Susceptibility testing of Mycobacterium tuberculosis: comparison of the BACTEC TB-460 method and flow cytometric assay with the proportion method

Tuberculosis is a leading cause of morbidity and mortality worldwide. Susceptibility testing of the causative agent, Mycobacterium tuberculosis, is critical for control of the disease. This study compared the flow cytometric susceptibility assay with the proportion method and the BACTEC TB-460 system. There was agreement between the flow cytometric and proportion methods for 73 (94%) of 78 isoniazid tests, and complete agreement for 26 ethambutol and rifampicin tests. In contrast, the proportion and BACTEC methods failed to agree for 22%, 15% and 8% of isoniazid, ethambutol and rifampicin tests, respectively. These findings indicated that susceptibility testing by the flow cytometric assay is accurate, with results available within 24 h of initiation of the testing procedure.

Interleukin-6 enhances production of anti-OspC immunoglobulin G2b borreliacidal antibody

Protection against infection with Borrelia burgdorferi is dependent primarily on induction of complement-dependent antibody that can kill the spirochete. Measuring the production of sustained high levels of borreliacidal antibody is thus paramount for determining potential vaccine efficacy. We investigated the borreliacidal antibody response in sera and the amount of antibody produced by cultured lymph node cells of C3H/HeJ mice vaccinated with outer surface protein C (OspC). We showed that recombinant OspC was a weak stimulant of borreliacidal antibody production compared to whole cells of OspC-expressing B. burgdorferi. Mice vaccinated with B. burgdorferi in adjuvant produced a high level (titer, 5,120) of anti-OspC borreliacidal antibody, which waned rapidly. Similarly, borreliacidal antibody production by cultured lymph node cells from vaccinated mice peaked soon after vaccination and then decreased. Treatment of lymph node cells with interleukin-6 (IL-6) augmented borreliacidal antibody production, particularly immunoglobulin G2b, whereas treatment with anti-IL-6 inhibited the borreliacidal response. These findings demonstrate a previously unrecognized role for IL-6 in borreliacidal antibody production that may have important implications for vaccine development.

Production of borreliacidal antibody to outer surface protein A in vitro and modulation by interleukin-4

Borreliacidal antibody production is one of several parameters for establishing the effectiveness of Borrelia burgdorferi vaccines. The production of borreliacidal antibody was studied in vitro by culturing immune lymph node cells with macrophages and B. burgdorferi. We showed that borreliacidal antibody, directed primarily against outer surface protein A (OspA), was readily produced by lymph node cells obtained from C3H/HeJ mice vaccinated with formalin-inactivated B. burgdorferi in aluminum hydroxide, but not recombinant OspA. Anti-OspA borreliacidal antibody was detected in supernatants of cultures of lymph node cells obtained on day 7 after vaccination, peaked on day 17, and rapidly declined. The borreliacidal activity was attributable to immunoglobulin G1 (IgG1), IgG2a, and IgG2b antibodies. When lymph node cells were treated with interleukin-4 (IL-4), production of borreliacidal antibody was inhibited but was unaffected by treatment with anti-IL-4 antibodies. These results suggest that other cytokines, but not IL-4, are mainly responsible for production of the secondary borreliacidal antibody response.

Detection of borreliacidal antibodies in dogs after challenge with Borrelia burgdorferi-infected ixodes scapularis ticks

Detection of borreliacidal antibodies is an accurate serodiagnostic test for confirmation of Lyme disease in humans. In this study, 13 pathogen-free beagles, 12 to 26 weeks old, were infected with Borrelia burgdorferi by tick challenge. Dogs were monitored for clinical signs and symptoms of Lyme disease along with borreliacidal antibody production against B. burgdorferi sensu stricto isolates 297 and 50772. Ten (77%) dogs developed lameness in one or more legs within 210 days after attachment of Ixodes scapularis ticks. Eight (80%) of the lame animals had concurrent fever of > or =38 degrees C. Spirochetes were also recovered from the skin and joints of 12 (92%) dogs, but rarely from other organs. Borreliacidal antibodies against B. burgdorferi isolate 297 were detected in only four (31%) dogs, and the levels of killing antibodies remained low for the duration of the infection. In contrast, borreliacidal antibodies against B. burgdorferi isolate 50772 were detected in 13 (100%) dogs within 21 days of infection. Furthermore, the borreliacidal antibody levels correlated with the severity of B. burgdorferi infection. Detection of borreliacidal antibodies, especially against B. burgdorferi isolate 50772, is also a reliable serodiagnostic test for detection of Lyme disease in dogs.

Flow cytometric testing of susceptibilities of Mycobacterium avium to amikacin, ciprofloxacin, clarithromycin and rifabutin in 24 hours

OBJECTIVE

To develop a biologically safe flow cytometric susceptibility test that depends on detection and enumeration of actively growing Mycobacterium avium organisms in drug-free and antimycobacterial agent-containing medium.

METHODS

Prior to analysis by flow cytometry, all M. avium susceptibility test samples were inactivated by exposure to paraformaldehyde. The susceptibilities of 20 clinical isolates of M. avium to amikacin, ciprofloxacin, clarithromycin, and rifabutin were tested by the flow cytometric and BACTEC methods.

RESULTS

Agreement was 97% between the results of the two methods. The results of flow cytometric susceptibility tests were available 24 h after inoculation of drug-containing medium, while the BACTEC method required 4-8 days to complete.

CONCLUSIONS

The flow cytometric assay is safe, simple and reproducible.

Occurrence of severe destructive lyme arthritis in hamsters vaccinated with outer surface protein A and challenged with Borrelia burgdorferi

Arthritis is a frequent and major complication of infection with Borrelia burgdorferi sensu stricto. The antigens responsible for the induction of arthritis are unknown. Here we provide direct evidence that a major surface protein, outer surface protein A (OspA), can induce arthritis. Hamsters were vaccinated with 30, 60, or 120 microg of recombinant OspA (rOspA) in aluminum hydroxide and challenged with B. burgdorferi sensu stricto isolate 297 or C-1-11. Swelling of the hind paws was detected in 100, 100, and 50% of hamsters vaccinated with 30, 60, or 120 microg of rOspA, respectively. In addition, arthritis developed in 57% of hamsters vaccinated with a canine rOspA vaccine after infection with B. burgdorferi sensu stricto. When the canine rOspA vaccine was combined with aluminum hydroxide, all vaccinated hamsters developed arthritis after challenge with B. burgdorferi sensu stricto. Histopathologic examination confirmed the development of severe destructive arthritis in rOspA-vaccinated hamsters challenged with B. burgdorferi sensu stricto. These findings suggest that rOspA vaccines should be modified to eliminate epitopes of OspA responsible for the induction of arthritis. Our results are important because an rOspA vaccine in aluminum hydroxide was approved by the Food and Drug Administration for use in humans.

Evaluation of whole-cell and OspC enzyme-linked immunosorbent assays for discrimination of early lyme borreliosis from OspA vaccination

A recombinant Lyme borreliosis vaccine consisting of outer surface protein A (OspA) is commercially available for vaccination of humans against infection with Borrelia burgdorferi. Vaccination with OspA induces an antibody response that makes serologic interpretation of infection with B. burgdorferi difficult, especially by screening tests based on whole-cell preparations of B. burgdorferi. We show that an enzyme-linked immunosorbent assay with B. burgdorferi sensu stricto 50772, which lacks the plasmid encoding OspA and OspB, or a full-length recombinant OspC protein can identify patients infected with B. burgdorferi. We found that 69 and 65% of serum samples from patients with case-defined early Lyme borreliosis had anti-B. burgdorferi sensu stricto 50772 and anti-OspC reactivities, respectively. In addition, little or no reactivity was detected with sera obtained from individuals vaccinated with OspA. Unfortunately, 51 and 33% of sera from healthy patients and sera from patients with other illnesses were also reactive against B. burgdorferi sensu stricto 50772 and OspC, respectively. Although these assays can discriminate B. burgdorferi infection from vaccination with OspA, their lack of specificity highlights the necessity for confirming equivocal or positive reactivities with more specific serodiagnostic tests.

Detection of borreliacidal antibodies in Lyme borreliosis patient sera containing antimicrobial agents

The borreliacidal-antibody test has been used for the serological detection and confirmation of Lyme borreliosis. However, the presence of antimicrobial agents in serum can confound the accurate detection of borreliacidal antibodies. In this study, we developed a Bacillus subtilis agar diffusion bioassay to detect small concentrations of antimicrobial agents in serum. We also used XAD-16, a nonionic polymeric resin, to adsorb and remove high concentrations of amoxicillin, cefotaxime, ceftriaxone, cefuroxime, doxycycline, and erythromycin without significantly affecting even small concentrations of immunoglobulin M (IgM) or IgG borreliacidal antibodies. High concentrations of penicillin could also be removed by adding 1 U of penicillinase without significantly influencing the levels of borreliacidal antibodies. These simple procedures greatly enhance the clinical utility of the borreliacidal-antibody test.

Safe determination of susceptibility of Mycobacterium tuberculosis to antimycobacterial agents by flow cytometry

We showed previously that susceptibility testing for Mycobacterium tuberculosis labeled with fluorescein diacetate could be accomplished rapidly by using flow cytometry. However, safety was a major concern because mycobacteria were not killed prior to flow cytometric analysis. In this study, we developed a biologically safe flow cytometric susceptibility test that depends on detection and enumeration of actively growing M. tuberculosis organisms in drug-free and antimycobacterial agent-containing medium. The susceptibilities of 17 clinical isolates of M. tuberculosis to ethambutol, isoniazid, and rifampin were tested by the agar proportion and flow cytometric methods. Subsequently, all flow cytometric susceptibility test samples were inactivated by exposure to paraformaldehyde before analysis with a flow cytometer. Agreement between the results from the two methods was 98%. In addition, the flow cytometric results were available 72 h after the initiation of testing. The flow cytometric susceptibility assay is safe, simple to perform, and more rapid than conventional test methods, such as the BACTEC system and the proportion method.

Macrophages interact with enriched populations of distinct T lymphocyte subsets for the induction of severe destructive Lyme arthritis

Severe destructive Lyme arthritis was detected in the hind paws of hamsters infused with enriched populations of either CD4+ or CD4- T lymphocytes along with macrophages exposed in vitro to formalin-inactivated Borrelia burgdorferi and then infected with the Lyme spirochete. Swelling was detected 4 days after infection, increased rapidly, peaked on day 8 of infection, and gradually decreased. Similarly, severe destructive arthritis was induced in hamsters infused with enriched populations of unfractionated T lymphocytes and macrophages exposed to spirochetes after infection with B. burgdorferi. Histopathological examination affirmed that hamsters infused with CD4+, CD4-, or unfractionated T lymphocytes and macrophages exposed to B. burgdorferi-induced arthritis. In addition, macrophages exposed in vitro to B. burgdorferi demonstrated both conventional and coiling phagocytosis, suggesting a mechanism by which CD4+ and CD4- T lymphocytes induce arthritis, respectively. These findings demonstrate that both CD4+ and CD4- subpopulations of T lymphocytes are capable of interacting with macrophages for the induction of severe destructive Lyme arthritis.

Borreliacidal antibody production against outer surface protein C of Borrelia burgdorferi

Early Lyme borreliosis sera with significant titers of anti-outer surface protein C (OspC) borreliacidal antibodies were identified. Human anti-OspC borreliacidal antibodies could be either IgM or IgG. Significant concentrations of borreliacidal activity were detected after vaccination of mice with OspC. Detection of anti-OspC borreliacidal activity was dependent on surface expression of OspC by Borrelia burgdorferi isolate 50772. The ability of OspC to induce borreliacidal antibodies in vivo and after vaccination offers another possible explanation for the ability of vaccination with OspC to protect against infection with B. burgdorferi. Furthermore, detection of anti-OspC borreliacidal antibodies, especially IgM antibodies, in early Lyme borreliosis sera provides additional evidence that borreliacidal antibody detection may be useful for the serodiagnosis of early Lyme borreliosis.

Flow cytometric testing of susceptibilities of Mycobacterium tuberculosis isolates to ethambutol, isoniazid, and rifampin in 24 hours

Susceptibility testing of Mycobacterium tuberculosis is seriously limited by the time required to obtain results. We show that susceptibility testing of clinical isolates of M. tuberculosis can be accomplished rapidly with acceptable accuracy by using flow cytometry. The susceptibilities of 35 clinical isolates of M. tuberculosis to various concentrations of isoniazid, rifampin, and ethambutol were tested by the agar proportion method and by flow cytometry. Agreement between the results from the two methods was 95, 92, and 83% for isoniazid, ethambutol, and rifampin, respectively. Only 11 discrepancies were detected among 155 total tests. The results of flow cytometric susceptibility tests were available within 24 h of inoculation of drug-containing medium, while the proportion method required 3 weeks to complete. The flow cytometric method is also simple to perform.

Inhibition of the production of anti-OspA borreliacidal antibody with T cells from hamsters vaccinated against Borrelia burgdorferi

The serious morbidity associated with Lyme borreliosis has focused considerable effort on the development of a comprehensive vaccine for protection against infection with Borrelia burgdorferi. Induction of borreliacidal antibody by vaccination or infection has been shown to correlate with protection of humans and animals against infection with the Lyme spirochete. In this report, we showed that high levels of borreliacidal antibody (titer of 1,280) were produced in vitro when T and B cells from hamsters 14 days after vaccination were incubated with macrophages and B. burgdorferi. By contrast, T and B cells from hamsters 7 or 21 days after vaccination failed to initiate production of borreliacidal activity. Furthermore, the T cells from hamsters 7 or 21 days after vaccination inhibited the in vitro production of borreliacidal antibody when cocultured with T and B cells obtained from hamsters 14 days after vaccination. When cell-free supernatants from the suspensions of T and B cells from hamsters 14 days after vaccination were absorbed with recombinant OspA, they lost nearly all borreliacidal activity. The removal of anti-OspA antibody resulted in a decrease in borreliacidal titer from 1,280 to less than 4. These results demonstrate that T cells from vaccinated animals can prevent a sustained production of protective borreliacidal antibody.

Macrophages and enriched populations of T lymphocytes interact synergistically for the induction of severe, destructive Lyme arthritis

Hamsters receiving both macrophages exposed to Formalin-inactivated Borrelia burgdorferi (Mphi-FBb) and enriched populations of either immune or naive T lymphocytes developed severe swelling of the hind paws when infected with B. burgdorferi. Swelling was detected 6 days after infection, peaked on day 10, and gradually decreased. Swelling was also observed in the hind paws of hamsters infused with only Mphi-FBb or only enriched populations of either immune or naive T lymphocytes after infection with B. burgdorferi. However, the swelling detected in these hamsters was less severe and of shorter duration. In addition, hamsters receiving both macrophages not exposed to Formalin-inactivated B. burgdorferi (Mphi-NFBb) and enriched populations of either immune or naive T lymphocytes failed to develop severe swelling after infection with B. burgdorferi. No swelling was also observed in hamsters infused with both Mphi-FBb and enriched populations of immune T lymphocytes and then inoculated with spirochetal growth medium. We further showed that macrophages and enriched populations of T lymphocytes did not interact synergistically for controlling B. burgdorferi infection, as spirochetes were readily recovered from the tissues of all cell transfer recipients infected with B. burgdorferi. These findings demonstrate that hamsters infused with both Mphi-FBb and enriched populations of either immune or naive T lymphocytes develop a more fulminate arthritis after infection with B. burgdorferi than recipients infused with either cell type alone. These findings suggest that macrophages and T lymphocytes interact synergistically for the induction of severe, destructive Lyme arthritis.

Interlaboratory comparison of test results for detection of Lyme disease by 516 participants in the Wisconsin State Laboratory of Hygiene/College of American Pathologists Proficiency Testing Program

In 1991, we reported that 55% of laboratories participating in the Wisconsin Proficiency Testing Program could not accurately identify serum samples from Lyme disease patients containing antibody against Borrelia burgdorferi. The purpose of this study was to determine whether the accuracy of Lyme disease test results reported by approximately 500 participants in the Wisconsin State Laboratory of Hygiene/College of American Pathologists Lyme Disease Survey had improved. From 1992 through 1994, 50 serum samples were sent to participants of the survey. Each laboratory received 28 serum samples from individuals with Lyme disease according to the case definition of the Centers for Disease Control and Prevention and 22 serum samples from healthy individuals. Unfortunately, the serodiagnosis of Lyme disease by participants had not improved. The specificity of the Lyme disease assays steadily decreased from approximately 95% to approximately 81% during the 3-year period of the survey. False-positive test results approached 55% with some of the serum samples from healthy donors. A serum sample containing antibody against Treponema pallidum was reported as positive by 70% of the participants. In addition, the sensitivity fluctuated between 93 and 75%, depending upon the conjugate used by the laboratories. These results suggest that stronger criteria must be applied for approving and continuing to approve commercially available kits for the serodiagnosis of Lyme disease.

Rapid susceptibility testing of Candida albicans by flow cytometry

The emerging magnitude of human fungal infections has renewed interest in developing rapid and standardized methods for susceptibility testing. We demonstrated that susceptibility testing of Candida albicans can be accomplished rapidly by using flow cytometry. Test results were available within 8 to 24 h after C. albicans isolates were incubated with amphotericin B, itraconazole, and flucytosine. This is an improvement of 24 to 60 h in the time to availability of susceptibility test results compared to the time to availability of National Committee for Clinical Laboratory Standards-recommended broth macrodilution test results. In addition, the flow cytometric endpoints, mean channel fluorescence, and number of fluorescence-labeled C. albicans cells were easy to interpret for greater sensitivity and reliability. Flow cytometry provides a more accurate means of obtaining antifungal susceptibility test results.

Characterization of the protective borreliacidal antibody response in humans and hamsters after vaccination with a Borrelia burgdorferi outer surface protein A vaccine

Significant borreliacidal antibody was induced in volunteers and hamsters 60 days after primary and secondary vaccination with high concentrations of recombinant outer surface protein A (rOspA). However, the borreliacidal antibody response waned rapidly. Only 1 person had detectable cidal activity 180 days after vaccination. Similarly, the borreliacidal antibody response waned rapidly in hamsters by week 10 of vaccination. By contrast, the total anti-rOspA antibody response remained elevated in volunteers and hamsters. When isolates of Borrelia burgdorferi sensu lato were incubated in sera from vaccinated humans or hamsters, only the vaccine-specific isolate was killed. These results were confirmed by challenging rOspA-vaccinated hamsters with different isolates of B. burgdorferi sensu lato. The results showed that monitoring total rOspA antibody is inappropriate for evaluating the efficacy of an rOspA vaccine. The rOspA vaccine must be improved to yield comprehensive protection and maintain sustained levels of protective borreliacidal antibodies.

Sensitivity and specificity of the borreliacidal-antibody test during early Lyme disease: a "gold standard"?

The serodiagnosis of early Lyme disease has been plagued with problems of sensitivity and specificity. We found that the flow-cytometric borreliacidal-antibody test had a sensitivity of 72% for the detection of patients with early Lyme disease. By contrast, the sensitivity of the enzyme immunofluorescence assay was 28%. The enhanced sensitivity of the borreliacidal-antibody test was due to the use of Borrelia burgdorferi 50772, which lacks OspA and OspB. When B. burgdorferi 297, which expresses both OspA and OspB, was used, the sensitivity of the borreliacidal-antibody test was 15%. Our results also showed that the borreliacidal-antibody test was specific. No borreliacidal activity was detected in normal sera or in sera from patients with mononucleosis, rheumatoid factor, or syphilis. These results demonstrate that the flow-cytometric borreliacidal-antibody test may be the laboratory "gold standard" for the serodiagnosis of Lyme disease.

Macrophages exposed to Borrelia burgdorferi induce Lyme arthritis in hamsters

The mechanism(s) by which Lyme arthritis is induced has not been elucidated. In this study, we showed that macrophages have a direct, effector role in the pathogenesis of Lyme arthritis. Severe destructive arthritis was induced in recipients of macrophages obtained from Borrelia burgdorferi-vaccinated and nonvaccinated hamsters exposed to Formalin-inactivated B. burgdorferi in vitro and then challenged with the Lyme spirochete. Swelling of the hind paws was detected within 8 h of infection, increased rapidly, and peaked at 21 h. This initial swelling decreased, and by day 4 only slight swelling was detected. Severe swelling of the hind paws was detected 8 days after infection and increased rapidly, with peak swelling occurring on day 11. Histopathologic examination affirmed that macrophages exposed to Formalin-inactivated spirochetes induced a severe destructive Lyme arthritis. The onset and severity of the severe destructive arthritis were dependent on the number of macrophages transferred. By contrast, macrophages not exposed to Formalin-inactivated B. burgdorferi failed to induce severe destructive arthritis in recipients after challenge with B. burgdorferi. Similarly, severe destructive arthritis was not detected in recipients of macrophages injected with spirochetal growth medium. Our results also showed that transferred macrophages could not protect hamsters from infection with B. burgdorferi, as spirochetes were readily recovered from their tissues when cultured. These findings demonstrate that macrophages exposed to B. burgdorferi are directly involved in the induction of Lyme arthritis.

Lyme disease spirochetes in ticks collected from birds in midwestern United States

In a tick-spirochete survey conducted from all 1989 through fall 1992 in north-western Wisconsin, 4,256 birds (composed of 91 species) were examined for ticks. Infestations were recorded for 400 birds (composed of 30 species). Of 1,184 ticks taken from 335 birds (composed of 26 species), 60 (5%) Haemaphysalis leporispalustris (Packard) from 8 species of birds were infected with the Lyme disease spirochete. Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwalt & Brenner. Similar surveys conducted in 1990 and 1991 in Minnesota and Michigan yielded 223 H. leporispalustris from 61 birds (composed of 23 species), all free of spirochetes. However, 1 B. burgdorferi-infected Ixodes scapularis (Say) was found on 1 bird species in Minnesota. Most ticks were collected in fall from ground-foraging birds such as thrushes and sparrows. These results confirm that tick-infested birds are important in disseminating Lyme disease spirochetes and may also play a role as sources for infecting ticks.

Detection of anti-Borrelia burgdorferi antibody responses with the borreliacidal antibody test, indirect fluorescent-antibody assay performed by flow cytometry, and western immunoblotting

Borreliacidal antibodies participate in the resolution of Lyme disease by clearing Borrelia burgdorferi sensu lato from the host. Detection of borreliacidal antibodies is also valuable for determination of the specific serodiagnosis of Lyme disease. We show in this work that antibody detected by the borreliacidal antibody test did not correlate with antibody detected by the indirect fluorescent-antibody assay or Western immunoblotting. Detection of borreliacidal antibody decreased with elimination of the spirochete from the host in the presence or absence of therapy. By contrast, the antibody responses detected by the indirect fluorescent-antibody assay or Western immunoblotting remained elevated or continued to expand, respectively. This suggests that the borreliacidal antibody test is a prognostic indicator for clearance of the spirochete. Additional investigations with humans are needed to confirm the prognostic potential of the borreliacidal antibody test.

Abilities of OspA proteins from different seroprotective groups of Borrelia burgdorferi to protect hamsters from infection

The ability of vaccination with recombinant OspA from six seroprotective groups of Borrelia burgdorferi sensu lato to induce protection against infection with homologous and other Lyme spirochetes was examined in hamsters. Antisera generated against the OspA proteins of B. burgdorferi sensu stricto S-1-10 and C-1-11 (seroprotective groups 1 and 2, respectively), Borrelia afzelii BV1 (seroprotective group 4), and Borrelia garinii LV4 (seroprotective group 5) were able to kill the homologous spirochete in vitro but not other isolates. Surprisingly, antisera against B. afzelii PKo (seroprotective group 6) and B. burgdorferi sensu lato LV5 (seroprotective group 3) OspA proteins were unable to kill the homologous organism, although LV5 OspA antisera killed the heterologous isolates S-1-10 and LV4. In vivo vaccination studies supported the in vitro findings, confirming that vaccination with a single OspA protein does not provide complete protection against challenge with all Lyme disease spirochetes. In addition, OspA antibodies from some isolates may not protect against the homologous isolate. The induction of protective antibodies against other B. burgdorferi proteins may be necessary to insure a comprehensive Lyme disease vaccine.

Rapid susceptibility testing of Mycobacterium tuberculosis (H37Ra) by flow cytometry

The resurgence of tuberculosis has caused considerable effort to be focused on the development of rapid methods for determining the susceptibility of Mycobacterium tuberculosis to antimycobacterial agents. We demonstrated that susceptibility testing of M. tuberculosis can be accomplished rapidly by using flow cytometry. Results of tests were available within 24 h after M. tuberculosis organisms were incubated with ethambutol, isoniazid, rifampin, or streptomycin. The method was based on the ability of viable M. tuberculosis organisms to hydrolyze fluorescein diacetate (FDA) and the detection of fluorescent mycobacteria by flow cytometric analysis. The assay system also did not require multiplication of the mycobacteria. In contrast, M. tuberculosis organisms exposed to antimycobacterial agents hydrolyzed significantly less FDA. The use of flow cytometry and FDA staining shows considerable promise as a rapid method for obtaining susceptibility test results.

Detection of borreliacidal antibodies by flow cytometry. An accurate, highly specific serodiagnostic test for Lyme disease

BACKGROUND

Borreliacidal antibodies can be detected in serum samples from patients with early or late Lyme disease symptoms. When these serum samples are incubated with Borrelia burgdorferi and complement, spirochetes are rapidly killed. Detection of these antibodies can be used as a serodiagnostic test.

METHODS

Individual serum samples containing IgM or IgG borreliacidal antibodies were Used to develop a method for detection using flow cytometry. An additional 10 case-defined Lyme disease serum samples and 10 normal serum samples were used to confirm appropriate flow cytometric parameters. To determine specificity, 157 normal serum samples and 104 potential cross-reactive serum samples were tested for borreliacidal activity and antibodies to B burgdorferi using indirect fluorescent antibody or enzyme immunoassay.

RESULTS

Flow cytometry can be used to detect borreliacidal activity within 16 to 24 hours after incubation of B burgdorferi organisms. Lyme disease serum, and complement. Significant borreliacidal activity was detected in all Lyme disease serum samples. The percentages of positive normal serum samples were comparable (6% to 10%) using all three assays. In addition, the indirect fluorescent antibody and enzyme immunoassay identified 41 (39%) and 47 (45%) potential cross-reactive serum samples as positive, respectively. In contrast, significant borreliacidal activity was not detected in any potential cross-reactive serum samples.

CONCLUSION

Detection of borreliacidal antibody, unlike indirect fluorescent antibody and enzyme immunoassay, is an accurate, highly specific serodiagnostic test for detection of Lyme disease.

Development of destructive arthritis in vaccinated hamsters challenged with Borrelia burgdorferi

We present the first direct evidence that adverse effects, particularly severe destructive arthritis, can develop in vaccinated hamsters after challenge with Borrelia burgdorferi sensu lato isolates. Hamsters were vaccinated with a whole-cell preparation of Formalin-inactivated B. burgdorferi sensu stricto isolate C-1-11 in adjuvant. A severe destructive arthritis was readily evoked in vaccinated hamsters challenged with the homologous B. burgdorferi sensu stricto isolate C-1-11 before high levels of protective borreliacidal antibody developed. Once high levels of C-1-11 borreliacidal antibody developed, hamsters were protected from homologous challenge and development of arthritis. Vaccinated hamsters, however, still developed severe destructive arthritis when challenged with other isolates of the three genomic groups of B. burgdorferi sensu lato (B. burgdorferi sensu stricto isolate 297, Borrelia garinii isolate LV4, and Borrelia afzelii isolate BV1) despite high levels of C-1-11 specific borreliacidal antibody. Vaccines that contained whole spirochetes in adjuvant induced destructive arthritis, but this effect was not dependent on the isolate of B. burgdorferi sensu lato or the type of adjuvant. These studies demonstrate that caution is necessary when employing whole spirochetes in adjuvant for vaccination to prevent Lyme borreliosis. Additional studies are needed to identify the antigen(s) responsible for the induction and activation of arthritis and to define the immune mechanisms involved.

Seroprotective groups of Lyme borreliosis spirochetes from North America and Europe

Five distinct seroprotective groups among North American and European isolates of Borrelia burgdorferi sensu stricto, Borrelia garinii, and Borrelia afzelii have been identified using the in vitro borreliacidal assay. The predominant North American seroprotective group comprised isolate 297 and B. burgdorferi isolates from California, Illinois, Wisconsin, New York, and Texas. A second group was represented by isolate C-1-11. The majority of European isolates belonged to a seroprotective group composed of B. garinii. Another European group contained isolates classified genetically as genospecies group VS461 (B. afzelii). A fifth group, represented by isolate LV5, could kill both North American and European isolates of B. burgdorferi sensu lato. These results suggest that combinations of immunogenic protective proteins of spirochetes will be necessary to provide a comprehensive vaccine.

Ability of canine Lyme disease vaccine to protect hamsters against infection with several isolates of Borrelia burgdorferi

We used flow cytometry to determine levels of borreliacidal antibodies in hamsters after vaccination with a commercially available canine Lyme disease vaccine. In addition, we evaluated the ability of vaccinated hamsters to resist infection with several isolates of Borrelia burgdorferi. Borreliacidal antibodies could be detected 1 week after a primary vaccination, peaked at weeks 3 to 5, and then rapidly declined. One week after a booster vaccination, borreliacidal activity was detected at a dilution of 1:10,240, and it decreased fourfold by week 10 after the booster vaccination. Vaccinated hamsters were protected against infection with < or = 10(6) B. burgdorferi 297 organisms during the peak borreliacidal response (5 weeks after primary vaccination or 2 weeks after booster vaccination). However, hamsters were not fully protected from development of Lyme arthritis when the titer of borreliacidal antibodies was < 1:5,120. In addition, no significant borreliacidal activity was induced against B. burgdorferi C-1-11, LV4, or BV1, which belong to three other seroprotective groups. These studies demonstrate that vaccination with the canine Lyme disease vaccine induces protective antibodies against B. burgdorferi 297. However, significant levels of borreliacidal antibodies are not produced until 5 weeks after vaccination, and protection is short-lived. In addition, no borreliacidal activity was induced against other isolates of B. burgdorferi. Because of this, the incorporation of multiple isolates or protein subunits may be necessary to increase the effectiveness of future vaccines.

Differentiation of borreliacidal activity caused by immune serum or antimicrobial agents by flow cytometry

We demonstrated that borreliacidal activity caused by immune serum and complement can easily be differentiated by flow cytometry from killing activity caused by antimicrobial agents that are commonly used for the treatment of Lyme disease. Assay suspensions containing normal or immune serum were incubated with Borrelia burgdorferi in the presence or absence of ceftriaxone, doxycycline, penicillin, and phosphomycin for 2, 8, 16, and 24 h. Samples containing killing activity were identified by using flow cytometry and acridine orange. In 30 min, the effects of immune serum and complement were easily distinguished from the killing of spirochetes by antimicrobial agents by adding fluorescein isothiocyanate-conjugated goat anti-hamster immunoglobulin. This simple procedure greatly enhanced the usefulness of the borreliacidal assay by eliminating a major source of false-positive reactions.

Lyme disease: laboratory diagnosis and serologic testing

Although identified less than 20 years ago, Lyme disease has proved to be the most common tick-borne disease in the United States: some 10,000 cases were reported in 1992. In some cases the disease may be transitory and of little consequence but in others it may become chronic and severely disabling. Accurate diagnosis is, therefore, of great importance but, as this article shows, laboratory testing techniques still need improvement.

Detection of borreliacidal antibody by using acridine orange and flow cytometry

Borreliacidal antibody has been shown to be important for the serodiagnosis of Lyme disease and determination of immune status. Our results show that borreliacidal antibody can be rapidly and accurately detected by flow cytometry. Acridine orange was added to normal and immune sera containing Borrelia burgdorferi organisms in the presence and absence of complement prior to data acquisition by flow cytometry. The flow cytometric parameters of side scatter and detection of acridine orange fluorescence were used to determine events per minute (number of labeled spirochetes), percent shift in fluorescence (number of dead spirochetes), and mean channel fluorescence (intensity of fluorescence-labeled spirochetes) of acridine orange-labeled spirochetes. Borreliacidal antibody was detected as early as 4 h, with optimal detection 16 to 24 h after incubation of B. burgdorferi organisms with immune serum and complement. Our results also showed that complement was necessary for detection of borreliacidal antibody. Flow cytometry with acridine orange-labeled spirochetes provides a rapid means for detection of borreliacidal antibody.

Seroprotective groups among isolates of Borrelia burgdorferi

We demonstrated that different seroprotective groups exist among isolates of Borrelia burgdorferi and Borrelia garinii. The major group was composed of isolates 297, B31, S-1-10, MMTI, IPT, and ATCC 35211 and 21 isolates obtained from California, Illinois, New York, Texas, and Wisconsin. A second group was composed of European isolates PBi and G25. A third group was composed of a single isolate, C-1-11. These groupings were supported by Western immunoblot findings. In addition, the seroprotective groups were confirmed by passive transfer of immune sera and challenge of recipient hamsters with the homologous isolate or other isolates of B. burgdorferi or B. garinii. These studies demonstrate that a monovalent vaccine will not provide complete protection against infection with all isolates of B. burgdorferi.

Recovery of Borrelia burgdorferi by filtration

Bacterial contamination frequently interferes with successful recovery of the Lyme spirochete from cultures of tissue from Borrelia burgdorferi-infected humans, rodents, or ticks. We used 0.20- and 0.45-microns-pore-size syringe-tip filters to recover spirochetes from cultures contaminated with other bacteria. Low concentrations (1 to 10/ml) of B. burgdorferi organisms could be recovered from cultures seeded with 1 x 10(8) to 4 x 10(8) Staphylococcus aureus, Streptococcus faecium, Escherichia coli, or Bacillus subtilis organisms per ml. We also used this technique to recover B. burgdorferi from contaminated environmental and clinical cultures of B. burgdorferi. We conclude the filtration is an efficient method for recovering Lyme spirochetes from contaminated samples and increasing the number of successful isolations of B. burgdorferi.

Characterization of the borreliacidal antibody response to Borrelia burgdorferi in humans: a serodiagnostic test

An in vitro assay was used to characterize the borreliacidal activity of sera from Lyme disease patients. The mean percentage of killing was 23% with sera from patients with a single erythema migrans lesion, 42% from patients with multiple lesions, 58% from patients with Lyme arthritis of short duration, and 83% from patients with Lyme arthritis of long duration. Borreliacidal activity was abrogated when Lyme disease serum was treated with anti-human IgM or IgG1. In addition, human sera from Lyme arthritis patients containing borreliacidal antibody prevented the induction of Lyme arthritis in irradiated hamsters challenged with the Lyme spirochete. Removal of outer surface protein A antibodies from late Lyme disease sera caused reductions in the borreliacidal antibody titer. The results demonstrate an important role for borreliacidal antibody against infection with B. burgdorferi in humans and confirm that detection of borreliacidal antibody in human sera can be a specific serodiagnostic test for Lyme disease.

Performance of 45 laboratories participating in a proficiency testing program for Lyme disease serology

OBJECTIVE

We show that significant interlaboratory and intralaboratory variations exist in Lyme disease proficiency testing.

DESIGN

Six case-defined Lyme serum samples and three serum samples from individuals with no history of Lyme disease were randomized in four shipments and distributed to 45 participating laboratories.

RESULTS

Interlaboratory and intralaboratory performances were highly variable. Approximately 4% to 21% of laboratories failed to identify correctly positive serum samples with titers of 512 or more using polyvalent serum or immunoglobulin G conjugates. With lower levels of anti-Borrelia burgdorferi antibody in the serum sample, approximately 55% of participating laboratories did not identify a case-defined serum. There was also a striking inability of many laboratories to reproduce their results on split samples from the same individual. In addition, 2% to 7% of laboratories identified serum samples from individuals with no known exposure to B burgdorferi as positive using polyvalent serum. The false positivity rate increased to 27% with the use of immunoglobulin G conjugate.

CONCLUSIONS

Our results indicate that there is an urgent need for standardization of current testing methodologies. Until a national commitment is made, serological testing for Lyme disease will be of questionable value for the diagnosis of the disease.

In vitro susceptibilities of Borrelia burgdorferi to five oral cephalosporins and ceftriaxone

We determined the in vitro susceptibilities of eight Borrelia burgdorferi isolates to five oral cephalosporins. MICs for B. burgdorferi 297 were 23 micrograms/ml (cephalexin), 45 micrograms/ml (cefadroxil), 91 micrograms/ml (cefaclor), 0.13 microgram/ml (cefuroxime), 0.8 microgram/ml (cefixime), and 0.02 microgram/ml (ceftriaxone). When B. burgdorferi isolates were exposed to concentrations twice the MIC of cefuroxime, cefixime, or ceftriaxone, at least 72 h of incubation was required to kill 99% of the organisms.

Immunoglobulin G2 confers protection against Borrelia burgdorferi infection in LSH hamsters

We showed that immune serum and its immunoglobulin fractions, specifically immunoglobulin G2 (IgG2), could confer complete protection to irradiated hamsters challenged with the Lyme disease spirochete. Immune serum and its immunoglobulin fractions also killed Borrelia burgdorferi in vitro. Depletion of complement in vivo abrogated the ability of IgG2 to confer complete protection against B. burgdorferi. Furthermore, the majority of antibody reactivity directed against B. burgdorferi was found in the IgG2 fraction. These findings demonstrate that IgG2 plays an important role in acquired resistance against infection with B. burgdorferi. Additional studies are needed to determine the mechanism(s) by which B. burgdorferi evades host defenses despite the development of an effective borreliacidal antibody response.

Detection of borreliacidal antibodies in hamsters by using flow cytometry

Flow cytometry can be used to detect antibody that kills Borrelia burgdorferi. Borreliacidal activity was detected within 3 h of incubating B. burgdorferi with immune serum and complement. Right-angle light scatter and propidium iodide fluorescence were the cytometric parameters which correlated best with in vitro killing of B. burgdorferi. Flow cytometry is a rapid method for determining the presence of borreliacidal activity and may lead to a better serodiagnostic test for the detection of Lyme disease.

Depletion of complement and effects on passive transfer of resistance to infection with Borrelia burgdorferi

When irradiated hamsters are passively immunized with immune serum before challenge with Borrelia burgdorferi, they are completely protected from arthritis and infection. The complement dependency of this protection was addressed by treating hamsters with cobra venom factor. Depletion of complement abrogated the ability of immune serum obtained 1 and 10 weeks after infection to confer complete protection. By contrast, depletion of complement had no effect on the ability of 3-week immune serum to confer protection. These results suggest that complement-dependent, and possibly complement-independent, antibodies are important for preventing the induction of Lyme arthritis.

Lyme disease assay which detects killed Borrelia burgdorferi

We developed an in vitro assay showing that Borrelia burgdorferi organisms were killed by serum from patients with Lyme disease. Twenty of 20 Lyme disease serum samples caused B. burgdorferi killing in a range of 36 to 99% compared with the mean number of viable spirochetes when sera from 10 healthy individuals were used. The percentage of killing of B. burgdorferi increased with convalescent serum from patients with early Lyme disease. The borreliacidal activity was detectable in some sera diluted 640-fold and was abrogated after treatment with anti-human immunoglobulin G. In contrast, pooled or individual normal human serum did not cause a decrease in the number of viable B. burgdorferi. Borreliacidal activity was also not detected in sera from patients with relapsing fever, rocky mountain spotted fever, syphilis, mononucleosis, rheumatoid factor, or DNA antibodies. Our results show that borreliacidal activity can be used as a specific serodiagnostic test for detecting Lyme disease.

Borreliacidal activity of sera from hamsters infected with the Lyme disease spirochete

An in vitro borreliacidal assay that accurately reflects the levels of protective antibody determined by passive transfer of immunity studies was developed. Borreliacidal antibody in sera obtained from normal hamsters infected with Borrelia burgdorferi was readily detected. When immune serum containing complement was incubated with B. burgdorferi organisms, spirochetes were killed within 2 h. Treating immune serum with anti-hamster immunoglobulin G abrogated the borreliacidal activity. Killing of B. burgdorferi in serum was detected 1 week after infection; it peaked at week 3 and gradually declined. Relatively high levels of borreliacidal antibody were found, especially in week 3 immune serum, which could be diluted 1,280-fold. The decrease in borreliacidal antibody after infection may account for occurrences of reinfection and the remitting course of Lyme disease.

Isolation and characterization of Borrelia burgdorferi from Illinois Ixodes dammini

Ixodes dammini ticks from two northwestern Illinois sites were found to be infected with Borrelia burgdorferi at rates of 19 and 32%. B. burgdorferi isolates, one from each site, had protein and antigenic patterns similar to those of the B-31 strain. An indirect immunofluorescence method proved to be more sensitive than dark-field microscopy in detection of these spirochetes. A modified BSK medium containing rifampin was found to be more efficient for spirochete isolation than unsupplemented BSK medium.

Characterization of the protective antibody response to Borrelia burgdorferi in experimentally infected LSH hamsters

We show that serum obtained from normal hamsters infected with Borrelia burgdorferi can confer complete protection on irradiated recipients challenged with the Lyme spirochete. Borreliacidal activity was detected 7 days after infection, peaked at weeks 3 to 5, and thereafter decreased. Relatively high borreliacidal activity was detected in immune serum at weeks 3 and 5 of infection. The borreliacidal activity did not correlate with antibody used for the serodiagnosis of Lyme disease, which remained elevated throughout experimental infection. Our results also demonstrated that blocking antibody and antigenic variation in B. burgdorferi did not account for the decreasing titer of protective antibody. These findings indicate that protection against reinfection gradually wanes.

Lyme disease: clinical features, classification, and epidemiology in the upper midwest

Lyme disease can be classified using the terminology of syphilis. In this series of 95 cases from the upper midwest, early cases, defined as an illness of less than 2 months, were more likely to have lived in or recently visited a highly endemic area. Unlike late cases, early cases presented entirely in the nonwinter months (p less than .001). Early disease was further subdivided into primary and secondary disease. Ninety percent of primary and 43% of secondary cases had erythema migrans, while no late cases had active erythema migrans (p less than .001). Clinical manifestations of nonspecific inflammation, except for arthralgia, were more common in early than late disease (p less than .01). In secondary cases, monoarticular arthritis was slightly more common than polyarticular arthritis, with the reverse occurring in late disease (p less than .05). Indirect fluorescent antibody testing revealed a ratio of IgM to IgG antibodies to be helpful in distinguishing early from late disease. Antibacterial therapy in early, primary cases caused Jarisch-Herxheimer reaction 7% of the time. Despite longer and more frequent parenteral therapy, late Lyme disease frequently required retreatment, owing to poor clinical response (p less than .05).

Survey for Ixodes spp. and Borrelia burgdorferi in southeastern Wisconsin and northeastern Illinois

Forested areas adjacent to Milwaukee, Wis., and Chicago, Ill., were investigated for rodents and ticks infected with Borrelia burgdorferi, the causative agent of Lyme disease. White-footed mice (Peromyscus leucopus or Peromyscus maniculatus), meadow voles (Microtus pennsylvanicus), and eastern chipmunks (Tamias striatus) were captured; and specimens from these animals were cultured for B. burgdorferi to define whether the midwestern Lyme disease area currently encompasses these large metropolitan centers. During 1988, B. burgdorferi was successfully cultured from the tissues of two M. pennyslvanicus voles captured from the Chicago area. However, no Ixodes spp. ticks were captured. None of 274 animals captured from sites I3 and 12 additional sites in Wisconsin and Illinois during the summer of 1989 were infected with B. burgdorferi or Ixodes spp. In addition, no ticks were recovered when the underbrush in 11 contiguous areas was flagged. Apparently, B. burgdorferi is rarely found in these areas because of the absence of the appropriate tick vectors. Further studies are needed to monitor the dispersal of B. burgdorferi-infected Ixodes dammini into this heavily populated midwestern region.

Effects of bovine serum albumin on the ability of Barbour-Stoenner-Kelly medium to detect Borrelia burgdorferi

The ability of decreasing inocula of Borrelia burgdorferi to grow in otherwise identical Barbour-Stoenner-Kelly (BSK) media containing different lots of bovine serum albumin (fraction V) was determined. These media differed significantly in ability to detect B. burgdorferi. Some BSK media required inocula of 2 x 10(5) organisms per ml for detection, while other media could stimulate growth after inoculation with less than 2 organisms per ml. In addition, organisms from the less sensitive BSK media were thinner, longer, and less tightly coiled. The endpoint dilutions of indirect fluorescent-antibody titers, especially immunoglobulin M, exhibited up to 16-fold decreases, and both immunoglobulin G and M titers were more difficult to interpret with diagnostic slides prepared from some longer, thinner B. burgdorferi. These results demonstrate that, when performing laboratory investigations which rely on B. burgdorferi, it is essential that the quality of the BSK medium be determined.

Histopathology of Lyme arthritis in LSH hamsters

The authors studied the histopathologic evolution of arthritis in nonirradiated and irradiated hamsters infected with Borrelia burgdorferi. Nonirradiated hamsters injected in the hind paws with B. burgdorferi developed an acute inflammatory reaction involving the synovium, periarticular soft tissues, and dermis. This acute inflammatory reaction was short-lived and was replaced by a mild chronic synovitis as the number of detectable spirochetes in the synovium, periarticular soft tissues, and perineurovascular areas diminished. Exposing hamsters to radiation before inoculation with B. burgdorferi exacerbated and prolonged the acute inflammatory phase. Spirochetes also persisted longer in the periarticular soft tissues. A major histopathologic finding was destructive and erosive bone changes of the hind paws, which resulted in deformation of the joints. These studies should be helpful in defining the immune mechanism participating in the onset, progression, and resolution of Lyme arthritis.

Efficacy of the urinary bladder for isolation of Borrelia burgdorferi from naturally infected, wild Peromyscus leucopus

The efficacy of culturing urinary bladder tissue for Borrelia burgdorferi from naturally infected, wild Peromyscus leucopus mice was determined. The urinary bladder cultures were as efficient as spleen, kidney, and blood tissue cultures. The rapid B. burgdorferi isolation (mean, 6 days) from mouse urinary bladders should aid in defining new Lyme disease foci.