0 Symbiotic Spirochetes In Animal Models

Recently, I noticed this intriguing item in the news that is of interest to many medical professionals around the world who are struggling to care for patients' difficult to eradicate C. difficile infections: A recent murine study[1] provided evidence that a simple mixture of six phylogenetically diverse intestinal bacteria - including novel species - can re-establish a health-associated microbiota and clear C. difficile infection from mice.

With this outcome, it's possible that medical professionals will no longer apply the treatment of last resort - fecal transplants - to save human patients' lives. Instead, all patients with raging C. difficile infections will have to do is swallow a pill or consume food that contains the strains of bacteria needed to reverse dysbiosis and rebalance the microbiota in their stomachs so that C. difficile is no longer a threat.

Over time, researchers are uncovering the complicated dynamic between different microorganisms which live inside the human gut. Also, they are refining their understanding of the dynamic between different microorganisms inside animals with increasing speed as more invasive studies can be completed in animals than can be easily completed in humans. Among these studies are those on the relationship between spirochetes and other microorganisms found in ruminants such as cattle and sheep, termites, and molluscs.

Symbiotic Spirochetes In Termites
 

Microscopic image of Mixotricha paradoxa
covered with thousands of Treponema spirochetes

One interesting and complex symbiotic relationship involving spirochetes is found within termites' guts. Spirochetes are one of the most abundant bacteria present in the gut fluid of termites, and the symbiotic relationship between various microbes in termites of all kinds actually predates the evolution of termites from their wood-feeding roach ancestors over 120 million years ago [2].

Most termites have spirochetes which are free-living in the gut fluid, but they have also been found as ectosymbionts attached to protists inside termite guts. Mixotricha paradoxa is protozoa found inside the gut of the Australian termite species, Mastotermes darwiniensis. It was originally thought the long tiny hair-like structures covering the length of its body were short cilia - outgrowths from the protozoa itself. However, upon closer examination years later, scientists Cleveland and Grimstone[3] discovered these were not cilia but a dense carpet of Treponema spirochetes - spirochetes which help propel Mixotricha paradoxa forward while it uses its own anterior flagella to steer in the right direction. How it coordinates this movement is unknown - it is surmised that they automatically synchronize due to their proximity.

These spirochetes not only help Mixotricha paradoxa move forward, though. One thing Mixotricha paradoxa does to help its host, the termite, do is help break down cellulose into sugars and then hydrogen, acetate, and carbon dioxide from the wood it eats. From there, what the Treponema spirochetes are predicted to do is oxidize the acetate which was produced and use it to support 100% of the termite's respiration requirements.[4]

What makes this symbiosis even more complex is that it doesn't stop there. No, not only does Mixotricha paradoxa have a Treponema spirochete helping it survive - but it also has three more bacterial species onboard: A lot of rod-shaped bacteria related to Bacteroides live on its surface, and is suspected to help breakdown cellulose as it sits alongside the Treponema spirochetes; a spherical form of bacteria lives inside Mixotricha which is hypothesized to act as mitochondria for the protozoa (as Mixotricha does not have its own mitochondria); a large spirochete attributed to the genus Canaleparolina.[5]

Not much is known about these three bacterial species' lives in Mixotricha paradoxa, and more research is needed. The most recent research on Mixotricha paradoxa adds to this complex symbiotic dynamic, as it has been discovered that not all glycolytic activities in Mixotricha paradoxa are produced by its microorganisms - cellulases have been detected in the salivary glands of Mastotermes darwiniensis - the termite itself.[6]

Symbiotic Spirochetes In Ruminants

The bovine or cow stomach has a wide variety of organisms inside it - such as fungi, bacteria, archaea, protista, and viruses. All these organisms help break down food, especially plant matter and in particular, cellulose. And like the Mixotricha paradoxa inside the Australian termite, Mastotermes darwiniensis, the organisms are all dependent on each other to some degree and use the byproducts of one another for their own benefit.

Cows - unlike people - have four stomach compartments to digest their food: the rumen, the reticulum, the omasum, and the abomasum. The rumen is the largest compartment, and it contains a huge number of different microbes. The reticulum is responsible for creating cud and trapping indigestible substances like rocks or nails - and unfortunately, can be subject to more injury than the other compartments. The omasum sends large substances to the rumen and reticulum while allowing smaller substances to pass on to the abomasum. And the abomasum is very similar to a human stomach, as it produces stomach acids and enzymes to break down proteins before sending the result to the small intestine.

While the most common bacteria in the bovine stomach are gram-positive cocci and rods, a smaller percentage of their population are spirochetes which play a role in ruminant digestion. Organisms such as Treponema bryantii, a saccharolytic spirochete, enhances the breakdown of cellulose while cellulolytic bacteria of different species break down plant cell walls into soluble sugars.

Two interesting passages from the publication, Interspecies bacterial interactions in biofilms, by James, Beaudette, and Costerton[7], highlight the relationship between Treponema bryantii and other microbes studied in vitro from bovine rumen:

"Observations of biofilms on cellulose particles from the rumen revealed cellulolytic as well as noncellulolytic bacteria enmeshed in the exopolysaccharide matrix of the biofilm. Addition of a noncellulolytic species, Treponema bryantii, to cultures of a cellulolytic species, Fibrobacter succinogenes or Ruminococcus albus, resulted in an enhanced rate of cellulose degradation. Presumably, T. bryantii utilized the hydrolytic products (eg, glucose or cellobiose) from the cellulolytic bacteria which may repress and/or inhibit the cellulolytic enzymes."

"...Microscopy of biofilms formed during protocooperative cellulose digestion by R. flavefaciens and T. bryantii revealed that cellulolytic R. flavefaciens cells were attached directly to cellulose particles, while the spirochete, T. bryantii, was located in the upper biofilm layers. This spatial arrangement and the mobility of spirochetes in viscous environments suggest that this organism may move through the biofilm, scavenging the products of the cellulolytic bacteria."

The first study of Treponema bryantii in 1980, Treponema bryantii sp. nov., a rumen spirochete that interacts with cellulolytic bacteria[8], offers more specifics in its abstract as to its biological requirements:

"...When cocultured in these media the spirochete used, as fermentable substrates, soluble sugars released from cellulose by the cellulolytic bacterium. In cellulose-containing agar medium the spirochete enhanced cellulose breakdown by the Bacteroides succinogenes strain. Electron microscopy showed that the helical spirochete cells possessed an outer sheath, a protoplasmic cylinder, and two periplasmic fibrils. Under a CO2 atmosphere, in a reduced medium containing inorganic salts, rumen fluid, glucose, and NaHCO3, the spirochete grew to a final density of 1.9 X 10(9) cells/ml. Succinate, acetate, and formate were products of the fermentation of glucose by growing cells. CO2 (HCO3-), branched short-chain fatty acids, folic acid, biotin, niacinamide, thiamine, pyridoxal, and a carbohydrate were required for growth of the spirochete."

Spirochete Symbiosis In Molluscs

While so far there is no evidence molluscs harbor spirochetes which have symbiotic relationships with its host or other microorganisms, spirochetes which coexist peacefully within their host are worth noting.

Spirochetes from the genus Cristispira have been found inside more than 50 species of 22 families of marine bivalves and 3 freshwater bivalves. It has been shown to be a commensal organism living within molluscs and has not been shown to provide any benefit or disadvantage to molluscs such as Prince Edward Island oysters.

This past May, an interesting paper was published, Spirochetes in gastropods from Lake Baikal and North American freshwaters: new multi-family, multi-habitat host records[9].

The abstract states:

"We describe the first records of spirochetes in the gut of fourteen species of continental gastropods from a range of habitats and representing six families (Amnicolidae, Baicaliidae, Bithyniidae, Pyrgulidae, Lithoglyphidae and Benedictiidae). The bacteria were mainly found in the crystalline style sac, as has been reported in marine bivalves. The surveyed habitats include water bodies in North America and Eurasia, including deep water hydrothermal vent and gas hydrate zones in Lake Baikal. Spirochetes were present both in mature and young snails, but were not detected in embryos before hatching, indicating lateral transfer. The surveyed gastropods range in trophic strategy, including phyto-, detrito- and bacteriophagous grazers and filter feeders. Our results indicate that spirochetes are commensal in the surveyed gastropods with potential limited benefit and no detriment to the host animal. We suggest that the specialized internal habitat of the crystalline style sac in molluscs is likely to reveal unrecognized spirochete diversity that will shed new light on gastropod trophic ecology and spirochete diversity."

More research is needed to determine which limited benefits different spirochetes may provide for their hosts.

Looking at the symbiotic and commensal relationships between animals and spirochetes - or between spirochetes and other microbes - one has to wonder what kind of relationships different spirochetes have with us and microbes within us. Humans already play host to spirochetes which are considered commensal Treponema and unfortunate hosts to spirochetes which are pathogenic such as those which cause syphilis and Lyme disease (Borreliosis). But is there more to this story than is often told? Do these bacteria have deeper relationships?

References:

1) Trevor D. Lawley, Simon Clare, Alan W. Walker, Mark D. Stares, Thomas R. Connor, Claire Raisen, David Goulding, Roland Rad, Fernanda Schreiber, Cordelia Brandt, Laura J. Deakin, Derek J. Pickard, Sylvia H. Duncan, Harry J. Flint, Taane G. Clark, Julian Parkhill, Gordon Dougan. Targeted Restoration of the Intestinal Microbiota with a Simple, Defined Bacteriotherapy Resolves Relapsing Clostridium difficile Disease in Mice. PLoS Pathogens, 2012; 8 (10): e1002995 DOI: 10.1371/journal.ppat.1002995
2) Grimaldi, D. and Engel, MS. Evolution of the insects. 2005. Cambridge University Press, NewYork, NY.
3) Cleveland, L.R., and A.V. Grimstone. The fine structure of the flagellate Mixotricha paraodoxa and its associated micro-organisms. 1964. Society 159:668-686.
4) Leadbetter, J.R. Acotgenesis from H2 Plus CO2 by Spirochetes from Termite Guts. 1999. Science 283:686-689.
5) Brugerolle G. Devescovinid features, a remarkable surface cytoskeleton, and epibiotic bacteria revisited in Mixotricha paradoxa, a parabasalid flagellate. Protoplasma. 2004 Oct;224(1-2):49-59.
6) Konig, H., Li Li, Wenzel, M, Frohlich, J.  Bacterial Ectosymbionts which Confer Motility. p. 86 Molecular Basis of Symbiosis. 2006. Springer-Verlag.
7) G A James, L Beaudette and J W Costerton. Interspecies bacterial interactions in biofilms. Journal of Industrial Microbiology & Biotechnology. Volume 15, Number 4 (1995), 257-262, DOI: 10.1007/BF01569978
8) Stanton TB, and Canale-Parola E. Treponema bryantii sp. nov., a rumen spirochete that interacts with cellulolytic bacteria. Arch Microbiol. 1980 Sep;127(2):145-56.
9) Tatiana Sitnikova,Ellinor Michel, Yulia Tulupova, Igor Khanaev, Valentina Parfenova, Larisa Prozorova. Spirochetes in gastropods from Lake Baikal and North American freshwaters: new multi-family, multi-habitat host records. Symbiosis. May 2012, Volume 56, Issue 3, pp 103-110.

Additional Reading:
Xinning Zhang and Jared R. Leadbetter. Evidence for Cascades of Perturbation and Adaptation in the Metabolic Genes of Higher Termite Gut Symbionts. mBio vol 3. no.4 e00223-12. http://mbio.asm.org/content/3/4/e00223-12.full
Nordhoff M, Wieler LH.Berl Munch Tierarztl Wochenschr. 2005 Jan-Feb;118(1-2):24-36 .[Incidence and significance of treponemes in animals].[Article in German]

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2 Article: Anaplasmosis Plus Lyme Disease In Dogs = Sick As Dogs

The West Salem Veterinary Clinic reposted part of an August 2011 article on its site in the La Crosse Tribune in Wisconsin recently.

The original article is found here:
http://westsalemvetclinic.vetstreet.com/blog/ticks

Here are two paragraphs I want share with all dog lovers out there:

Anaplasmosis phagocytophilum, previously known as Ehrlichia equi, is very prevalent in this area. It is spread by the same ticks as Lyme Disease and it can be a co-infection (both infections occurring at the same time) with Lyme Disease. Experts at IDEXX Laboratories, the manufacturers of the IDEXX SNAP® 4DX™ test, maintain that when a dog contracts Lyme disease or anaplasmosis alone, its immune system is more likely to suppress disease. However, a dog with both infections at once is more likely to become sick. IDEXX created the 4DX test to test for Heartworm, Lyme, Anaplasmosis, and Ehrlichia canis (another tick-borne disease that is not as prevalent in this area.)

If your dog shows any of the previously listed symptoms, he or she should be examined and tested. If your dog is positive for anaplasmosis, he or she should have a complete blood cell count performed to further evaluate for active disease. If your dog lives in this area, he or she should be on tick control year-round, screened with the 4DX test annually and vaccinated for Lyme Disease. Visiting dogs from other areas need tick control and screening as well. You cannot catch these diseases directly from your dog, but you are exposed to the same ticks in the environment as your dog, so be sure to use tick repellent on yourself and check for ticks on yourself as well as on your dog on a daily basis.

Now, my question is, how much more severe is the course of infection in humans who are infected by both Borrelia burgdorferi and Anaplasmosis phagocytophilum?


How do humans differ from dogs in this infectious disease model?

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0 Reader Mail Bag: What Lyme Disease Research Is Needed?

A reader, Misty, recently commented on my request for topics for discussion this week:

"I like all your ideas for topics - and hope you'll be able to continue posting. I love your "blog - it is one of the most sane Lyme sites on the web, if not the most sane and balanced.

What I wonder is - do we have enough information and diagnostic tools to be able to design useful studies on Lyme?

- we can't tell reliably who has it or doesn't
- the manifestations of Lyme in each person can be different and based on complications of co-infections and the genetic predisposition of the person to exaggerated inflammatory response
- then there is the pesky post-Lyme-Syndrome/Chronic Lyme issue of whether there is infection or post-infection inflammation

So, you may have covered it already, but I am interested in hearing about ideas for scientific studies - where is the research most needed?"

thanks,
misty

Well, Misty, addressing your questions and points:

I think we can design useful studies on Lyme disease even without being capable of accurately testing every patient who has Lyme disease. Improving serological testing and being able to accurately assess whether one has or does not have Lyme disease at present are only two pieces of the bigger picture, and there are more angles from which to approach the Lyme disease problem.

Research that can be useful in gaining a better understanding of what Borrelia burgdorferi and other Borrelia do is important to understanding how to effectively diagnose and treat infection and perhaps distinguish between patients who are affected by Lyme disease and those who are affected by a different condition.

Here's a few ideas I have on what to consider for further study:

1) Do a comparative study which looks at the proteins in the CSF of patients with chronic Lyme disease versus patients with late stage untreated and patients with acute Lyme disease.

Earlier this year, we've seen the study where hundreds of proteins were found in the CSF of patients with post-treatment Lyme disease symptoms and compared against patients with Chronic Fatigue Syndrome. The protein profile for each group was different, and each group's profile differed from healthy controls.

Let's take this study one step further, and see if there is a protein profile that distinguishes between patients who were designated as suffering from post-treatment Lyme disease symptoms and those who are  late stage and newly infected.

The outcome of this study may shed some light on what markers are present for different stages of the disease. Having different markers for different stages of the disease may help guide better test research and development.

References:
Steven E. Schutzer, Thomas E. Angel, Tao Liu, Athena A. Schepmoes, Therese R. Clauss, Joshua N. Adkins, David G. Camp II, Bart K. Holland, Jonas Bergquist, Patricia K. Coyle, Richard D. Smith, Brian A. Fallon, Benjamin H. Natelson. Distinct Cerebrospinal Fluid Proteomes Differentiate Post-Treatment Lyme Disease from Chronic Fatigue Syndrome. PLoS ONE 6(2): e17287. doi:10.1371/journal.pone.0017287 http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017287

2) Conduct longer term in vivo GFP and/or iRFP studies on mice and other mammals.

In this GFP protein study on mice, spirochetes' motion was monitored in vivo rather than in vitro (go to link to watch video of spirochetes attaching to endothelial walls). Rather than study it for as short a period of time as was done, a longer time frame for study as well as multiple studies over time in the same hosts would be educational.

With longer term imaging, one can see if spirochetes become intracellular and for how long. One can see which parts of the body they travel to and see them hide in immunological niches. One can see how likely different strains are to enter the CNS and how quickly they enter the CNS post-inoculation. (We already know specific strains are more neurotropic than others, but how serious a problem is this for the host? Does it depend on the host animal?)

Perhaps a GFP or iRFP study on mice could also be combined with an antibiotic treatment study. If we can trace the activity and polymorphic state of spirochetes in vivo, then we can see if antibiotics of specific types can affect "cyst"-like forms of spirochetes in vivo, too.

3) Repeat Klempner intracellular studies with a longer observation time and longer ceftriaxone infusion.

Also - give two weeks' ceftriaxone then provide no treatment for a few months. Try a different duration of ceftriaxone. Recheck the host animal for signs of infection at 3 months, 6 months, a year, then two years.

How can an in vivo study of this issue be completed?

References:
Kostis Georgilis, Monica Peacocke, and Mark S. Klempner. Fibroblasts Protect the Lyme Disease Spirochete, Borrelia burgdorferi, from Ceftriaxone In Vitro. Journal of Infectious Diseases. Vol. 166, pp. 440-444. 1992.
Mark S. Klempner, Richard Noring and Rick A. Rogers. Invasion of Human Skin Fibroblasts by the Lyme Disease Spirochete, Borrelia burgdorferi. The Journal of Infectious Diseases. Vol. 167, No. 5 pp. 1074-1081. May 1993. http://www.jstor.org/pss/30112679

4) Use new maltodextrin enhanced imaging study in animal subjects (and later people) to see where bacteria is.

This is a very new imaging method, but the advantages are clear: Maltodextrin is viewed by pathogenic bacteria as food, whereas regular mammalian cells (human, mouse, other) and even commensal or friendly bacteria in the gut do not view maltodextrin as food and they work to eliminate it.

With the addition of a maltodextrin contrast agent, one should be able to see where pathogenic bacteria are present in the body in vivo and do so safely.

And there's more:

"In experiments using a rat model, the researchers found that the contrast agent accumulated in bacteria-infected tissues, but was efficiently cleared from uninfected tissues. They saw a 42-fold increase in fluorescence intensity between bacterial infected and uninfected tissues. However, the contrast agent did not accumulate in the healthy bacterial microflora located in the intestines. Because systemically administered glucose molecules cannot access the interior of the intestines, the bacteria located there never came into contact with the probe. 

They also found that the probes could detect as few as one million viable bacteria cells. Current contrast agents for imaging bacteria require at least 100 million bacteria, according to the researchers. 

In another experiment, the researchers found that the maltodextrin-based probes could distinguish between bacterial infections and inflammation with high specificity. Tissues infected with E. coli bacteria exhibited a 17-fold increase in fluorescence intensity when compared with inflamed tissues that were not infected."

All of these items in bold are of particular interest to those wishing to see where Borrelia burgdorferi is present during infection. If - as a number of researchers have stated - Borrelia burgdorferi are actually low in number and produce high amounts of inflammation in tissues, maltodextrin contrast should be able to confirm this finding. We'd also have a better idea of where the bacteria is in vivo without having to do a tissue biopsy, and be able to detect biofilms if any have formed.

Initial studies should be conducted on animal models, and if proven safe and effective, I see no reason why human studies wouldn't follow.

References:
Xinghai Ning, Seungjun Lee, Zhirui Wang, Dongin Kim, Bryan Stubblefield, Eric Gilbert, Niren Murthy.Maltodextrin-based imaging probes detect bacteria in vivo with high sensitivity and specificity. Nature Materials, 2011; DOI: 10.1038/nmat3074
Scientific American: http://blogs.scientificamerican.com/lab-rat/2011/07/25/making-bacteria-visible/
Science Daily: http://www.sciencedaily.com/releases/2011/07/110718121605.htm
Nature: http://www.nature.com/nmat/journal/v10/n8/full/nmat3074.html

5) Complete more treatment studies on patients with documented late stage Lyme disease and coinfections such as Ehrlichiosis and Babesiosis.

If it's problematic to differentiate between those who suffer from a chronic, persisting infection and those who suffer from an autoimmune disorder, then circumvent the issue by finding people who are truly late stage, untreated Lyme disease patients who have coinfections and study how long it takes for them to get well on combination treatments.

Many Lyme patient activists promote more studies for those of us suffering from persistent post-treatment symptoms when perhaps it is more advantageous to first push for the study of patients who have never been treated and have evidence of late stage symptoms. There are far more studies on acutely infected patients than there are on late stage patients, and this needs to be addressed, I think, in order to bridge the gap between acute cases and post-treatment cases (chronic Lyme; PLDS) and work past any controversy.

6) Run comparative studies on all labs which conduct Lyme disease tests - C6/ELISA and Western Blot IgM and IgG.

Test all existing labs for sensitivity and specificity for various strains including Borrelia lonestari and miyamotoi - include the relapsing fever Borrelias. It would be informative to know how all the labs perform and why they receive the results they do.

These are just some of the ideas I have on studies which could be conducted that give us more answers.

Regardless of these suggestions, one has to be aware of the limitations of using animal studies to model what happens in human infection. For one thing,  even non-human primate studies may not show evidence of a Borrelia burgdorferi brain infection, even with an N40 strain of Bb which is neurotropic. For another, mice do not get brain infections and are thus a poor model for studying neuroborreliosis.

References:
Ramesh, G., Borda, J., Dufour, J., Kaushal, D., Ramamoorthy, R., Lackner, A., & Philipp, M. (2008). Interaction of the Lyme Disease Spirochete Borrelia burgdorferi with Brain Parenchyma Elicits Inflammatory Mediators from Glial Cells as Well as Glial and Neuronal Apoptosis. American Journal Of Pathology, 173 (5), 1415-1427 DOI: 10.2353/ajpath.2008.080483
Diego Cadavid, Tim O'Neill, Henry Schaefer, and Andrew R. Pachner (2000). Localization of Borrelia burgdorferi in the Nervous System and Other Organs in a Nonhuman Primate Model of Lyme Disease.Laboratory Investigation, 80 (7), 1043-1054

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0 News: In Wisconsin, Illnesses spread by ticks on rise

The Wisconsin Rapids Tribune has this article on tap today:

Illnesses spread by ticks on rise

Excerpts:

Consistent testing and an increase in deer ticks are driving up the number of tick-borne illnesses reported annually in Wisconsin, health officials said.

Statewide, cases of the bacteria infections anaplasmosis and ehrlichiosis -- both spread by deer ticks -- increased 70 percent from 2009 to 2010, when 546 cases were reported, according to state data.

"It's nice to be able to pick (anaplasmosis and ehrlichiosis) up, so a patient can be properly treated," said Diep Hoang Johnson, an epidemiologist for Wisconsin's Division of Public Health. "If lyme disease (tests) come back negative, they may not get treated and they may have one of these diseases."

and

"Marx said the increase in tick diseases other than lyme likely is because of more efficient testing and health care providers' improved efforts to report the illnesses."

Comments:

It's important to keep in mind that not every tick bite leads to a case of Lyme disease, and a negative Lyme disease test result does not necessarily mean the patient does not have Lyme disease (antibodies may not have been present at the time the test was taken) - nor does it indicate what other tickborne infections a person may have such as Ehrlichiosis or Babesiosis (as well as a few viruses which are spread by tick bites).

It's important for doctors and patients to familiarize themselves with the range of tickborne infections which are out there and be aware of the symptom spectrum for all them, as well as for doctors to take a detailed history from patients to see where they have traveled and resided to determine which tickborne diseases they are at greater risk of contracting. This provides a starting point for which coinfections to test for - but is by no means definitive as these diseases spread and even change in geographic location and density.

Read more of this news article at: http://www.wisconsinrapidstribune.com/article/20110828/CWS0101/108280518/Illnesses-spread-by-ticks-rise

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4 News: Abbott Introduces New Vector-Borne Pathogen Test

Excerpt:

Abbott's Ibis Biosciences today introduced a new molecular assay to detect a wide variety of vector-borne microorganisms, including those known to cause Lyme Disease, Rocky Mountain Spotted Fever, Babesiosis, Ehrlichiosis and Anaplasmosis.

The PLEX-ID™ Vector-borne test, which is intended for non-diagnostic use, has been designed to support bioresearch, environmental surveillance, and other activities central to the detection and identification of vector-borne pathogens.

Dr. Eshoo led a study in which vector-borne disease surveillance researchers in New York and Connecticut collected 299 blacklegged ticks. The ticks were analyzed using the Ibis technology for a wide range of vector-borne microorganisms. Results showed that two-thirds of the ticks were infected with B. burgdorferi, the agent of Lyme disease, and a third of these positive ticks contained other tick-borne co-infections such as Babesia microti or Anaplasma phagocytophilum. The research demonstrated that the Ibis technology can detect and identify B. burgdorferi as well as co-infection in ticks with other vector-borne pathogens quicker than traditional lab methods.

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9 Recap Of Dr. Zemel and Dr. Cameron Chat

ZEMEL VS. CAMERON

I'm going to be posting comments here during the course of the chat, then offer additional feedback here afterwards.

So far, this is off to a slow start. I don't know if it's the live chat software or if the servers are flooded with Lyme disease patients, but it's 10 minutes in and we barely have introductions. Dr. Cameron apparently wasn't logged in or having trouble logging in.

Okay, now things are moving along, and questions about testing are being posted by the audience. Questions on how to test for Lyme disease and on seronegative Lyme disease.

(I think that the servers are really busy - huge lag time on my end. I emailed my questions in advance, and I don't know if they are taking a combination of emailed questions or live - what is the deal here?)

Not that Milton! We said
Milton Carrero!

Milton Carrero, live chat moderator just wrote, "Because the questions are so many, and often similar I'm trying address the most prevalent topics associated with Lyme disease" - I suspect only a small fraction of questions and comments that got emailed or posted are showing up here and they may not ever pick mine. Or yours.

Okay, now we're getting a mix of questions and answers on different topics, some personal and some general. One man asks about the relationship between lipogranuloma cysts and late stage Lyme disease, a good question about the existence of chronic Lyme disease being investigated by an NIH study, the ineffectiveness of oral antibiotics for neurological Lyme disease, one mother's question about the relationship between her daughter's symptoms of anxiety and depression after Lyme disease...

Is Lyme disease underreported, why not continue to treat the patient if he is suffering, what is the role of coinfections, treatment approach by each organization, question about neurological testing... It's hard to keep up now, and the questions and answers are a jumble.

Okay, it looks like it's wrapping up now... Dr. Zemel has to leave even though Milton said an extra 15 minutes could be extended for the live chat.

My questions never made it into the chat - did any of yours?

In case you're wondering, here is a copy of what I sent out:

---

Mr. Carrero, I'd like to ask the following questions of Dr. Zemel and Dr. Cameron for Friday, July 1, chat on Lyme disease:

For Dr. Zemel, I have the following questions:

1) Since there is evidence that Borrelia burgdorferi can be intracellular and studies indicate a small number of spirochetes can survive antibiotic treatment, what further studies can be conducted to provide evidence of persistent post-antibiotic infection in human hosts? Are there any currently being done which address these issues?

2) What mechanisms does Borrelia burgdorferi use which lead to immune dysregulation in the human host, and what research do you know of being conducted now that could determine how to prevent immune dysregulation in the infected human host?

For Dr. Cameron, I have the following questions:

1) Do you and other members of ILADS compare case studies and have you been working on conducting your own clinical trials based on those case studies? Lyme patients are sorely in need of more research for effective treatment and hopefully shorter term treatment.

2) Have you and other members of ILADS considered writing a detailed, scientific book with citations that explains for both public and medical professionals why your treatment guidelines are more in line with the state of the science on Lyme disease? If not, would you? It would be great to have a better understanding why long-term treatment is an effective approach for a number of patients beyond their own success stories.

Thank you,

Camp Other

---

My general thoughts about the chat:

I think that a live, in-person presentation of the material would be more effective than the live chat presentation. One thing which kept happening is that even with leaving audience participation limited, questions and answers to those questions were being posted out of sync and hard to follow.

The answer to a previous question asked minutes ago would show up directly after a question which was just posted, making it difficult for the audience to line up questions and answers.
In a real time, in-person presentation, an answer would immediately follow a question. I would have preferred something along the lines of streaming video with a split screen that looked like a Presidential debate if I have to watch something like this again.

It's not clear to me from where Milton was drawing his questions at all times. Sometimes they seemed to be taken from email, and at other times from the live chat box. I wish that the Morning Call could put together a page showing all of the questions they'd been asked because I (and I'm sure others) are curious about what they are - and perhaps leave it up to Dr. Zemel and Dr. Cameron to address them in writing at a later time either for the Morning Call or elsewhere.

At any rate, my questions did not get asked. I'm wondering how much success I would have if I wrote the doctors directly.

Okay, comments on what was said:

"Dr. Lawrence Zemel: Approximately 10 percent of people who have had Lyme Disease will develop persistant symptoms following appropriate treatment. Most of these patients are no longer considered infected. Previous research has shown that at least 50 percent of people with "chronic Lyme Disease" never had Lyme Disease in the first place. We as physicians are obligated to treat these patients in the most humane and safe way possible."

Dr. Zemel, please provide references and citations for your statements. Up to 10 percent of early cases of infection have resulted in treatment failure and by extension, persisting symptoms. In a number of studies, the authors retreated individual patients - in some cases, with IV antibiotics when the study was based on oral antibiotics. They went on to improve, when they hadn't improved earlier. Do you call this a discrepancy, or is this a case where a garden variety Lyme disease infection became neuroborreliosis and researchers decided to give the patient additional treatment? Consider the real life scenario of a patient who fails early oral antibiotic treatment and does not go on to receive additional treatment when symptomatic. How do you differentiate between an individual case which requires more treatment versus one which has immediately become an autoimmune case?

Can you please cite evidence and research on how many patients with Chronic Lyme disease never had Lyme disease to begin with? I'd like to know more about that research.

It seems to me that between the IDSA Lyme disease guidelines panel's article in the NEJM and your comments that you tend to focus on this group of patients who never had Lyme disease in the first place. I know nothing about this group. Please focus on those of us who have had it and conduct more research for effective treatment for us. We deserve humane, safe, and effective treatment.

"Dr. Lawrence Zemel: Dr Cameron is correct: early treatment with antibiotics may blunt an antibody response, but at that point, no further treatment is needed."

But what about early treatment which is inadequate? Dr. Zemel, you're making an assumption that everyone who gets treated early has had enough antibiotics for a long enough duration of time. If a patient only receives 10 days of doxycycline - which is what some patients receive from their doctors (and not 21-28 days of oral antibiotics) is that enough? What if the patient has neuroborreliosis and they only receive a short course of doxycycline? What if they are allergic to doxycycline - could they have treatment failure from having had a shorter course of a third line choice which was not the most effective antibiotic to use for Borrelia burgdorferi?

A patient, Steve Hollingworth, had this to say:

"The NIH's study brief at http://www.clinicaltrials.gov/ct2/show/NCT01143558?recr=Open&cond=lyme+disease&cntry1=NA%3AUS&cntry2=EU%3AIE&age=1&rank=1 actually says "It is currently unknown why some patients continue to have symptoms. One possibility is that the antibiotics have not successfully gotten rid of all of the bacteria. Current tests for Lyme disease cannot tell whether the bacteria have been successfully eliminated from the body." Care to comment on that government statement?"

and

"In particular, how does the doctor expect an infection in the brain by the Lyme spirochete to be eradicated by oral antibiotics, when no appropriate oral antibiotic is capable of crossing the blood-brain barrier?"

Go Steve! Please keep asking these kinds of questions! This is the line of questioning which is sorely needed in these discussions.

Sadly, they never did answer your question about the NIH, did they? But you got this response from Dr. Zemel on your second one:

"Dr. Lawrence Zemel: Steve, CNS infections are treated with intravenous antibiotics. Thank you for sharing the other information."

Steve, I take it that this answer was inadequate for you? It was for me. While Dr. Zemel is technically correct, he is answering the letter of the question and not the spirit of it. His response didn't address my concern that a number of cases of neuroborreliosis are missed in diagnosis and not treated adequately. Dr. Brian Fallon has cited research which shows a relationship between neuroborreliosis and the development of chronic, persisting symptoms. Diagnosing and treating neuroborreliosis early on seems key to me in preventing persisting symptoms.

Backtracking a bit, I'd like to make a comparison here on the responses both doctors gave:

"Dr. Lawrence Zemel: There are at least 3 studies that demonstrated the lack of benefit from the use of long-term antibiotics, suggesting that persistent symptoms are no longer antibiotic sensitive.

Daniel Cameron: Dattwyler published several papers on Late Lyme disease with success. Donta also described successes, The original Logigian papers on neurologic LD also described successes. The Krupp clincal trial supported treatment."

Dr. Cameron, you get points for citing names for research. Dr. Zemel, given my knowledge and experience in the Lyme world, I know which studies you are likely to be referring to - but for the sake of the audience, please give names and citations for your studies.

I often wonder why in mentioning any studies on long-term antibiotic use, most of the media does not mention Dattwyler's research - given he is a member of the IDSA and has done a lot of Lyme research. Same goes for Logigian, who has cowritten work with Dr. Steere.

Biostatisticians such as Alison Delong have analyzed the raw data and data reporting on the clinical trials and studies related to the 2006 Lyme disease guidelines and came to the conclusion that while the studies were well designed, the data could be finessed in different ways and extended antibiotic treatment did, in fact, help a sub-population of the groups studied.Her team concluded that more research is necessary - something I've been saying all along.

Further discussion by both of you about the data on this sub-population would be very insightful for us all.

"Daniel Cameron: The three trials -Klemner's and Fallon describe patients ill an average of 4.7 to 9 years after treatment failures. Patients this severe for this long need much more support and treatment than was offered in the trials."

Dr. Cameron, where are these patients now? How are they doing? Were they on any treatment after the trials? Has anyone followed up on them?

Time for another comparison, this time on the issue of if Lyme disease is underreported:

"Dr. Lawrence Zemel: Most likely under reported. Estimates are that Lyme Disease may be two to three times more prevalent than the CDC data

Daniel Cameron: There are at least 10 time more cases than the 30,000 cases reported to the CDC per epidemiologist projections. The chief epidemiologist in Connecticut estimate in testimony there are 24 times the numbers in their state."

So, guys, you both agree on something: Lyme disease IS underreported, anywhere from 2 times the reported number of cases are out there on upwards of 10 times. What about the citation by the CDC of there being 6-12 times the number of reported cases in highly endemic areas?

Could we please hire more epidemiologists and expand surveillance? I noticed it's getting the lowest amount of funding from the NIH. Can you shift funding from another area even if funding isn't increased for 2012? I'd like to aim for a more accurate estimate here if nothing else.

"Dr. Lawrence Zemel: Dr Cameron's data is pure speculation. Current testing for the Lyme bacteria picks up all spirochetes in North America, at all commercial labs. One lab in California has not been shown to produce reliable results."

Dr. Zemel, please provide citations and research to support your claims. Last I checked, research indicated that Borrelia lonestari is not picked up by standardized lab tests for Lyme disease, and according to Durland Fish, neither is Borrelia miyamotoi. There may be other strains which have yet to be discovered which are not picked up.

I'm hoping that Dr. Ben Luft's research will lead to better testing in the future.

"Dr. Lawrence Zemel: Chris: Persistent symptoms may represent earlier tissue damage even though the bacteria is gone. Futher more, antibodies to the Lyme bacteria may be toxic. Persistent symptoms do not necessarily mean ongoing infection."

Dr. Zemel, can you explain how to detect evidence a patient has tissue damage, persistent infection, or a combination of both?

In stating that "antibodies to the Lyme bacteria may be toxic", could you explain more to me and everyone else reading along? This sort of statement requires clarification and sounds off a cause for concern in everyone not knowing what you mean.

"Daniel Cameron: Many of these chronically ill patients remain sick. Symptomatic treatment with pain medication, Lyrica, Neurontic etc often fail. Antibiotics have helped many of these patients."

Dr. Cameron, do you have a record of case studies on these patients? Have you conducted any larger scale studies on the treatment of post-treatment Lyme disease patients (to use Dr. Maloney's term, which is growing on me) which show which patients receive benefit from pain medication and which fail?

I'd be curious to know, because some subset of patients I know of have received some relief from pain medication while others have not. Do they have different conditions? I have also found some people have had abdominal pain and other pain is relieved by use of small doses of specific antidepressants and tranquilizing medications such as Ativan. Any comments on this?

"Daniel Cameron:
Krause first introduced the concept that Babesia and Lyme together can lead to a severe presentation."

True. Krause also wrote the Babesiosis treatment guidelines for 2006, if I recall correctly, and acknowledges that Babesia can relapse and may need additional treatment - especially in immunocompromised patients.

"Dr. Lawrence Zemel: Coinfections do not interfere with diagnostic testing. If patients have high fever and other flu like symptoms, then tests for anaplasma and Babesia are indicated."

You know what? This is a good response. But time and again, what I have noticed is that the reasonable response the ID doctor gives is not what is happening with people who are showing up to their primary care physician or urgent care clinic. Based on patients' own self reporting, what I hear about are people who were not accurately diagnosed early on by their family doctor and went on to develop more severe symptoms

If the agreed upon mantra between ILADS and IDSA doctors is "early treatment usually leads to success", Dr. Zemel, what is your organization doing to ensure patients get diagnosed and treated early on for both coinfections and Lyme disease, since coinfections can increase the severity and duration of symptoms?

"Dr. Lawrence Zemel: IDSA recommends oral antibiotics for 10-21 days for early Lyme Disease, one month for Lyme arthritis, and intravenous antibiotics for CNS disease or persistent arthritis."

Dr. Zemel, why is the treatment range such a wide number of days? How does a clinician make the decision to use 10 days versus 21 days? What if 10 days doesn't work - is retreatment advisable then?

If someone takes the recommended 2 tabs of doxycycline after a tick bite as prophylaxis, does that prevent a seropositive test from developing later if the prophylactic treatment fails and the patient goes on to develop Lyme disease later? This is important to know, and to let doctors know not to rely to heavily on tests and look at the clinical picture.

"Dr. Lawrence Zemel: Dr Cameron, while physicians have a right to treat with antibiotics, they have a responsibility to practice medicine in the safest way possible, following established scientific principles. Avoiding science is not in society's best interest."

I agree with this statement on face value. But I don't always agree with the implied statement behind it, which is, "long-term antibiotic treatment is not safe and is not scientifically supported".

I think that more research is required on this issue, in terms of efficacy, and I think that long-term antibiotic use confers the same kinds of risks for many different kinds of infections. One has to weigh the risks and benefits in any medical treatment, and recognize there will always be risks. For example, I had to get a colonoscopy and sign a paper before the exam, a paper telling me there was a small chance I could die from the procedure - miniscule - but the benefits outweigh the risk. Do you make sure you don't have colon cancer or do you avoid the small chance of death? Most people would go for the colonoscopy. (No cancer was found, thankfully!)

"Dr. Lawrence Zemel: Medicine should be practiced by physicians and not by politicians. Physicians should engage in a dialogue with their patients."

Microbiologists and molecular biologists will hopefully split the difference for you all.

I'm really tired of your infighting. Jane! Stop this crazy thing! I want to get off!

"Daniel Cameron: We need many more physicians to diagnosed and treat chronic Lyme disease. We will have less chronic LD if they are recognized early. Finally, more physcians will offer more options for patient within HMO's"

Dr. Cameron, I'm going to emphasize this bit: We need many more physicians to diagnose and treat Lyme disease, period. Early on, along with coinfections, so that people can avoid persistent symptoms.

Saying that more physicians and HMOs should be participating in increased early diagnosis and treatment is a positive statement on your end for both patients and for how it reflects on ILADS, because critics have stated that as long as ILADS stands to profit from their position there is no reason for the current situation to change.

"Dr. Lawrence Zemel: Insurance companies respond to evidence based medicine. Since there is no evidence, that IV therapy beyond 4-6 weeks is effective, they should rightfully deny coverage."

Dr. Zemel, what do you do about insurance companies denying patients access to any IV therapy to begin with? Let alone beyond 6 weeks?

"Dr. Lawrence Zemel: A small vocal group of constituents should not be dictating medical care."

Oh, I agree. But what does science have to say about this? If all we have is a hypothesis and not a proven and accepted theory, is it ethical to base treatment guidelines on a hypothesis or is more research required?

"Daniel Cameron: We need more dialogue among physicians to come to common ground for the increasing number of patient who fail treatment."

Yes, I agree here, too. But first and foremost, we need more research, more meticulously reported case studies, and clinical trials using antibiotic and non-antibiotic treatments. If you've got a hypothesis you want to provide evidence for, I'd like to see both sides actually do something about it to help patients.

More treatment studies, please? And more scientific research on Bb pathogenesis, please?

Are you familiar with William Burgdorfer's "thirty years quote"? I want to hear Dr. Zemel's response to it.

"Dr. Lawrence Zemel: Lois: Most physicians are now testing for Lyme Disease if there is a reasonable likelihood that Lyme disease is present. It is probably not accurate to say that Lyme Disease is still underdiagnosed in most Lyme areas."

Do you have references and evidence to support your statements? What about patients in the southeast US? The midwest? The west coast? Canada? There are many reports patients have given of being told by doctors that Lyme disease is rare and not in their area when according to what limited epidemiological data is on record and their state health departments, Lyme disease is not rare. How do you recommend closing this gap between doctors' knowledge and knowledge of other institutions?

More Q & A:

"[Comment From Dedee]
Is it common for scientific principles to not be challenged? New discoveries cannot be made without challenging science."

"Dr. Lawrence Zemel: Dedee: I entirely agree with you. This is why scientific guidelines are continually updated. The problem occurs when the public and wayward physicians ignore the science."

It's a good question, Dedee. And Dr. Zemel, it's a good answer.

The problem is, I think treatment and diagnosis is lagging behind the science at the moment, and that right now, not enough is understood about chronic Lyme disease and Lyme disease's pathogenesis to effectively treat everyone in a timely fashion.

When one makes the statement, "We don't know what causes persisting symptoms", what that should mean is "We don't know what causes persisting symptoms". Period. The rest is speculation, and what the cause is may not be a uniform, one-size-fits-all answer. This is why I ask for more research, and I want to see more independent research from parties not invested in either "side", if there have to be sides at all.

Ah, look! This sounds like consensus. Sorta...

"[Comment From Ellen] My insurance will not cover the antibiotics my doctor prescribes and I can not afford them out of pocket. What are your thoughts on homeopathic and herbal treatments?"

"Dr. Lawrence Zemel: Ellen: I'm not aware of evidence to support alternative treatments in place of antibiotics. Can you please educate me?"

"Daniel Cameron:
Many of my patients with chronic issued try many different alternative medications. We need more research on new strategies."

I initially found it amusing that Dr. Zemel is asking for a patient to educate him on the use of alternative treatment. But then I got pissed off. As someone who is supposed to be upholding his own guidelines, if that patient needs antibiotics, he could be providing advice as to how to get authorization for antibiotics if they are medically necessary and/or advise further testing to substantiate her diagnosis for treatment. Instead, he is humoring her.

But in the end, the message I'm getting out of this: Alternative treatments are currently not evidence-based treatments for Lyme disease. Sure, people try them, and some may help with some symptoms - but we need more research on them.

"Daniel Cameron: ILADS published an evidence based guideline in 2004 reviewing the evidence. See our website at ILADS .org. We expect a new guideline soon. Many of our members are now publishing. The publication should help the dialogue."

I hope that you are providing more peer-reviewed-from-established-journal citations and references to support your guideline, and that we get to see it soon. I eagerly await the outcome of all this work you've been doing.

"Dr. Lawrence Zemel: The ILADS guidelines were reviewed by the British Health Agency and found to lack scientific credibility. Most major specialty organizations in North America and Europe have endorsed the IDSA guidelines."

Dr. Cameron, there's a reason why I said what I did above.

Interesting, Dr. Zemel. Could you please explain why each of these countries overseas have adopted IDSA's guidelines and not written their own, given that they have historically had somewhat different diseases and disease presentations? (This is becoming less the case with bird migration affecting infection distribution and rate.)

And then there are these differences in approach. Why is it in much of Europe doctors are trained to look for more cases of neuroborreliosis and treat them earlier on, whereas in the US they aren't? Recent evidence from EUCALB and your not-cited organizations state that the percentage of American-based Bb infected patients in Europe show a percentage of neurological symptoms equal to those found in European-based Bb infected patients. (It's in that recent Institute of Medicine report that was posted in April.)

Another patient weighs in...

[Comment From Julia Wagner]
Actually - while a dialogue will help, it is not uncommon in medicine to have multiple schools of thought that inform a physician, who can make the call that is best for that patient - the same approach should be used with Lyme - and physcians need to be educated that 2 schools of thought. Any scientist who vociferously opposes other thinking, is limited the potential for progress in medicine - we need to follow the science as it emerges, and not ignore or disparage this. The science just evolving last year was significant in explaining "chronic lyme" from the 13 subtrains genotyped by Dr. Luft with some having serious neuro sx and others a more limited easy to cure disease, to lymphadenopathy study finding spirochetes hiding in the lymphs as another means to evade the immune system. I so no reason why the IDSA should fight other points of view - physicians should be informed about emerging science period, and treat their patients to get them well. Chalking up all remaining symptons to "aches and pains of daily living" is not acceptable when other viable options have not been explored."

I've bolded what I particularly would want to emphasize of your good points - thank you for contributing to this discussion. We need more people to ask questions referring to the science related to Lyme disease.

PS Julia: Please have someone proofread your question or type it into Word or some other text editor to run it through spell check first. I know you didn't mean to post typos, but it makes it harder to read.

---

So after this, Milton asked questions about vaccines, but they went unanswered as the chat was shut down at 1 pm EST.

This is all I have to say on this for now.

What are your thoughts about it?

Refer to the original chat transcript here:
http://www.courant.com/health/mc-health-chat-lyme-disease,0,4675217.htmlstory

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4 Top 10 Tips For Doing Your Own Lyme Disease Research

Here are my top 10 tips to share for doing your own Lyme disease research. Pretty simple and straightforward - and if you have any to add, please share in comments below.

1) Use the scientific, Latin terms for everything. You can use common terms, too, but Latin will give you more results and more specific results.

Examples:

Instead of "Lyme disease" use "Borreliosis".
Instead of "Neuro Lyme" use "neuroborreliosis".
Instead of "Lyme bacteria" or "infection" use "Borrelia burgdorferi".

2) Find out which terms microbiologists and scientific researchers use in their own papers and classes and then apply them to your search.

Examples:

Instead of "coinfection" use "polymicrobialism" or "polymicrobial".
Instead of "can't think straight" use "cognitive symptoms".
Instead of "spinal tap" use "lumbar puncture".
Instead of "shooting and burning pains" use "paresthesia".
Etc. - you get the idea.

Look at online and offline medical dictionaries for words that describe your symptoms and plug those into a search engine.

3)  Move your search away from general Google search to Google Scholar. You can get specific results for only scientific papers and patents that way.


4) Whenever you don't understand a term, use Wikipedia for an explanation.

I add a note of caution here: Wikipedia is not always right, though it usually is correct on basic science definitions.

If you aren't sure, double-check by doing a more general search and rely on college and university web sites for definitions. You may want to restrict your domain search to .edu web sites.

5)  Read educational institution web sites in general.

You may be surprised to find out what research is being done now on Lyme disease and coinfections which hasn't been published yet. Bookmark these items and check PubMed for the university name and researcher(s) name(s) periodically, as a paper will eventually be published.

6) Passively collect research information on your own web site or inbox by using RSS feeds.

If you look at the right column of this page and scroll down, you will see a number of Lyme disease and other disease-related and alternative medicine articles that are directly getting posted to this site all the time.

You can do the same with your own web site - or if you don't have a web site - by using an RSS reader or by subscribing to an RSS feed that gets sent to your email address.

This way, research comes to you and you don't have to always go do a search for it.

7) Look at major professional organizations' web sites - even if you may not agree with everything said - at least you will know what's going on.

Read the IDSA's web site periodically and be aware of how they view the issues around Lyme disease and infectious diseases in general. See what the NIH, CDC, and organizations have to say, and even more, dig deeper and look at what people from those organizations say in their research on PubMed and other online publication hubs. Some of what you find may surprise you.

8) Look at major online science web sites geared towards  a more general audience  (not specifically written for professionals) periodically.

Science Daily is a good example of this, and if you look at the bottom of each article, you will often see a link to the original paper or source on which they based their article. Check out the original source for more information - often it leads to finding out about other research the same researchers did on Lyme disease and coinfections.

Also, use the search function in Science Daily to look up terms such as "Lyme disease", "Borrelia", "Babesia" and even "Malaria". You may find interesting articles and older research from their archives this way.

9) Buy microbiology, acarology, and entomology text books for cheap and used at college bookstores which are trying to get rid of all old textbooks, "fire sales",  Amazon.com, and independent used bookstores near you.

While these textbooks can be dated, you might find information in them that could be useful and give you ideas of where to search next. Note that a lot of the basic information on Lyme Borrelia hasn't changed - but there has been a more refined and detailed understanding of what Borrelia is about over time, though, and those details need to be picked up by reading more recently published papers and books. (I say this, stating that a lot of Lyme disease research I see being cited online for and by patients is a bit outdated - we need to update these sites to reflect the state of the science.)

(You can also see if any friends or relatives have some lying around they're willing to lend or give to you.)

10) Search various libraries online, and participate in your local interlibrary loan program.

Can't afford that $500. book on microbiology? See if you can borrow it through your library's interlibrary loan program.

You will usually have a shorter time limit on borrowing books that are in high demand - some books have to be returned in a week. So if you need more time to work on it, ask someone to copy select passages for you from it to make notes on them later after you return the book.

Also, in many areas you can sign up for a program that will allow others to pick up books for you at the library on your behalf if you are housebound and too ill to go out - see if your area has one and sign up if you need it. This is good program to use in general for any material you may want to borrow for your own personal use.

And a bonus, Number 11:

Have a family member, friend, or friend of a friend who is already studying clinical microbiology, molecular biology, and/or genetics (immunology is helpful, too) help you decipher what you don't understand - and to tell you whether or not they think the findings are significant and which questions are not answered by a particular study that would be useful to have answered.

This may be a tricker bit, because not everyone is going to either have the time to respond to your request for help on this or hold the belief that your research is not worth the effort because they may believe that Lyme disease cannot persist and you are wasting your time.

Unfortunately, this is the truth of it - but in the true spirit of scientific inquiry and basically being stubborn, some people may be willing to help you at least a little bit.

My advice here is the less well-known the person is to you, the better it is to keep personal details out of the query. Also, keep your email or discussion brief, polite, and to the point while avoiding discussing the controversy. This is not to invalidate or dismiss your experience - but being said out of practicality and diplomacy: Busy people are more likely to respond to something in an unbiased fashion if you keep it simple and short.

Happy researching!

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0 Phage Therapy and Borrelia burgdorferi

EDITED February 27, 2012 to include information on specific phages of B. burgdoferi.

Earlier this week, we discussed the use of phage therapy - the medical use of viruses found in nature that kill bacteria.

Phage therapy has been a part of regular medical treatment in Eastern Europe for over 85 years, but most of the research published has been in the Russian and Georgian languages since the primary former Soviet institution for the research and collection of a huge phage library has been in Tblisi, Georgia.

Eliava Institute of Tblisi, Georgia -
major bacteriophage research center

Those familiar with the Georgian language have stated that detailed documentation for double-blind controls was lacking in research mentioned, so the work as a whole wasn't taken seriously once translated. However, if research came from patient case studies, then documentation wouldn't require blind controls and simply record individual patients' responses. Either way, it is unknown to me how much of the research has been translated or has been made available for translation, given many people do not speak Georgian and because part of the research was written in the era of censorship in Soviet Georgia, some research may not have been published at all - even in a Russian translation.

Tbilisi's Eliava Institute, however, is not the only place in Eastern Europe that has conducted phage research - the Polish Academy of Science has a special institute that is also involved in phage research and therapy. You can learn about their current research here:
The Ludwik Hirszfeld Institute of Immunology and Experimental Therapy (Polish Academy of Science) and read specific research papers in English right here: Evergreen College Guide to Polish Phage Research.

Both of these institutions have had success in treating local patients as well as visitors from abroad. And with growing antibiotic resistance worldwide, one has to wonder why is it phage therapy isn't being used in the west to treat more patients? Why isn't it being used to treat Borrelia burgdorferi, the bacteria which causes Lyme disease?

These are two different questions, one of history and politics, and one of science. To explore them both requires a bit more backstory and examination of the FDA's regulations regarding the adoption of new medical therapies.

In the 1990's, entrepreneurs from the US and Canada traveled to the Eliava Institute to investigate their use of phage therapy and see if they could use the same medical treatment to help patients in the United States. Due to the FDA's regulatory system on all new therapies - especially combination or "cocktail" drug therapies - the use of phage therapy on patients in the United States would be a long way off, and any company investing in phage therapy would be using it for other purposes first.

As a result, in the United States, phage therapy is being used as a spray to protect all kinds of food (the FDA approved of treating cheese first, then other foods) from developing Listeria monocytogenes, bacteria that can lead to severe infection and sometimes even be fatal in vulnerable populations. There have also been treatments developed for veterinary healthcare, such as ear drops for dogs to treat ear infections (otitis media), and the most recent application of phages is using them on surgical equipment and clinic surfaces.

The road to adopting phage therapy for use on treating people in the western hemisphere has been a somewhat rocky one, given that the first entrepeneurs who went to Tblisi and came back to form a phage therapy research startup company had a bit of a falling out: The main financial backer for the company, Canadian Caisey Harlingten, was rumored to have had arguments over who would receive patent rights on work created with the company's new CEO, Richard Honour, and Honour decided to shut down work being done at the Eliava Institute and develop genetically modified phages in the US.

After this, personnel which had been recruited from Tblisi to go work in the United States for Harlingten's company were not happy with this arrangement, jumped ship, and went on to form their own startup, Intralytix. Intralytix - unlike other pioneering phage startups - decided to focus on phage treatments for animals and general products instead of human therapy.

After three years of operating at a loss, Caisey Harlingten resigned from his company, Phage Therapeutics - as did Richard Honour and the chief financial officer.

Last I read, Phage Therapeutics was supposed to have a particular phage that kills 93% of a broad spectrum of over 1,000 of S. aureus and S. epidermidis strains that were isolated from patients in the US, Canada, and South America. This phage was supposed to have been in preclinical trials and was supposed to enter clinical trials against eye infections.

But somewhere along the line, Phage Therapeutics changed hands, their stock devalued, and I discovered that as of February 22, 2008, Phage Therapeutics International Inc. was acquired by Surge Solutions Group, Inc. in a reverse merger. SSGI, Inc., through its subsidiary, Surge Solutions Group, Inc., provides construction and environmental services in Florida. Nothing to do with phage technology. What happened to the above mentioned broad spectrum phage mix?

Where one company falls, others spring up to take their place. There are a growing number of startups in the phage business, but mostly doing business like Novophage, which specializes in using phages to remove biofilms from industrial equipment.

The first clinical trials using phage therapy were conducted in Europe and America. One clinical trial involved a cocktail of eight bacteriophages (five against Pseudomonas aeruginosa, two against Staphlococcus aureus, and one against Escherichia coli) on leg ulcers in 2008 at The Wound Care Center in Lubbock, Texas.  Following that trial, the Southwest Regional Wound Care Center used bacteriophages along with other methods to treat antibiotic-resistant infections under a limited study. Further information on this study has not been published to date.

Bacteriophages are being studied in fighting against E. coli infections in Bangladesh, and phase 2a clinical trials in the UK have been conducted for using phage therapy on chronic inner ear infections caused by Pseudomonas aeruginosa at the Royal National Throat, Nose, and Ear Hosptial in London. Very positive results on clinical and bacteriological efficiency and safety concerns have been reported on this latter trial.

In 2010, a nebulizer treatment using bacteriophages of Burkholderia cepacia complex (full text) to treat cystic fibrosis was developed, and earlier study was completed on the development of an inhaler to treat Staphylococcus aureus or Pseudomonas aeruginosa. So far, the inhalers have yet to be tested on people.

There is an international conference on bacteriophages that is held in Olympia, Washington, and hosted by Evergreen College. Dr. Elizabeth Kutter, professor of microbiology at the college took a keen interest in bacteriophage therapy years earlier, and had traveled to Tbilisi herself to investigate the treatment and their results. Since then, she has been actively pursuing research into bacteriophages and promoting it for use in medicine. The college has its own special phage projects page you can look at to see research conducted on phage therapy around the world.

Even though there is interest in bacteriophages, few clinical evaluations have been published on them because the data available are at a very early stage, making it difficult to attract further funding - and as mentioned earlier, the use of phage often involves a "cocktail" of more than one virus to treat a patient and this challenges the FDA's regulatory standpoint on cocktail treatments.

Also, using phage therapy in Eastern Europe focused mainly on treatment for wounds and intestinal infections - conditions which could be treated using phages topically in ointments, sprays, and dressings or capsules and enemas. Intravenous therapy (IV) - while used on occasion - did not make up the majority of treatments given, so little has been known about their effectiveness.

There is some evidence that phage therapy can work in IV therapy, but it was suggested that in this form it is more likely to come with a drawback: just as Lyme disease patients experience a Herxheimer reaction from antibiotic therapy, patients receiving phage therapy can also have a Herxheimer reaction from phage therapy. One veterinary study, though, has shown that no notable negative reactions or effects were noted (Soothill, 2004).

As as a commenter on my previous post mentioned, there are shortcomings as well as benefits to the use of phage. But overall, the risks of using phage therapy seem lower than those of antibiotics so far because the antibiotic resistance issue and risk of C. difficile are gone (someone is even working on phage therapy for C. difficile).

Despite the growing evidence that phage therapy can be safe and effective, there are some challenges that even people who are most unfamiliar with phage therapy have pointed out at least one of them:

• We don't know much about how phages interact with gut flora. Suspicions are most are benign if not helpful because we already have bacteriophages living in our stomachs and intestines all the time.
• Some research has shown one kind of phage - T-even bacteriophage - show inhibition of lysis in low-oxygen environments. 
• Both carbohydrates and bile salts can interfere with bacteriophages ability to replicate in the stomach. 
• If a bacteriophage that was lytic becomes lysogenic, it will integrate with its host, enabling it to transfer bacterial virulence genes into other bacteria. This is why therapeutic phages must be entirely lytic and cannot carry toxic or housekeeping genes associated with lysogeny.

Even though these drawbacks exist, research is underway to find solutions that address them because the risk of not having phage therapy can be worse for some patients with very deadly infections which are becoming increasingly antibiotic resistant.

Can phage therapy work on killing Borrelia burgdorferi?

So far I have not seen any phage therapy research for Borrelia burgdorferi - however, the Phage Therapy Center for patients in Tblisi, Georgia claims they have phage therapy to treat Lyme disease coinfections.

In terms of phage therapy for Lyme disease itself, though - the best answer I can give at this writing is a theoretical maybe someday.

This is based on the idea that there is a phage for every bacteria out there if we were only to look for it and find it. It's also based on the idea that we have the technology available to potentially modify Lyme disease's known phages in order to change its behavior - or perhaps create a delivery system which could lyse Borrelia in a manner that phage does.

But so far - unlike Staphloccocus and other bacteria - few phages which attack and kill Borrelia have been documented. Publications on virulent phages of Borrelia are sparse, and there is only a little more documentation on phages in spirochetes as a whole.

B3-like morphology
phage on spirochete

In 1982, Hayes, Burgdorfer, and Barbour recorded their observations of a phage attacking Borrelia burgdorferi in vivo and took photographs to record the event. The images captured are of a B3-like bacteriophage, described by the researchers as having a "40- to 50-nm elongated head and a tail 50 to 70 nm in length. It appears devoid of collars or kite-tail structure".

There are two aspects of these images below which are  compelling: One is that they give us a rare glimpse of a phage which can actually kill Borrelia burgdorferi. (Wouldn't it be fabulous if we could somehow find a way to harness this as a treatment method, and find phages for all strains of Borrelia?) The second is that we have a photo of gemmae - a form of Borrelia which is not mentioned much in today's genomic oriented Borrelia research.

•  (a) Section profile of a gemma with its attendant membrane bound granules or spherical bodies. Arrows indicate cross-section profiles of bacteriophage heads. (b) Internal attachment of bacteriophage to outer membrane material after plasmolysis of the spirochete. Arrows indicate remnants of plasma membrane.

A passage within the text, "Bacteriophage in the Ixodes dammini Spirochete, Etiological Agent of Lyme Disease", sheds some light on what is known about this phage and its relationship to Borrelia burgdorferi:

"Thus far, only those spirochetes showing left-handed coiling have been found to be phage infected. Figure ld shows phages that are associated with a spirochete with left-handed coiling. Bacteriophage heads in longitudinal and cross-sectional profiles were also observed within granules located within the aneurysmic blebs (Fig. 2a).

Completely assembled phages were more clearly seen in rarely occurring plasmolysed cells (Fig. le and 2b). In negatively stained preparations of spirochetes, they have only been detected internally (Fig. 2c). Bacteriophages previously reported to infect other spirochetes (15-17) are described as polyhedral and tailed (7) or cubic (5) in symmetry."

It appears that only those spirochetes which coil in a counterclockwise direction had phages. Why didn't any spirochetes with a clockwise coil have phages? Is there some inherent difference in their surface which makes it harder for phage to adhere to them?

In 1993, Neubert et al wrote about finding phage which were induced while introducing the antibiotic, ciprofloxacin, to Borrelia spirochetes. These A-1 and B-1 type phages were not virulent phages such as Hayes et al's B3-like phage.

The ultimate Borrelia book, "Borrelia: Molecular Biology, Host Interaction and Pathogenesis", has some passing mention of phages of Borrelia as well as a map of known and possible prophages in its plasmids. It also mentions a more recent discovery than Hayes, Burgdorfer, and Barbour's B3-like phage.

phiBB-1, prophage of
Borrelia burgdorferi

In 2001, Eggers et al published their discovery of a phage of Borrelia burgdorferi (Bb) named phiBB-1 (also written as φBB-1). It is not the best candidate for use in bacteriophage therapy because it is a prophage - also known as a temperate phage or lysogenic phage.

Lysogenic phages remain inactive as viruses when they are prophages, and only replicate together with the host genome unless mobilized. In contrast, virulent phages, having replicated and assembled into complete virions, cause rapid lysis and death of the bacterial cell, with release of 10–100 virions per phage; these virions then find more prey and die out when they cannot find any more bacteria.

Every time Borrelia burgdorferi divides, the viruses internalized in its plasmids divide with it. The viruses are an integral part of the plasmids and contribute to the functionality and antigenic variation of the spirochete - they have become part of the bacteria. In technical terms: The phiBB-1 prophage is capable of transducing a cp32 (circular plasmid) between cells of the same isolate and between different Bb isolates (gene transfer between different Borrelia spirochetes). This means this prophage could play a role in the genetic diversity of different Bb isolates.

Lytic-Lysogenic Phage Cycles
image by Suly12, Wikipedia

See the image to the left. If a bacteriophage is virulent, it will deposit its genes into bacteria so that it replicates and kills the bacteria from inside by lysing its membrane. The viruses then continue in search of more of the same bacteria to feast on. This is called the lytic cycle.

But if a bacteriophage is temperate or lysogenic, though - a prophage - then it will deposit its genes into bacteria so that they mix with the bacteria's own genes and divide with them each time the bacteria divides. This is called the lysogenic cycle.

Borrelia burgdorferi's plasmids contain virus genes which are locked into the lysogenic cycle.


Hypotheses Of Altering Phages To Lyse Borrelia

In order to put phiBB-1 to work at killing Bb, someone would have to genetically engineer it or introduce some agent which turns it into a virulent phage that kills Bb rather than adding its own DNA to its plasmids. Or, maybe phiBB-1 could be modified in a different way: don't bother changing its prophage nature, just program it to turn off DNA replication and gene expression in the bacteria's plasmids.

Another thing that could be done is to have someone extract the lysing proteins that work with phiBB-1 and find a method of delivery to Bb so those proteins could go to work on killing Bb outside in - maybe attach it to a non-pathogenic adenovirus that is programmed for such an adventure. There are such delivery systems being experimented with in general right now - but nothing yet for Borrelia.

These are wild hypotheses about how an existing phage we know about could be used to kill Bb, but it is not proven this would work. People are thinking of the biotech applications of phiBB-1 - but so far, I have seen only one patent application referring to its use.

The best option, obviously, would be to find naturally occurring phages which lyse Borrelia burgdorferi (as well as other strains) and find a method for using them to treat patients - though there are likely to be technical challenges in applying this as well.


References:
Wired magazine: http://www.intralytix.com/Intral_News_Wired.htm
A controlled clinical trial of a therapeutic bacteriophage preparation in chronic otitis due to antibiotic-resistant Pseudomonas aeruginosa; a preliminary report of efficacy. Wright A, Hawkins CH, Anggård EE, Harper DR. Clin Otolaryngol. 2009 Aug;34(4):349-57.
Viruses Vs. Superbugs: A Solution to the Antibiotics Crisis? By Thomas Häusler
Soothill, J.S. Hawkins, C. Anggard, E.A. & Harper, D.R. (2004) Therapeutic use of bacteriophages. Lancet Inf. Dis. 4, 544-545.
Microbiologist, the magazine of the Society for Applied Microbiology (June 2009, Vol.10 No.2)
Bacteriophage Therapy: Exploiting Smaller Fleas. Stan Deresinski. Clin Infect Dis. (2009) 48 (8): 1096-1101. doi: 10.1086/597405 link: http://cid.oxfordjournals.org/content/48/8/1096.full
Bacteriophage in the Ixodes dammini Spirochete, Etiological Agent of Lyme Disease. Stanley F. Hayers, Willy Burgdorfer, Alan G. Barbour. Journal of Bacteriology, June 1983, p. 1436-1439. link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC217620/pdf/jbacter00247-0414.pdf
Demonstration of Cotranscription and 1-Methyl-3-Nitroso-Nitroguanidine Induction of a 30-Gene Operon of Borrelia burgdorferi: Evidence that the 32-Kilobase Circular Plasmids Are Prophages. Hongming Zhang and Richard T. Marconi. Journal of Bacteriology. December 2005, Vol. 187, No. 23 p. 7985-7995.
Bacteriophages induced by ciprofloxacin in a Borrelia burgdorferi skin isolate. Neubert U, Schaller M, Januschke E, Stolz W, Schmieger H. Zentralbl Bakteriol. 1993 Aug;279(3):307-15. link: http://www.ncbi.nlm.nih.gov/pubmed/8219501 Bacteriophage-like particles associated with a spirochete. Berthiaume L, Elazhary Y, Alain R, Ackermann HW. Can J Microbiol. 1979 Jan;25(1):114-6.
link: http://www.ncbi.nlm.nih.gov/pubmed/427652
http://en.wikipedia.org/wiki/Lysogenic_cycle

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