at risk of developing A-RLA [9].

We conducted a systematic review to summarize the literature documenting the changes in immunologic (e.g., immune response or cytokine and chemokine expression) and genetic biomarkers (e.g., expression and polymorphisms in genes regulating the immune system) in response to LB and their role in the development of A-RLA. The objective of this study was to evaluate the potential predictive value of these biomarkers in the progression of LA to A-RLA.

Methods

Literature Search

We conducted a systematic review of studies examining biomarkers among patients with A-RLA from MEDLINE via OVID, EMBASE and Web of Science. We examined studies published from 1 January 1982 to 15 December 2017. A broad search using the following MeSH terms was conducted: (Lyme) AND (arthritis) AND (antibiotic-refractory OR antibiotic OR refractory). We limited our search to studies conducted in humans and published in English with the inclusion of biologic markers associated with or predictive of disease risk and/or prognosis. The systematic review was conducted in line with the Preferred Reporting for Systematic Review and Meta-Analyses (PRISMA; see Fig. 1 and Supplementary Table 1) [10]. All abstracts and titles were screened independently in duplicate with any conflicts determined by a third reviewer.
Fig. 1

Flowchart of the study selection and systematic literature review process. The flow diagram describes the systematic review of literature on the biologic markers of antibiotic-refractory LA in humans. A total of 26 unique studies were identified for qualitative analysis

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were defined using the Population, Exposure, Comparator, Outcome, Study Design (PECOS) table (Supplementary Table 2). We included studies examining biologic markers of any type among adults or children with no age or sex restrictions. The exposure of interest was LA. A broad array of outcomes of interest was included, such as associations of biomarkers with A-RLA in a population sample, association of biomarkers with A-RLA compared with responsive LA and prediction of A-RLA at the time of diagnosis of LA. Any potentially relevant study design, either intervention or observational, was included. Case reports and review articles were excluded. Studies prior to 1982 were not considered as it is the discovery date of B. burgdorferi. Only publications in English were included in this study.

Data Extraction

We developed and tested a data extraction template using two blinded reviewers. All relevant study and population characteristics were extracted in addition to specific methods around biologic sample collection and biomarker quantification (Supplementary Table 3). All data extracted were performed in duplicate. Upon completion of data extraction, we grouped studies into those reporting associations with immune response and genetic biomarkers separately for synthesis and comparative discussion.

Compliance with Ethics Guidelines

This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

Results

In total, 26 studies were identified that met the specified search criteria and contained relevant results of interest, which are summarized in Table 1. All studies were of patient populations from the USA, with the exception of one from Germany [11]. These studies represented a relatively homogeneous study population, with most cases being ascertained from Tufts Medical Center or Massachusetts General Hospital [12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26]. However, there were a few reports that did not state where cases were ascertained [17], many of which were conference abstracts [28, 29, 30, 31, 32, 33, 34, 35]. One study was conducted across the USA [36]. Of the studies that reported sex distributions within the study populations, all included both males and females [11, 12, 17, 18, 20, 21, 22, 23, 24, 25, 36]. In addition, of the studies that reported study population ages, most were from adult populations but also included children above the age of 12 years [17, 18, 20, 21, 22, 23, 24, 25]. The study from Germany [11] was exclusively from a pediatric population with two reports that were only in adults [12, 36]. All biologic samples used for analysis were derived from peripheral blood, serum or synovial fluid and/or tissue.
Table 1

Characteristics of the selected studies

Objective

Studya

Number of subjects

Males (%)

Age (years)

Specimens

A-RLA

Comparative group(s)

Range

Average

Etiology of A-RLA vs. responsive LA and/or other arthritis

Strle et al. 2017 [13]

81

60 Antibiotic-responsive LA

   

Serum and SF

Crowley et al. 2016 [14]

114

58 Healthy controls

91 Antibiotic-responsive LA

   

Serum, PBMCs, SF

Strle et al. 2014 [31]

159

    

SF

Drouin et al. 2013 [19]

109

74 Healthy controls

21 Rheumatoid arthritis

77 Antibiotic-responsive LA

   

SF and serum

Strle et al. 2012 [21]

101

76 Antibiotic-responsive LA

 

12–79

 

PBMCs

Strle et al. 2011 [35]

12

5 Antibiotic-responsive LA

   

SF

Kannian et al. 2007 [24]

41

23 Antibiotic-responsive LA

66

13–64

41

Serum

Shin et al. 2007 [25]

35

17 Antibiotic-responsive LA

75

12–79

38

SF and tissue

Nimmrich et al. 2014 [11]*

8

23 Antibiotic-responsive LA

37.5

 

11 ± 2

Serum

Londono et al. 2014 [17]

14

6 Other arthritis

50

11–43

16

SF

Vudattu et al. 2011 [34]

16

15 Antibiotic-responsive LA

   

PBMCs and SF mononuclear cells

Shen et al. 2010 [22]

12

6 Antibiotic-responsive LA

67

11–54

29

PBMCs and SF mononuclear cells

Kannian et al. 2007 [23]

7

6 Antibiotic-responsive LA

77

12–64

25

PBMCs and SF mononuclear cells

Lochhead et al. 2017 [12]

27

5 Pre-treatment controls

8 Other arthritis

69

17–76

45

SF

Lochhead et al. 2015 [29]

10

6 Antibiotic-responsive LA

5 Other arthritis

   

SF

Strle et al. 2011 [27]

101

76 Antibiotic-responsive LA

   

SF

Steere et al. 2006 [26]

71

50 Antibiotic-responsive LA

   

Not specified

Mechanisms of A-RLA vs. healthy controls

Pianta et al. 2015 [15]

89

52 Healthy controls

   

Serum, SF

Crowley et al. 2015 [16]

94

57 Healthy controls

   

Serum, SF

Vudattu et al. 2013 [18]

16

15 Antibiotic-responsive LA 13 healthy controls

69

12–62

29

Peripheral blood and SF

Crowley et al. 2015 [30]

114

    

SF

Crowley et al. 2014 [32]

     

Serum

Pianta et al. 2014 [33]

     

SF and serum

Katchar et al. 2013 [20]

15

8 Antibiotic-responsive LA

4 Healthy controls

53

12–78

29

Peripheral blood and SF

Genetics of A-RLA

Strle et al. 2015 [28]

     

SF

Early vs. late manifestations of LD

Uhde et al. 2016 [36]

11

67 Healthy controls

63.6

 

53 ± 21

Serum

All studies were of patient populations from the USA, except as noted (*) from Germany

A-RLA antibiotic-refractory Lyme arthritis, EM erythema migrans, RA rheumatoid arthritis, PBMCs peripheral blood mononuclear cells, FS synovial fluid, LD Lyme disease

aEmpty cells denote information not available from the original study

The immune responses to B. burgdorferi, its antigens, or other proteins in A-RLA were evaluated in ten studies [14, 15, 16, 19, 24, 28, 30, 31, 32, 33], whereas six studies examined other biomarkers (predominantly immune markers) of A-RLA [11, 13, 17, 21, 27, 36]. Of the selected studies, five examined various types of immune cells in A-RLA [18, 20, 22, 23, 34], while five other studies evaluated an array of genetic markers [12, 26, 28, 29, 35]. As shown in Table 2, the studies that investigated immune responses demonstrated significantly higher reactivity to matrix metalloproteinase (MMP)-10 [14, 30], annexin A2 [15, 33], apolipoprotein B-100 [16, 32] and endothelial cell growth factor (ECGF) [19] in A-RLA patients compared with healthy controls. Additionally, compared with antibiotic-responsive LA, A-RLA patients had significantly higher reactivity to the variable major protein-like sequence-expressed (VlsE) lipoprotein [24] as well as to human ECGF (hECGF) [31]. When stimulated with B. burgdorferi or interferon (IFN)-γ, A-RLA patients also exhibited particularly high levels of MMP-1, MMP-2, MMP-3, MMP-9, MMP-13, interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF), C–C motif chemokine ligand (CCL)-2, C–X–C motif chemokine ligand (CXCL)-9 and CXCL-10 in fibroblast-like synoviocytes [28].
Table 2

Summary of studies reporting immune biomarkers in antibiotic-refractory LA in humans

Study

Biomarker class

Biomarker(s)

Assay

Summary of results

Strle et al. 2017 [13]

Innate immune cytokine response

CCL3, TNF-α, CXCL9, IL-17F

Luminex assay

A total of 21 mediators associated with innate, T-helper 1 cell and T-helper 17 cell immune responses were assessed in serum and SF

IL-17F in serum and CCL2, CCL3, TNF-α and CXCL9 in SF were significantly higher in A-RLA compared with antibiotic-responsive LA

Crowley et al. 2016 [14]

Immune response in A-RLA

MMP-10 stimulated PBMCs, serum MMP-10, synovial fluid MMP-10, synovial fluid MMP-3

Bead-based multiplex coupled with Luminex assay

The response was specific to MMP-10-stimulated PBMCs that had a significantly higher T-cell and B-cell reactivity in A-RLA compared with healthy controls and antibiotic-responsive LA

Pianta et al. 2015 [15]

Cytokine response and expression

T-cell reactivity (IFN-γ response) and IgG response to annexin A2/annexin A2 protein levels in SF and serum

ELISA

Significantly higher response (IFN-γ and IgG) to annexin A2 and elevated annexin A2 protein levels (in SF and serum) among A-RLA compared with healthy controls

Crowley et al. 2015 [16]

Cytokine response

T-cell reactivity (IFN-γ response) and IgG response to apolipoprotein B-100 and apolipoprotein B-100 in serum

ELISA

Apolipoprotein B-100 protein levels were also significantly higher in serum of A-RLA compared with healthy controls

Significantly higher IgG response to apolipoprotein B-100 among A-RLA compared with healthy controls

T-cell reactivity (IFN-γ) was borderline significant (p = 0.06) in A-RLA compared with healthy controls

Strle et al. 2015 [28]

Cytokine response

MMP1, MMP2, MMP3, MMP9, MMP13, IL-6, IL-8, IL-10, TNF, CCL2, CXCL9, CXCL10 from FLS simulated with B. burgdorferi

Luminex assay

A total of 8 MMPs and 21 cytokines and chemokines were assayed in FLS

A-RLA exhibited significantly higher levels of IL-6, IL-8, IL-10, TNFα, CCL2, CXCL9, CXCL10

Crowley et al. 2014 [32]

Cytokine response

Response of T cell (autoantibody) to MMP-10

Not specified

Higher numbers of A-RLA patients had robust or autoantibody T-cell responses to MMP-10—compared with antibiotic-responsive LA, healthy controls or rheumatoid arthritis patients

Strle et al. 2014 [31]

Levels of inflammatory cytokines and chemokines and response to cytokines

Th17-associated mediators and frequency of autoantibody responses to hECGF

Luminex

Higher levels of Th17 associated mediators (e.g., IL-23) and a greater frequency of autoantibody responses to hECGF among A-RLA compared with antibiotic-responsive LA

Crowley et al. 2014 [32]

Cytokine response

T-cell and B-cell reactivity (IgG anti-ApoB antibodies) to apolipoprotein B-100

ELISA

Significantly higher frequency of A-RLA had T-cell and B-cell responses to anti-ApoB IgG antibodies compared with healthy controls and patients with EM

Pianta et al. 2014 [33]

Cytokine response

Anti-annexin A2 IgG autoantibody response in serum

ELISA

Significantly higher autoantibody response in A-RLA compared with healthy controls, but similar to that in antibiotic-responsive LA

Drouin et al. 2013 [19]

Autoantibody and autoantigen responses

Anti-ECGF IgG autoantibody response in serum and ECGF in serum

ELISA

Significantly higher number of A-RLA had positive autoantibody responses to ECGF compared with healthy controls

A-RLA exhibited ECGF autoantibodies more frequently than in antibiotic-responsive LA

A-RLA showed significantly higher levels of ECGF in SF compared with antibiotic-responsive LA

Strle et al. 2012 [21]

Strle et al. 2011 [35]

Chemokine and cytokine levels

CXCL9, CXCL10, IL-6, IL-8, IL-10, IL-1β, CCL2, CCL3, CCL4, TNF, IFNγ

Bead-based multiplex assay

CXCL9, CXCL10, IL-6, IL-8, IL-10, IL-1β, CCL2, CCL3, CCL4, TNF, IFNγ were more common in (and in significantly higher levels in the SF of) A-RLA compared with antibiotic-responsive LA

Kannian et al. 2007 [23]

Antibody response

IgG antibody titers in response to B. burgdorferi antigens in serum

ELISA

In A-RLA, during the first 1–3 months after treatment, antibody response to the VlsE peptide declined while the titers to B. burgdorferi DbpA, OspA and Arp increased

Synovial inflammation persisted in A-RLA after infection compared with antibiotic-responsive LA

Shin et al. 2007 [25]

Chemokines and cytokines levels in response to antibiotic treatment

CXCL8, CXCL9, CXCL10, IL-1β, IL-5, IL-6, CCL2, CCL3, CCL4, TNF, IFNγ

Cytometric bead array

Compared with antibiotic-responsive LA, A-RLA exhibited significantly higher CXCL8, CXCL9, CXCL10, CCL4, IL-6, IL-1β, TNF and IFNγ during the antibiotic treatment period and higher CXCL9, CXCL10, IL-5, IL-1β, CCL2, CCL3 and CCL4 following the treatment

Uhde et al. 2016 [36]

Acute phase reactants

CRP and amyloid A

ELISA

Significantly higher CRP but not amyloid A in A-RLA compared with healthy controls

Nimmrich et al. 2014 [11]

Protein expression

p58, OspC, P100, VlsE, P39, Ospa and p18

Western blot

Significantly higher IgG p58 and OspC expression—but not P100, VlsE, P39, Ospa and p18—in A-RLA compared with antibiotic-responsive LA

Vudattu et al. 2013 [18]

Leukocytes

Monocytes, CD4+ T cells, in peripheral blood or SF

Flow cytometry

Compared with healthy controls, A-RLA exhibited higher levels of monocytes and CD4+ T cells in peripheral blood

Compared with antibiotic-responsive LA, A-RLA had lower CD4+ T cells in SF

Katchar et al. 2013 [20]

Lymphocytes

CD3+ T cells in peripheral blood, CD56 bright NK cells and Vα24+ iNKT cells in SF

Flow cytometry

A-RLA had lower CD3+ T cells in peripheral blood compared with healthy controls and lower CD56 bright NK cells and Vα24+ iNKT cells in SF compared with antibiotic-responsive LA

Vudattu et al. 2011 [34]

Lymphocytes and phenotypes of lymphocytes

CD4+ T cells and expression of GITR and OX40 receptors

Flow cytometry

Increased CD4+ T cells and GITR and OX40 receptors expression in A-RLA compared with antibiotic-responsive LA

Shen et al. 2010 [22]

Phenotypes of lymphocytes

IL-4+CD4+Th2 cells, IL-17+CD4+ T cells, FoxP3+Treg cells

Flow cytometry

Significantly higher numbers of IL-4+CD4+Th2 cells, IL-17+CD4+T cells and FoxP3+Treg cells were found in A-RLA compared with antibiotic-responsive LA

Kannian et al. 2007 [23]

Lymphocytes

OspA161–175-specific T cells

Flow cytometry

No significant differences in OspA161–175-specific T-cell frequencies or proliferation responses between A-RLA and antibiotic-responsive LA

Londono et al. 2014 [17]

Histologic findings

Lining layer thickness, global cellular infiltration, lymphoid aggregates, obliterative macrovascular lesions

Histologic analysis (tissue staining)

Lining layer thickness, global cellular infiltration, lymphoid aggregates, obliterative macrovascular lesions were all more common in A-RLA compared with other arthritis cases

MMPs matrix metalloproteinases, PBMCs peripheral blood mononuclear cells, SF synovial fluids, FLS fibroblast-like synoviocytes, hECGF human endothelial cell growth factor, EM erythema migrans, DbpA decorin binding protein A, VlsE variable major protein-like sequence expressed lipoprotein, Arp arthritis-related protein, OspA outer surface protein A, OspC outer surface protein C, CRP C-reactive protein, GITR glucocorticoid-induced TNFR-related protein, A-RLA antibiotic-refractory Lyme arthritis

Compared with healthy controls, A-RLA patients exhibited significantly higher levels of C-reactive protein (CRP) in their blood or synovial fluid/tissue [36]. Compared with antibiotic-responsive LA patients, studies found a significantly higher level of immune mediators associated with T-helper 1 and T-helper 17 cell immune responses, such as CCL2, CCL3, CCL4, TNF-α, CXCL9, CXCL-10, IL-6, IL-8, IL-10, IL-1β, IL-17F, IL-23 and IFN-γ [13, 21, 27, 31]. Furthermore, A-RLA patients demonstrated significantly higher expression of the B. burgdorferi proteins p58 and outer surface protein (Osp) C compared with their antibiotic-responsive LA counterparts [11]. One study investigated histologic findings in the synovial tissue of A-RLA patients compared with other arthritis patients and found differences in lining layer thickness, global cellular infiltration, lymphoid aggregates and obliterative macrovascular lesions, which were more common in A-RLA patients [17].

When examining immune cell types, compared with healthy controls, A-RLA patients had higher levels of memory CD4+ T cells [18] in peripheral blood, while the CD3+ T cells were significantly lower [20]. Compared with antibiotic-responsive LA patients, A-RLA patients had lower levels of CD4+ T cells [18] (although higher levels were observed in one study [34]), CD56bright natural killer (NK) cells [20] and Vα24+ NKT cells [20] in synovial fluid. Higher numbers of IL-4+CD4+ Th2 cells, IL-17+CD4+ T cells and FoxP3+ Treg cells were all found in A-RLA patients compared with antibiotic-responsive subjects [22]. One study, however, did not find a significant difference in OspA161-175-specific T-cell frequencies or proliferation responses between A-RLA and responsive patients [23].

Five studies evaluated the genetic markers of A-RLA (Table 3). Of those, two studies examined the microRNA (miRNA) expression and reported that miR-146a, miR-142, miR-17, miR-155, miR-223 and miR-20a were significantly elevated in post- vs. pre-antibiotic treated A-RLA [12]. These miRNA species, in addition to let-7a, let-7c and miR-30fam, were also significantly higher in A-RLA patients compared with patients with osteoarthritis [12, 29]. Patients with A-RLA also exhibited higher levels of miR-146a, miR-155, miR-223 and miR-142 than the antibiotic-responsive LA patients [29]. Another study reported the frequency of the 1805GG single-nucleotide polymorphism (SNP) in the Toll-like receptor-1 gene (TLR-1) to be significantly lower in A-RLA patients than in the antibiotic-responsive LA patients [35]. Cells with this 1805GG SNP were shown to have an altered mRNA expression of the suppressor of cytokine signaling (SOCS)-3, suggesting that greater inflammatory responses in A-RLA patients with this polymorphism may be due to the loss of a cytokine regulatory pathway [28]. Lastly, allele haplotype frequencies of human leukocyte antigen (HLA) were investigated in one study and found that HLA-DRB1-DQA1-DQB1 haplotype frequencies were similar between A-RLA patients and subjects with antibiotic-responsive LA [26]. However, the frequency of DRB1 alleles differed markedly, and a significantly larger number of A-RLA patients showed binding to the outer surface protein A (OspA) than their antibiotic-responsive LA counterparts [26]. Our systematic assessment of the literature allowed us to identify an array of biomarkers that are commonly upregulated in the A-RLA compared with subjects with antibiotic-responsive LA (Table 4). These included a range of inflammatory markers (IL-6, IL-8, IL-10, IL-1β, IL-23, IL-17F, TNFα, IFNγ, CXCL9, CXCL10, CCL2, CCL3 and CCL4, CRP), factors related to innate and adaptive immune responses (e.g., CD4+ T cells, GITR receptors, OX40 receptors, IL-4+CD4+ Th2 cells, IL-17+CD4+ T-cells) and biomarkers such as annexin A2, hECGF.
Table 3

Summary of studies reporting genetic biomarkers in antibiotic-refractory LA in humans

Study

Biomarker class

Biomarker(s)

Assay

Summary of results

Lochhead et al. 2017 [12]

miRNA

miR-146a, miR142, miR17, miR-155, miR-223, miR20a, let-7a, let-7c

PCR

miR-146a, miR142, miR17, miR-155, miR-223 and miR20a were higher in post- vs. pre-antibiotic treated A-RLA

miR-146a, miR142, miR17, miR-155, miR-223, miR20a, let-7a and let-7c were higher in A-RLA compared with osteoarthritis

Lochhead et al. 2015 [29]

miRNA (extracellular)

miR-146a, miR-155 (inflammatory signature), miR-30fam (vascularization signature), miR223, miR142

qPCR

miR-146a, miR-155, miR-223 and miR-142 were higher in A-RLA compared with antibiotic-responsive LA

miR-146a, miR-155, miR-30fam, miR223 and miR-142 were upregulated in A-RLA compared with osteoarthritis patients

Strle et al. 2015 [28]

mRNA expression

SOCS3 mRNA expression in cells with 1805GG polymorphism in TLR1

QuantiGene and whole-genome RNASeq

Altered SOCS3 mRNA expression in A-RLA compared with antibiotic-responsive LA, i.e., greater inflammatory responses

Strle et al. 2011 [35]

SNPs

Frequency of 1805GG polymorphism in TLR1 gene

PCR

Frequency of the 1805GG polymorphism was lower in A-RLA compared with antibiotic-responsive LA

Steere et al. 2006 [26]

HLA typing and binding to OspA

HLA-DRB1-DQA1-DQB1/DRB1 allele frequency

High-resolution molecular HLA typing

HLA-DRB1-DQA1-DQB1 haplotype frequencies were similar between A-RLA and responsive LA

Larger number of A-RLA patients showed binding to OspA compared with antibiotic-responsive LA

SNPs single-nucleotide polymorphisms, TLR Toll-like receptors, OspA outer surface protein A, SOCS-3 suppressor of cytokine signaling-3, HLA human leukocyte antigen

Table 4

Summary of commonly upregulated biomarkers in antibiotic-refractory vs. -responsive LA in humans

Biomarker class

Biomarker

Specimens

Inflammatory markers

IL-6, IL-8, IL-10, IL-1β, IL-23, IL-17F, TNFα, IFNγ, CXCL9, CXCL10, CCL2, CCL3, CCL4, CRP

Serum and synovial fluids

Immunity-related markers

miR-146a, miR-155, miR-223 and miR-142, CD4+ T-cells, GITR receptors, OX40 receptors, IL-4+ CD4+ Th2 cells, IL-17+CD4+ T-cells and FoxP3+Treg cells

Peripheral blood and synovial fluids

Other markers

Annexin A2, hECGF

Serum and synovial fluids

Discussion

To date, there is a relatively limited evidence base of large, adequately powered studies to assess the predictive ability of biomarkers for A-RLA. Most studies presented here did not include more than 120 A-RLA cases. However, there is emerging information to suggest an array of both immunologic and genetic biomarkers that can be utilized in characterizing A-RLA. While most studies focused on immune response biomarkers, including cytokines, chemokines and immune cell typing, there were also a number of studies evaluating a range of genetic biomarkers, such as miRNAs, SNPs and haplotype frequencies that can be used to identify or predict a status of A-RLA in LB patients.

Of the genetic biomarkers that have been studied, there are several miRNAs that appear to be the highly promising. The miRNAs are small non-coding RNA molecules that function in post-transcriptional gene regulation [37, 38]. Altered miRNA expression has been implicated in the pathogenesis of several inflammatory and autoimmune diseases, including rheumatoid arthritis [39, 40]. In addition to inflammatory responses, miRNAs can also play a role in bone destruction and remodeling [41]. Only two studies examined differential miRNA expression in A-RLA patients in which some of the miRNAs identified here are consistent with those characterized in rheumatoid arthritis, i.e., miR-146a, miR-155, miR-223 and let-7a [39]. Other miRNAs, however, appear to be unique to A-RLA such as miR-142, miR-17, miR-20a, let-7c and miR-30fam [12, 29]. The miR-146 and miR-155 species are known to play a role in immune functioning as shown in mouse models where both were upregulated during B. burgdorferi infection [42, 43]. These studies demonstrated that miR-146a may act as a negative regulator of immune activation whereas miR-155 as a positive regulator [42, 43]. Important roles in cellular proliferation and regulation of inflammatory processes and responses were also suggested for miR-223 and miR-17 [44, 45, 46]. Higher levels of these miRNA species were reported in A-RLA patients [12, 29], indicating a status of dysregulated repair of the damaged tissue. With new insights into the roles of miRNAs in human diseases, it is likely that future research will reveal specific mechanisms through which these miRNAs contribute to A-RLA and how they may be used not only as predictive biomarkers of A-RLA patients but also as potential therapeutic targets.

There has been considerably more research on immune biomarkers as potential predictive factors of A-RLA. Of the most promising biomarkers examined, Th17-related cytokines appear to be of significant value. While several autoantigens have been identified that may be more prominent in A-RLA patients, such as MMP-10, annexin A2 [15, 33], apolipoprotein B-100 and ECGF [14, 15, 16, 19, 30, 32, 33], T-cell responses tend to occur later in LB manifestations and appear to be particularly associated with the manifestation of A-RLA [47]. Th17 cells are a subgroup of T-helper cells that have been shown to play a key role in autoimmune diseases, such as rheumatoid arthritis [48]. These cells are characterized by their ability to synthesize IL-17, a proinflammatory cytokine [49] previously implicated in the development of LA [8, 50]. Furthermore, inhibition of IL-17 was shown to inhibit the development of LA in mouse models infected with B. burgdorferi [51]. Findings from the present study indicate that IL-17F and IL-23 from Th17 cells are significantly elevated in A-RLA patients compared with antibiotic-responsive LA patients [13, 31]. The Th17 cells were also shown to play a role at the different LB stages in humans with a pronounced effect particularly at the early stages to help in combating the infection [13]. A continued Th17 response appears, however, to evolve at the later infection stages to trigger autoimmunity and lead to inflammatory arthritis [52]. Although their role in A-RLA in humans has yet to be fully elucidated, observations suggesting a role of the Th17 responses in the early as well as late stages of LB provide promise for their use in predicting disease complications, e.g., LA and/or A-RLA. In addition to Th17 responses, Th1 cells were also shown to play an important part in LA by providing a dominant immune response in the synovial fluid of LB patients [53]. Other Th1 response or innate immune response biomarkers that can be employed to differentiate A-RLA from the responsive LA phenotype include IL-6, IL-8, IL-10, IL-1β, IL-17F, IL-23, IFN-γ, TNF-α, CCL2, CCL3, CCL4, CXCL9 and CXCL-10 [13, 21, 27, 31].

Despite targeting an emerging field in LB research, the present study has a number of limitations. As previously mentioned, most of the selected studies recruited a small number of A-RLA cases (i.e., n < 120). These studies were likely, therefore, to be underpowered in detecting smaller changes in biomarker levels. In addition, a variety of controls were used between studies, which were typically healthy controls, other arthritis patients (i.e., rheumatoid arthritis, osteoarthritis) or antibiotic-responsive LA patients. This inconsistent selection on controls caused difficulty in generating a decisive evaluation for the predictive ability of the biomarkers across the studies and in the conversion of LA to A-RLA. Lastly, the reports included here were all case-control studies in which stored biospecimens were assessed retrospectively and may have not been standardized for all patients, e.g., in terms of timing for sample collection or if studies were multi-site in nature, leading to a lack of harmonized protocols across the selected studies. Furthermore, of the evaluated reports only one included examination of synovial tissue and synovial fluid [25]. It has been well documented that in LB patients with persistent arthritis, the spirochetes are preferentially detected in synovial tissue rather than synovial fluid [54]. This limitation may lead to an unsubstantiated conclusion that persistent spirochetal infection may be absent in A-RLA patients based on lack of synovial fluid testing.

As a few of the studies identified here were designed to examine the prediction of progression from LB to LA and subsequently to A-RLA, future studies need to be developed prospectively to adequately evaluate the predictive power of a selected set of factors from the biomarkers characterized here. Moreover, a comparison of the biomarkers proposed here—between patients with LA-related true joint swelling and those with joint pain—would be illuminating and can be proposed for future studies. Findings from these and other studies should also be validated against other similar study populations to evaluate the true predictive ability of the biomarkers of interest. Furthermore, future studies should investigate multiple biomarkers and combine both immune and genetic biomarkers to better compare—and strengthen—the prediction of A-RLA. It is likely that a combined biomarker approach in predicting resistance may yield the most clinical relevance as it examines multiple dysregulated pathways that play a concerted role in the etiology of A-RLA. Indeed, A-RLA is a joint disease that persists despite two-months of oral or one-month of intravenous antibiotics treatment [6] and may simply require prolonged antibiotic therapy beyond these limited courses [55]. Thus, the definition of “antibiotic refractory” appears to be an evolving concept, and the biomarker profiles described here could change with the different disease stages and therapy regimen.

Conclusion

In conclusion, the evidence base of biologic markers for A-RLA is limited to date. However, in the small set of studies conducted to date, a range of promising biomarkers have been identified. It appears that cytokines and chemokines related to the Th17 pathway together with a number of miRNAs species (miR-146a, miR-155 and let-7a) may be promising candidates in the prediction of A-RLA. Within well-powered and properly designed studies, a panel of multiple biomarkers may yield clinically relevant prediction of the possible antibiotic resistance at the time LA is first diagnosis.

Notes

Acknowledgements

Funding

Public Health Agency of Canada funded the work presented in this article and the article processing charges (AB).

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole and have given their approval for this version to be published.

Authorship Contribution

Alaa Badawi conceived the overall concept of the study and assisted in drafting the manuscript. Darren Brenner conducted the literature search and analysis and provided the first draft of the manuscript. Paul Arora advised on the analysis and assisted in interpretation of the results. All of the authors critically reviewed the manuscript, contributed substantive intellectual content and approved the final version submitted for publication.

Disclosures

Alaa Badawi, Darren Brenner and Paul Arora have nothing to disclose.

Compliance with Ethics Guidelines

This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors.

Data Availability

All data generated or analyzed during this study are included in this published article and supplementary information files.

Open Access

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Supplementary material

40121_2018_223_MOESM1_ESM.pdf (224 kb)
Supplementary material 1 (PDF 224 kb)

References

  1. 1.
    Radolf JD, Caimano MJ, Stevenson B, Hu LT. Of ticks, mice and men: understanding the dual-host lifestyle of Lyme disease spirochaetes. Nat Rev Microbiol. 2012;10:87–99.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Center for Disease Control and Prevention. How many people get Lyme disease? http://www.cdc.gov/lyme/stats/humancases.html. Accessed June 28, 2018.
  3. 3.
    Hinckley AF, Connally NP, Meek JI, Johnson BJ, Kemperman MM, Feldman KA, et al. Lyme disease testing by large commercial laboratories in the United States. Clin Infect Dis. 2014;59:676–81.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Government of Canada. Lyme disease. http://www.healthycanadians.gc.ca. Accessed July 24, 2018.
  5. 5.
    Steere AC, Sikand VK. The presenting manifestations of Lyme disease and the outcomes of treatment. N Engl J Med. 2003;348:2472–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Arvikar SL, Steere AC. Diagnosis and treatment of Lyme arthritis. Infect Dis Clin N Am. 2015;29(2):269–80.CrossRefGoogle Scholar
  7. 7.
    Franzen P. Antibiotic-refractory Lyme arthritis. Scand J Rheumatol. 2010;39(5):444.Google Scholar
  8. 8.
    Nardelli DT, Callister SM, Schell RF. Lyme arthritis: current concepts and a change in paradigm. Clin Vaccine Immunol. 2008;15(1):21–34.PubMedCrossRefGoogle Scholar
  9. 9.
    Steere AC, Gross D, Meyer AL, Huber BT. Autoimmune mechanisms in antibiotic treatment-resistant Lyme arthritis. J Autoimmun. 2001;16(3):263–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.  https://doi.org/10.1371/journal.pmed.1000097.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Nimmrich S, Becker I, Horneff G. Intraarticular corticosteroids in refractory childhood Lyme arthritis. Rheumatol Int. 2014;34(7):987–94.PubMedCrossRefGoogle Scholar
  12. 12.
    Lochhead RB, Strle K, Kim ND, et al. MicroRNA expression shows inflammatory dysregulation and tumor-like proliferative responses in joints of patients with postinfectious Lyme arthritis. Arthritis Rheumatol. 2017;69(5):1100–10.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Strle K, Sulka KB, Pianta A, et al. T-helper 17 cell cytokine responses in Lyme disease correlate with Borrelia burgdorferi antibodies during early infection and with autoantibodies late in the illness in patients with antibiotic-refractory Lyme arthritis. Clin Infect Dis. 2017;64(7):930–8.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Crowley JT, Strle K, Drouin EE, et al. Matrix metalloproteinase-10 is a target of T and B cell responses that correlate with synovial pathology in patients with antibiotic-refractory Lyme arthritis. J Autoimmun. 2016;69:24–37.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Pianta A, Drouin EE, Crowley JT, et al. Annexin A2 is a target of autoimmune T and B cell responses associated with synovial fibroblast proliferation in patients with antibiotic-refractory Lyme arthritis. Clin Immunol. 2015;160(2):336–41.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Crowley JT, Drouin EE, Pianta A, et al. A highly expressed human protein, apolipoprotein B-100, serves as an autoantigen in a subgroup of patients with Lyme disease. J Infect Dis. 2015;212(10):1841–50.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Londono D, Cadavid D, Drouin EE, et al. Antibodies to endothelial cell growth factor and obliterative microvascular lesions in the synovium of patients with antibiotic-refractory Lyme arthritis. Arthritis Rheumatol. 2014;66(8):2124–33.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Vudattu NK, Strle K, Steere AC, Drouin EE. Dysregulation of CD4+CD25(high) T cells in the synovial fluid of patients with antibiotic-refractory Lyme arthritis. Arthritis Rheumatol. 2013;65(6):1643–53.CrossRefGoogle Scholar
  19. 19.
    Drouin EE, Seward RJ, Strle K, et al. A novel human autoantigen, endothelial cell growth factor, is a target of T and B cell responses in patients with Lyme disease. Arthritis Rheum. 2013;65(1):186–96.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Katchar K, Drouin EE, Steere AC. Natural killer cells and natural killer T cells in Lyme arthritis. Arthritis Res Ther. 2013;15(6):R183.  https://doi.org/10.1186/ar4373.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Strle K, Shin JJ, Glickstein LJ, Steere AC. Association of a toll-like receptor 1 polymorphism with heightened Th1 inflammatory responses and antibiotic-refractory Lyme arthritis. Arthritis Rheumatol. 2012;64(5):1497–507.CrossRefGoogle Scholar
  22. 22.
    Shen S, Shin JJ, Strle K, et al. Treg cell numbers and function in patients with antibiotic-refractory or antibiotic-responsive lyme arthritis. Arthritis Rheumatol. 2010;62(7):2127–37.Google Scholar
  23. 23.
    Kannian P, Drouin EE, Glickstein L, Kwok WW, Nepom GT, Steere AC. Decline in the frequencies of Borrelia burgdorferi OspA161 175-specific T cells after antibiotic therapy in HLA-DRB1 0401-positive patients with antibiotic-responsive or antibiotic-refractory lyme arthritis. J Immunol. 2007;179(9):6336–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Kannian P, McHugh G, Johnson BJB, Bacon RM, Glickstein LJ, Steere AC. Antibody responses to Borrelia burgdorferi in patients with antibiotic-refractory, antibiotic-responsive, or non-antibiotic-treated lyme arthritis. Arthritis Rheumatol. 2007;56(12):4216–25.CrossRefGoogle Scholar
  25. 25.
    Shin JJ, Glickstein LJ, Steere AC. High levels of inflammatory chemokines and cytokines in joint fluid and synovial tissue throughout the course of antibiotic-refractory lyme arthritis. Arthritis Rheumatol. 2007;56(4):1325–35.CrossRefGoogle Scholar
  26. 26.
    Steere AC, Klitz W, Drouin EE, et al. Antibiotic-refractory Lyme arthritis is associated with HLA-DR molecules that bind a Borrelia burgdorferi peptide. J Exp Med. 2006;203(4):961–71.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Strle K, Jones KL, Drouin EE, Li X, Steere AC. Borrelia burgdorferi RST1 (OspC type A) genotype is associated with greater inflammation and more severe lyme disease. Am J Pathol. 2011;178(6):2726–39.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Strle K, Locchead R, Pianta A, Crowley JT, Arvikar S, Aversa J. Fibroblast-like synoviocytes shape and perpetuate the inflammatory immune responses associated with antibiotic-refractory lyme arthritis. Arthritis and Rheumatology Conference: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Scientific Meeting, ACR/ARHP; 2015. p. 1367.Google Scholar
  29. 29.
    Lochhead RB, Kim ND, Arvikar S, Strle K, Steere AC. Extracellular micrornas in synovial fluid reveal a marked proliferative signature in patients with antibiotic-refractory lyme arthritis. Arthritis and Rheumatology Conference: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Scientific Meeting, ACR/ARHP. 2015. p. 67.Google Scholar
  30. 30.
    Crowley JT, Drouin EE, Pianta A, et al. Matrix metalloproteinase-10 (stromelysin 2) is a target of robust autoimmune t and B cell responses in antibiotic-refractory lyme arthritis, but not in rheumatoid arthritis. Arthritis and Rheumatology Conference: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Scientific Meeting, ACR/ARHP; 2015. p. 67.Google Scholar
  31. 31.
    Strle K, Drouin EE, Steere AC. Th17 inflammatory responses occur in a subset of patients with erythema migrans or lyme arthritis, but are not predominant responses in joints. Arthritis Rheumatol. 2014;66:S866.Google Scholar
  32. 32.
    Crowley JT, Drouin EE, Wang Q, McHugh G, Costello CE, Steere AC. Apolipoprotein B is a target of T and B cell responses in a subgroup of patients with Lyme disease. Arthritis Rheumatol. 2014;66:S438.Google Scholar
  33. 33.
    Pianta A, Drouin EE, Arvikar S, Costello CE, Steere AC. Identification of annexin A2 as an autoantigen in rheumatoid arthritis and in Lyme arthritis. Arthritis Rheumatol. 2014;66:S437–8.Google Scholar
  34. 34.
    Vudattu NK, Drouin EE, Steere AC. High expression of GITR and OX-40 receptors on memory CD425 T cells in the joint fluid of patients with antibiotic-refractory lyme arthritis. Arthritis and rheumatism conference: annual scientific meeting of the American College of Rheumatology and Association of Rheumatology Health Professionals. 2011;63(10 suppl. 1).Google Scholar
  35. 35.
    Strle K, Shin JJ, Glickstein L, Steere AC. A toll-like receptor 1 polymorphism is associated with heightened T helper 1 responses and antibiotic-refractory Lyme arthritis. Arthritis and rheumatism conference: annual scientific meeting of the American College of Rheumatology and Association of Rheumatology Health Professionals. 2011;63(10 suppl. 1).Google Scholar
  36. 36.
    Uhde M, Ajamian M, Li X, Wormser GP, Marques A, Alaedini A. Expression of C-reactive protein and serum amyloid A in early to late manifestations of Lyme disease. Clin Infect Dis. 2016;63(11):1399–404.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Wahid F, Shehzad A, Khan T, Kim YY. MicroRNAs: synthesis, mechanism, function, and, recent clinical trials. Biochim Biophys Acta Mol Cell Res. 2010;1803(11):1231–43.CrossRefGoogle Scholar
  38. 38.
    Ambros V. The functions of animal microRNAs. Nature. 2004;431(7006):350–5.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Chen X-M, Huang Q-C, Yang S-L, et al. Role of micro RNAs in the pathogenesis of rheumatoid arthritis: novel perspectives based on review of the literature. Medicine. 2015;94(31):e1326.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Miao CG, Yang YY, He X, et al. New advances of microRNAs in the pathogenesis of rheumatoid arthritis, with a focus on the crosstalk between DNA methylation and the microRNA machinery. Cell Signal. 2013;25(5):1118–25.PubMedCrossRefGoogle Scholar
  41. 41.
    Ell B, Kang Y. MicroRNAs as regulators of bone homeostasis and bone metastasis. BoneKEy Rep. 2014;3:549.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Lochhead RB, Ma Y, Zachary JF, et al. MicroRNA-146a provides feedback regulation of lyme arthritis but not carditis during infection with Borrelia burgdorferi. PLoS Pathog. 2014;10(6):e1004212.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Lochhead RB, Zachary JF, Dalla Rosa L, et al. Antagonistic interplay between microRNA-155 and IL-10 during Lyme carditis and arthritis. PLoS One. 2015;10(8):e0135142.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Mogilyansky E, Rigoutsos I. The miR-17/92 cluster: a comprehensive update on its genomics, genetics, functions and increasingly important and numerous roles in health and disease. Cell Death Differ. 2013;20(12):1603–14.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Haneklaus M, Gerlic M, O’Neill LA, Masters SL. miR-223: infection, inflammation and cancer. J Intern Med. 2013;274(3):215–26.PubMedCrossRefGoogle Scholar
  46. 46.
    Shrestha A, Mukhametshina RT, Taghizadeh S, et al. MicroRNA-142 is a multifaceted regulator in organogenesis, homeostasis, and disease. Dev Dyn. 2017;246(4):285–90.PubMedCrossRefGoogle Scholar
  47. 47.
    Steere AC, Glickstein L. Elucidation of Lyme arthritis. Nat Rev Immunol. 2004;4(2):143–52.PubMedCrossRefGoogle Scholar
  48. 48.
    Tabarkiewicz J, Pogoda K, Karczmarczyk A, Pozarowski P, Giannopoulos K. The role of IL-17 and Th17 lymphocytes in autoimmune diseases. Arch Immunol Ther Exp. 2015;63:435–49.CrossRefGoogle Scholar
  49. 49.
    Tesmer LA, Lundy SK, Sarkar S, Fox DA. Th17 cells in human disease. Immunol Rev. 2008;223:87–113.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Codolo G, Amedei A, Steere AC, et al. Borrelia burgdorferi NapA-driven Th17 cell inflammation in Lyme arthritis. Arthritis Rheumatol. 2008;58(11):3609–17.CrossRefGoogle Scholar
  51. 51.
    Burchill MA, Nardelli DT, England DM, et al. Inhibition of interleukin-17 prevents the development of arthritis in vaccinated mice challenged with Borrelia burgdorferi. Infect Immun. 2003;71(6):3437–42.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Pfeifle R, Rothe T, Ipseiz N, et al. Regulation of autoantibody activity by the IL-23-TH17 axis determines the onset of autoimmune disease. Nat Immunol. 2017;18(1):104–13.PubMedCrossRefGoogle Scholar
  53. 53.
    Gross DM, Steere AC, Huber BT. T helper 1 response is dominant and localized to the synovial fluid in patients with Lyme arthritis. J Immunol. 1998;160(2):1022–8.PubMedGoogle Scholar
  54. 54.
    Nanagara R, Duray PH, Schumacher HR Jr. Ultrastructural demonstration of spirochetal antigens in synovial fluid and synovial membrane in chronic Lyme disease: possible factors contributing to persistence of organisms. Hum Pathol. 1996;27(10):1025–34.PubMedCrossRefGoogle Scholar
  55. 55.
    Middelveen MJ, Sapi E, Burke J, Filush KR, Franco A, Fesler MC, Stricker RB. Persistent borrelia infection in patients with ongoing symptoms of Lyme disease. Healthcare (Basel). 2018;6(2):E33.  https://doi.org/10.3390/healthcare6020033.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2018

Authors and Affiliations

  1. 1.Public Health Risk Sciences DivisionPublic Health Agency of CanadaTorontoCanada
  2. 2.Department of Nutritional Sciences, Faculty of MedicineUniversity of TorontoTorontoCanada
  3. 3.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  4. 4.Division of Enteric Diseases, National Microbiology LaboratoryPublic Health Agency of CanadaTorontoCanada
  5. 5.Cumming School of MedicineUniversity of CalgaryCalgaryCanada

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