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Gyllemark P, Sjöwall J, Forsberg P, Ernerudh J, Henningsson AJ. Intrathecal Th17-driven inflammation is associated with prolonged post-treatment convalescence for patients with Lyme neuroborreliosis. Sci Rep 2023; 13:9722. [PMID: 37322136 PMCID: PMC10272195 DOI: 10.1038/s41598-023-36709-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023] Open
Abstract
Lyme neuroborreliosis (LNB) is associated with increased levels of pro-inflammatory cytokines and chemokines in the cerebrospinal fluid (CSF). Residual symptoms after antibiotic treatment can have deleterious effects on patients and knowledge regarding the pathogenesis linked to prolonged recovery is lacking. In this prospective follow-up study, we investigated the B cell-associated and T helper (Th) cell-associated immune responses in well-characterized patients with LNB and controls. The aims were to assess the kinetics of selected cytokines and chemokines involved in the inflammatory response and to identify potential prognostic markers. We investigated 13 patients with LNB according to a standardized clinical protocol before antibiotic treatment and after 1, 6 and 12 months of follow-up. CSF and blood samples were obtained at baseline and after 1 month. As controls, we used CSF samples from 37 patients who received spinal anesthesia during orthopedic surgery. The CSF samples were analyzed for CXCL10 (Th1-related), CCL22 (Th2-related) and IL-17A, CXCL1 and CCL20 (Th17-related), as well as for the B cell-related cytokines of a proliferation-inducing ligand (APRIL), B cell-activating factor (BAFF) and CXCL13. The CSF levels of all the cytokines and chemokines, with the exception of APRIL, were significantly higher at baseline in patients with LNB compared with controls. All the cytokines and chemokines, except for IL-17A were significantly reduced at 1-month follow-up. Patients with quick recovery (< 1 month, n = 3) had significantly lower levels of CCL20 at baseline and lower levels of IL-17A at 1-month follow-up. Patients with time of recovery > 6 months (n = 7) had significantly higher levels of IL-17A at the one-month follow-up. No other cytokines or chemokines were associated with prolonged recovery. Dominating residual symptoms were fatigue, myalgia, radiculitis and/or arthralgia. In this prospective follow-up study of patients with LNB, we found significantly lower levels of CCL20 in those who recovered rapidly, and increased levels of IL-17A in patients with delayed recovery post-treatment. Our findings indicate persistent Th17-driven inflammation in the CSF, possibly contributing to a longer convalescence, and suggest IL-17A and CCL20 as potential biomarker candidates for patients with LNB.
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Affiliation(s)
- Paula Gyllemark
- Department of Infectious Diseases, Region Jönköping County, 551 85, Jönköping, Sweden.
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Johanna Sjöwall
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Infectious Diseases, Region Östergötland County, Linköping/Norrköping, Sweden
| | - Pia Forsberg
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jan Ernerudh
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anna J Henningsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- National Reference Laboratory for Borrelia and Other Tick-Borne Bacteria, Division of Clinical Microbiology, Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
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Tjernberg I, Gyllemark P, Zetterberg H, Blennow K, Ernerudh J, Forsberg P, Sjöwall J, Henningsson AJ. Cerebrospinal fluid markers of inflammation and brain injury in Lyme neuroborreliosis - a prospective follow-up study. Clin Chem Lab Med 2022; 60:1124-1132. [PMID: 35499913 DOI: 10.1515/cclm-2022-0097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/20/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate levels and kinetics of cerebrospinal fluid (CSF) markers of inflammation and brain injury in patients with Lyme neuroborreliosis (LNB). METHODS Adult patients with clinically suspected LNB were enrolled, in a prospective clinical study in the South East of Sweden. Patients were classified according to the European Federation of Neurological Societies' guidelines. Definite cases of LNB were re-examined one month later including a repeat CSF investigation. Routine laboratory parameters were investigated along with CSF levels of neurodegenerative markers glial fibrillary acidic protein (GFAp), total tau (t-tau) and neurofilament light protein (NFL), as well as neuroinflammatory markers soluble triggering receptor expressed on myeloid cells 2 (sTREM2), YKL-40 and CXCL13. Non-LNB served as controls. An additional comparison group consisted of spinal anesthesia subjects (SAS) without known central nervous system conditions. RESULTS CSF levels of sTREM2 and CXCL13 were elevated in definite LNB patients at diagnosis compared with non-LNB patients (p<0.001) and SAS (p≤0.01). In addition, CSF levels of sTREM2, YKL-40 and CXCL13 rapidly declined in at follow-up after antibiotic treatment. In contrast, CSF levels of GFAp and t-tau did not differ across LNB groups, and did not change after treatment. CONCLUSIONS Although in a limited number of LNB patients, the results indicate a predominance of microglial and neuroinflammatory involvement rather than parenchymal CNS injury in CSF at diagnosis of LNB with a prompt decline after antibiotic treatment. The findings provide pathogenetic insights and may be of value in differential diagnosis of CSF findings.
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Affiliation(s)
- Ivar Tjernberg
- Department of Clinical Chemistry and Transfusion Medicine, Region Kalmar County, Kalmar, Sweden.,Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden
| | - Paula Gyllemark
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,Department of Infectious Diseases, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jan Ernerudh
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden
| | - Pia Forsberg
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden
| | - Johanna Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,Department of Infectious Diseases in Östergötland, Linköping University, Linköping, Sweden
| | - Anna J Henningsson
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden.,National Reference Laboratory for Borrelia and Other Tick-Borne Bacteria, Division of Clinical Microbiology, Laboratory Medicine, Region Jönköping County, Linköping University, Linköping, Sweden.,Department of Clinical Microbiology in Linköping, Linköping University, Linköping, Sweden
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Haglund S, Lager M, Gyllemark P, Andersson G, Ekelund O, Sundqvist M, Henningsson AJ. CXCL13 in laboratory diagnosis of Lyme neuroborreliosis-the performance of the recomBead and ReaScan CXCL13 assays in human cerebrospinal fluid samples. Eur J Clin Microbiol Infect Dis 2021; 41:175-179. [PMID: 34626256 PMCID: PMC8732935 DOI: 10.1007/s10096-021-04350-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/16/2021] [Indexed: 12/02/2022]
Abstract
The chemokine CXCL13 is used as complement to serology in the diagnostics of Lyme neuroborreliosis (LNB). We evaluated and compared the semi-quantitative, cassette-based ReaScan CXCL13 assay with the quantitative recomBead CXCL13 assay using a collection of 209 cerebrospinal fluid samples. The categorical agreement between results interpreted as negative, grey zone, and positive by the two methods was 87%. The diagnostic sensitivity was higher using the recomBead assay, whereas specificity was higher using ReaScan. Few manual steps, and a short turn-around time with no batching of samples makes the ReaScan CXCL13 assay an attractive complement to serology in the diagnostics of LNB.
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Affiliation(s)
- Sofie Haglund
- Department of Laboratory Medicine in Jönköping, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Malin Lager
- Department of Laboratory Medicine in Jönköping, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Paula Gyllemark
- Department of Infectious Diseases, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gärda Andersson
- Department of Laboratory Medicine in Jönköping, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anna J Henningsson
- Department of Laboratory Medicine in Jönköping, Region Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Microbiology in Linköping, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden
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Melas N, Amin R, Gyllemark P, Younes AH, Almer S. Whipple's disease: the great masquerader-a high level of suspicion is the key to diagnosis. BMC Gastroenterol 2021; 21:128. [PMID: 33743602 PMCID: PMC7980341 DOI: 10.1186/s12876-021-01664-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/12/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Whipple's disease is a chronic infectious disease that primarily affects the small intestine, but several organs can simultaneously be involved. The disease is caused by a gram-positive bacterium called Tropheryma whipplei. The disease is difficult to suspect because it is rare with unspecific and long-term symptoms; it can be lethal if not properly treated. CASE PRESENTATION We here present three patients who presented with a plethora of symptoms, mainly long-standing seronegative arthritis and gastrointestinal symptoms in the form of diarrhea with blood, weight loss, fever, and lymphadenopathy. They were after extensive investigations diagnosed with Whipple's disease, in two of them as long as 8 years after the first occurrence of joint manifestations. The diagnosis was made by PCR targeting the T. whipplei 16S rRNA gene from small bowel specimen in all three patients, and, besides from histopathologic findings from the duodenum and distal ileum in one and mesenteric lymph nodes in another patient. CONCLUSIONS This report aims to raise awareness of a very rare disease that presents with a combination of symptoms mimicking other and significantly more common diseases.
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Affiliation(s)
- Nikolaos Melas
- Department of Gastroenterology and Emergency Care, Gävle Hospital, Gävle, Sweden
| | - Rasjan Amin
- Department of Anesthesiology and Intensive Care Unit, S:T Göran Hospital, Stockholm, Sweden
| | - Paula Gyllemark
- Department of Infectious Diseases, Region Jönköping County, Jönköping, Sweden.,Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Amil Haji Younes
- Department of Gastroenterology and Emergency Care, Gävle Hospital, Gävle, Sweden
| | - Sven Almer
- Department of Medicine, Karolinska Institutet, Solna, Sweden. .,Division of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
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Gyllemark P, Forsberg P, Ernerudh J, Henningsson AJ. Intrathecal Th17- and B cell-associated cytokine and chemokine responses in relation to clinical outcome in Lyme neuroborreliosis: a large retrospective study. J Neuroinflammation 2017; 14:27. [PMID: 28148307 PMCID: PMC5286657 DOI: 10.1186/s12974-017-0789-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/04/2017] [Indexed: 11/20/2022] Open
Abstract
Background B cell immunity, including the chemokine CXCL13, has an established role in Lyme neuroborreliosis, and also, T helper (Th) 17 immunity, including IL-17A, has recently been implicated. Methods We analysed a set of cytokines and chemokines associated with B cell and Th17 immunity in cerebrospinal fluid and serum from clinically well-characterized patients with definite Lyme neuroborreliosis (group 1, n = 49), defined by both cerebrospinal fluid pleocytosis and Borrelia-specific antibodies in cerebrospinal fluid and from two groups with possible Lyme neuroborreliosis, showing either pleocytosis (group 2, n = 14) or Borrelia-specific antibodies in cerebrospinal fluid (group 3, n = 14). A non-Lyme neuroborreliosis reference group consisted of 88 patients lacking pleocytosis and Borrelia-specific antibodies in serum and cerebrospinal fluid. Results Cerebrospinal fluid levels of B cell-associated markers (CXCL13, APRIL and BAFF) were significantly elevated in groups 1, 2 and 3 compared with the reference group, except for BAFF, which was not elevated in group 3. Regarding Th17-associated markers (IL-17A, CXCL1 and CCL20), CCL20 in cerebrospinal fluid was significantly elevated in groups 1, 2 and 3 compared with the reference group, while IL-17A and CXCL1 were elevated in group 1. Patients with time of recovery <3 months had lower cerebrospinal fluid levels of IL-17A, APRIL and BAFF compared to patients with recovery >3 months. Conclusions By using a set of markers in addition to CXCL13 and IL-17A, we confirm that B cell- and Th17-associated immune responses are involved in Lyme neuroborreliosis pathogenesis with different patterns in subgroups. Furthermore, IL-17A, APRIL and BAFF may be associated with time to recovery after treatment.
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Affiliation(s)
- Paula Gyllemark
- Department of Infectious Diseases, Region Jönköping County, SE-551 85, Jönköping, Sweden.
| | - Pia Forsberg
- Department of Clinical and Experimental Medicine and Department of Infectious Diseases, Linköping University, Linköping, Sweden
| | - Jan Ernerudh
- Department of Clinical and Experimental Medicine and Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden
| | - Anna J Henningsson
- Clinical Microbiology, Division of Medical Services, Jönköping, Region Jönköping County, Sweden
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Henningsson AJ, Gyllemark P, Lager M, Skogman BH, Tjernberg I. Evaluation of two assays for CXCL13 analysis in cerebrospinal fluid for laboratory diagnosis of Lyme neuroborreliosis. APMIS 2016; 124:985-990. [PMID: 27651242 DOI: 10.1111/apm.12596] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/26/2016] [Indexed: 11/29/2022]
Abstract
We evaluated the diagnostic performance of two assays, one bead-based assay and one enzyme-linked immunosorbent assay (ELISA), for the determination of CXCL13 levels in cerebrospinal fluid (CSF) from patients with suspected Lyme neuroborreliosis (LNB). Patients investigated for LNB were retrospectively included (n = 132): 35 with definite LNB, 8 with possible LNB with CSF pleocytosis but normal antibody index (AI), 6 with possible LNB with elevated AI but no CSF pleocytosis and 83 non-LNB patients. CSF samples had been drawn before antibiotic treatment and were analysed for CXCL13 by Quantikine ELISA (R&D Systems) and recomBead (Mikrogen). Receiver operating characteristic analyses based on the definite LNB and non-LNB groups revealed a best performance cut-off of 56 pg/mL for Quantikine and 158 pg/mL for recomBead (sensitivity and specificity 100% for both assays). When applying these cut-off levels on the study groups, the two assays performed equally well regarding sensitivity and specificity. In the group of patients with pleocytosis but negative AI, the majority of whom were children with short symptom duration, the CXCL13 analysis supported the LNB diagnosis in half of the cases. We consider CSF-CXCL13 analysis a useful diagnostic tool, in addition to Borrelia-specific AI, in laboratory diagnostics of LNB.
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Affiliation(s)
- Anna J Henningsson
- Department of Clinical Microbiology, Division of Medical Services, Region Jönköping County, Jönköping, Sweden.
| | - Paula Gyllemark
- Infectious Diseases, Region Jönköping County, Jönköping, Sweden
| | - Malin Lager
- Laboratory Medicine, Division of Medical Services, Region Jönköping County, Jönköping, Sweden
| | | | - Ivar Tjernberg
- Department of Clinical Chemistry and Transfusion Medicine, Kalmar County Council, Kalmar, Sweden.,Division of Microbiology and Molecular Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Henningsson AJ, Wilhelmsson P, Gyllemark P, Kozak M, Matussek A, Nyman D, Ekerfelt C, Lindgren PE, Forsberg P. Low risk of seroconversion or clinical disease in humans after a bite by an Anaplasma phagocytophilum-infected tick. Ticks Tick Borne Dis 2015; 6:787-92. [PMID: 26187418 DOI: 10.1016/j.ttbdis.2015.07.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 07/06/2015] [Accepted: 07/06/2015] [Indexed: 01/24/2023]
Abstract
The risk of contracting human granulocytic anaplasmosis (HGA) after a tick bite is mainly unknown. In this study we investigated the clinical and serological response in 30 humans bitten by ticks positive for Anaplasma phagocytophilum (Group A), 30 humans bitten by Borrelia burgdorferi sensu lato (s.l.)-positive ticks (Group B), and 30 humans bitten by ticks negative for both A. phagocytophilum and B. burgdorferi s.l. (Group C). Ticks, blood samples and questionnaires were collected from tick-bitten humans at 34 primary healthcare centres in Sweden and in the Åland Islands, Finland, at the time of the tick bite and after three months. A total of 2553 ticks detached from humans in 2007-2009 were analyzed by polymerase chain reaction, and 31 (1.2%) were positive for A. phagocytophilum, 556 (21.8%) were positive for B. burgdorferi s.l., and eight (0.3%) were co-infected by A. phagocytophilum and B. burgdorferi s.l. The overall prevalence of Anaplasma IgG antibodies in the included participants (n=90) was 17%, and there was no significant difference between the groups A-C. Only one of the participants (in Group C) showed a four-fold increase of IgG antibodies against A. phagocytophilum at the three-month follow-up, but reported no symptoms. The frequency of reported symptoms did not differ between groups A-C, and was unrelated to the findings of A. phagocytophilum and B. burgdorferi s.l. in the detached ticks. We conclude that the risk for HGA or asymptomatic seroconversion after a tick bite in Sweden or in the Åland Islands is low, even if the tick is infected by A. phagocytophilum.
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Affiliation(s)
- Anna J Henningsson
- Department of Clinical Microbiology, Ryhov County Hospital, S-551 85 Jönköping, Sweden.
| | - Peter Wilhelmsson
- Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, S-581 85 Linköping, Sweden
| | - Paula Gyllemark
- Department of Infectious Diseases, Ryhov County Hospital, S-551 85 Jönköping, Sweden
| | - Monika Kozak
- Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, S-581 85 Linköping, Sweden
| | - Andreas Matussek
- Department of Clinical Microbiology, Ryhov County Hospital, S-551 85 Jönköping, Sweden
| | - Dag Nyman
- The Åland Group for Borrelia Research, Bimelix Biomedical Laboratory, Torggatan 10, AX-22100 Mariehamn, Åland, Finland
| | - Christina Ekerfelt
- Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Linköping University, S-551 85 Jönköping, Sweden
| | - Per-Eric Lindgren
- Department of Clinical Microbiology, Ryhov County Hospital, S-551 85 Jönköping, Sweden; Division of Medical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, S-581 85 Linköping, Sweden
| | - Pia Forsberg
- Clinic of Infectious Diseases, Linköping University Hospital, and Department of Clinical and Experimental Medicine, Linköping University, S-551 85 Jönköping, Sweden
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