Volume 28, Number 4—April 2022
CME ACTIVITY - Research
Unique Clinical, Immune, and Genetic Signature in Patients with Borrelial Meningoradiculoneuritis1
Lyme neuroborreliosis (LNB) in Europe may manifest with painful meningoradiculoneuritis (also known as Bannwarth syndrome) or lymphocytic meningitis with or without cranial neuritis (peripheral facial palsy). We assessed host immune responses and the prevalence of TLR1 (toll-like receptor 1)–1805GG polymorphism to gain insights into the pathophysiology of these conditions. Regardless of LNB manifestation, most mediators associated with innate and adaptive immune responses were concentrated in cerebrospinal fluid; serum levels were unremarkable. When stratified by specific clinical manifestation, patients with meningoradiculoneuritis had higher levels of B-cell chemoattractants CXC motif chemokine ligand (CXCL) 12 and CXCL13 and T-cell–associated mediators CXCL9, CXCL10, and interleukin 17, compared with those without radicular pain. Moreover, these patients had a higher frequency of TLR1–1805GG polymorphism and more constitutional symptoms. These findings demonstrate that meningoradiculoneuritis is a distinct clinical entity with unique immune and genetic pathophysiology, providing new considerations for the study of LNB and borrelial meningoradiculitis.
Lyme borreliosis, which is caused by several species of the Borrelia burgdorferi sensu lato complex, is the most common vectorborne disease in the Northern Hemisphere. The first sign of infection is usually an expanding skin lesion, erythema migrans (EM), that appears within days or weeks at the site of the tick bite. If untreated, the infection may disseminate to involve other organ systems, including the central nervous system (CNS), heart, or joints (1,2).
Lyme neuroborreliosis (LNB) is the most common extracutaneous manifestation of Lyme borreliosis in Europe and the second most common such manifestation in North America (1,2). In Europe, LNB in adult patients typically begins as painful meningoradiculoneuritis (also known as Garin-Bujadoux-Bannwarth syndrome or Bannwarth syndrome), which is rare in the United States, or with cranial neuritis characterized by peripheral facial palsy (PFP) or lymphocytic meningitis (1–4). In addition, a subset of patients experience EM and symptoms indicative of LNB (e.g., headache, vertigo, concentration disturbance), but do not fulfill the European diagnostic criteria for LNB, namely cerebrospinal fluid (CSF) pleocytosis and intrathecal borrelial antibody production (5,6). This subset poses a particular diagnostic and clinical challenge because the etiology of illness is often unclear.
Pathogenic mechanisms that account for different clinical manifestations of LNB are not well understood. Clinical heterogeneity in Lyme borreliosis has been largely attributed to differences in the infecting B. burgdorferi s.l. species (1,2). In Europe, LNB is caused predominantly by B. garinii (and closely related B. bavariensis) but only rarely by B. afzelii, which is associated with skin manifestations, or B. burgdorferi sensu stricto, which is highly arthritogenic, implying a strong species-specific imprinting of clinically evidenced disease (1,2,7,8). However, although B. garinii has particular proclivity for the central nervous system (CNS) and undoubtedly serves as the initial trigger of LNB, Lyme borreliae do not express any known toxins that cause disease. Rather, the host immune response, which is shaped by various Borrelia species (9–13), is thought to be a key determinant of the clinical signs and symptoms of Lyme borreliosis, including LNB.
In addition to infection with a particular Borrelia species or strain, the immune responses are further augmented by alterations in the human genome. We have previously demonstrated that a single-nucleotide polymorphism (SNP; 1805GG) in the host toll-like receptor 1 (TLR1), a key pathogen sensing receptor for borrelia, is associated with more symptomatic early Lyme borreliosis and a greater frequency of postantibiotic, chronic inflammatory Lyme arthritis (12,14). This TLR1–1805GG SNP is associated with severe disease presumably because it enables maladaptive immune responses; EM patients with the TLR1–1805GG SNP had substantially higher levels of pro-inflammatory cytokines and chemokines in blood compared with those without the SNP. Moreover, in patients with Lyme arthritis, this SNP was associated with exceptionally high levels of the interferon (IFN) γ and IFN-γ–associated mediators CXC motif chemokine ligand (CXCL) 9 and CXCL10 in synovial fluid, supporting the predominant cellular and inflammatory T-helper 1 (Th1) responses in joints in these patients. Thus, host immune response, which is shaped by both microbial and host genetics, is a key driver of the clinical heterogeneity in Lyme borreliosis in general and probably in LNB, although this has not been tested directly.
Several studies in Europe and the United States have characterized host immune responses in patients with LNB in an effort to gain insights into pathogenesis and to identify biomarkers to aid in diagnosis (15–18). These studies demonstrated the activation of a broad-ranging innate and adaptive immune response in patients with LNB. In particular, LNB patients have marked CSF levels of CXCL13, a B-cell chemoattractant, compared with patients with other neurologic conditions (15–19), prompting the use of CXCL13 as an adjunct diagnostic biomarker of LNB (19–26). However, the role of host immunity in the pathogenesis of clinically distinct LNB manifestations and the possibility that these outcomes are associated with specific host genetic predisposition has not been explored.
We investigated the role of innate and adaptive immune responses and the TLR1–1805GG SNP in specific clinical manifestations of LNB. Our findings demonstrate that borrelial meningoradiculoneuritis is a distinct clinical entity with unique immune and genetic pathophysiology and offer new insights into the pathogenesis and diagnosis of this condition.
This study is based on 61 adult patients who met the modified European diagnostic criteria for LNB (5), defined by the presence of symptoms suggestive of neurologic involvement; CSF lymphocytic pleocytosis; demonstration of borrelial infection with intrathecal synthesis of borrelia antibodies (IT-Bb-Abs), isolation of borreliae from CSF; or presence of EM. For comparison, we included 59 patients with signs and symptoms indicative of LNB but without pleocytosis and termed them suspected LNB. All patients were seen at the Lyme borreliosis outpatient clinic by the same clinical team in the Department of Infectious Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia, during 2006–2013. The Medical Ethics Committee of the Ministry of Health, Republic of Slovenia (no. 35/08/06), and the Institutional Review Board of the New York Department of Health (IRB protocol no. 20-013) approved the study.
We collected clinical and demographic information using a structured questionnaire as described previously (3). In addition to their general medical history, patients were asked about tick bites, EM, and new onset or worsening of symptoms. We also assessed signs indicative of neurologic involvement (meningeal signs, PFP, other cranial nerve palsy, sensory or motor deficits, tremor) and the presence of EM (27). We subsequently grouped patients into 3 categories according to clinical and diagnostic criteria: 1) painful meningoradiculoneuritis accompanied by CSF pleocytosis; 2) LNB without radicular pain, consisting of PFP with CSF pleocytosis or lymphocytic meningitis without cranial neuritis (PFP/meningitis); and 3) suspected LNB with EM and neurologic symptoms suggestive of LNB, but normal CSF cell counts (3,6). Serum and CSF samples were obtained at first visit, usually before antimicrobial therapy, and stored at −80°C for subsequent analyses.
We defined CSF pleocytosis as a leukocyte count >5 × 106 cells/L. We determined IgM and IgG levels against B. burgdorferi s.l. in serum and CSF with indirect chemiluminescence immunoassay using recombinant OspC and VlsE antigens (LIAISON; Diasorin, https://www.diasorin.com). We assessed intrathecal synthesis of Borrelia IgG as described previously (28); antibody index values >1.4 were indicative of IT-Abs against B. burgdorferi s.l. We cultivated Borrelia in CSF as reported previously (29–31).
Cytokine and Chemokine Determinations
We assessed the levels of 17 mediators associated with innate (CC motif chemokine ligand [CCL] 2, CCL3, CCL4, interleukin [IL] 8, IL-10, tumor necrosis factor, IFN-α), and adaptive T-cell (TH1, IFN-γ, CXCL9, CXCL10; TH17, IL-17A, IL-21, IL-23; CCL19, CCL21) or B-cell (CXCL12, CXCL13) immune responses. We tested for these levels in matched patient serum and CSF samples using bead-based multiplex assays (EMD Millipore, https://www.emdmillipore.com) coupled with the Luminex-200 Analyzer (Luminex, https://www.luminexcorp.com). We quantified each inflammatory mediator in all samples in one complete experiment to minimize sample freeze-thaw and assay variation. We then stratified cytokine and chemokine levels according to clinical and laboratory findings in the same patients.
We determined TLR1–1805 genotypes (TT, TG, GG; G denotes the SNP) using PCR amplification followed by restriction fragment length polymorphism (RFLP) as described previously (12). In brief, we extracted total DNA from patients’ blood (QIAamp DNA Blood Mini Kit; QIAGEN, https://www.qiagen.com) and amplified it using specific primers: forward: 5′-GCAGGGGACAATCCATTCCAA-3′; reverse: 5′CCCAGAAAGAATCGTGCCCA-3′ (IDT). Each reaction contained 0.4 µM forward/reverse primers, 2 µL DNA (≥50 ng), and 2XDreamTaq PCR Master Mix (ThermoFisher Scientific, https://www.thermofisher.com). PCR amplicons were digested with PstI enzyme (New England BioLabs, https://www.neb.com) and visualized by electrophoresis (1.5% agarose gel, GelRed nucleic acid stain). We determined TLR1–1805 genotype in 65 patients with confirmed LNB (meningoradiculoneuritis, n = 40; LNB without radiculoneuritis [termed PFP/meningitis], n = 25) and for comparison in 71 EM patients without neurologic involvement. Because of the requirement for consent for genetic studies, these 65 LNB patients represent a different cohort from the 61 patients assessed in the rest of the study. In addition, we ascertained TLR1–1805 genotype in the general European population (n = 503) by datamining the Ensembl genome browser 104 (https://useast.ensembl.org/index.html).
We evaluated categorical variables (presence/absence of symptoms or TLR1-SNP) using Fisher exact test. We assessed quantitative variables (number of symptoms, cytokine levels) using Mann-Whitney nonparametric rank-sum test in Prism version 9.1.1 (https://www.graphpad.com). We applied Spearman correlation for cytokine associations. We adjusted for multiple comparisons using the Benjamini-Hochberg test; we set the false discovery rate (FDR) to 0.05 and considered p<0.05 statistically significant.
Clinical Characteristics According to LNB Presentation
Of the 120 patients in this study, 19 had meningoradiculoneuritis, 42 had LNB without radiculoneuritis (PFP/meningitis; 35 PFP, 7 lymphocytic meningitis), and 59 were classified as suspected LNB because they had clinical signs and symptoms indicative of LNB (EM with neurologic symptoms) but lacked CSF pleocytosis (5) (Table 1). Seventy-two participants were female (60%) and 48 male (40%); median age was 51 years. When stratified by specific clinical presentation, patients with meningoradiculoneuritis were more likely to have had an EM skin lesion during the course of disease than LNB patients without radicular pain (68% vs. 24%; p = 0.004). Meningoradiculoneuritis patients had more symptoms than LNB patients without radiculitis (median 6 vs. 3 symptoms; p<0.001) and their symptoms lasted longer (30 days vs. 10 days; p<0.001). Meningoradiculoneuritis patients had more symptoms (median 6 vs. 4 symptoms; p = 0.01) and symptoms of longer duration (30 vs. 16 days; p<0.03) than patients with suspected LNB. Of the 13 constitutional symptoms we assessed, patients with meningoradiculoneuritis had a higher frequency of 8 specific symptoms, 4 of which reached statistical significance (Figure 1). The most common symptoms were sleep disturbance, headache, and fatigue.
Immune Responses in Serum and CSF
In 61 patients with confirmed LNB (meningoradiculoneuritis or PFP/meningitis), most cytokines and chemokines associated with adaptive T-cell and B cell immune responses were more highly concentrated in CSF, the site of disease, than in serum (Table 2). This finding was particularly apparent for IFN-γ–inducible chemokines CXCL9 (median 347 vs. 170 pg/mL; p = 0.02) and CXCL10 (median 4,139 vs. 143 pg/mL; p<0.001) which recruit CD4+ T cells, as well as B-cell chemoattractants CXCL12 (median 1,541 vs. 820 pg/mL; p<0.001) and CXCL13 (median 352 vs. 9 pg/mL; p<0.001) which recruit B cells to site of infection. In contrast, mediators associated with innate and Th17 immune responses were present at lower overall concentrations and often at similar levels in serum and CSF (Table 2).
Immune Responses According to LNB Presentation
To determine if patients with different clinical presentations of LNB carry distinct immune signatures, we stratified cytokine and chemokine levels in CSF into 3 groups: meningoradiculoneuritis (n = 19), PFP/meningitis (n = 42), and suspected LNB (n = 59). Heat map analyses of global immune responses revealed that patients with meningoradiculoneuritis have the highest levels of most mediators tested; those with PFP/meningitis have intermediate levels, and those with suspected LNB have the lowest levels (Figure 2, panel A). We obtained similar results using unguided hierarchical clustering (Figure 2, panel B). Patients with meningoradiculoneuritis clustered primarily with the highest cytokine and chemokine levels and largest CSF leukocyte counts, whereas those with suspected LNB clustered with the lowest cytokine and chemokine levels and CSF leukocyte counts. Patients with PFP/meningitis were more interspersed. We observed these trends for cytokines and chemokines associated with both innate and adaptive immune responses.
We identified through statistical analyses 8 cytokines and chemokines with significant differences between groups (Figure 3), including mediators associated with innate (IL-8, IL-10, CCL3), and adaptive T-cell (CXCL9, CXCL10, IL-17) and B-cell (CXCL12, CXCL13) immune responses. We observed the highest levels and most pronounced differences between groups for B-cell chemoattractants CXCL12 (median values for meningoradiculoneuritis groups, 2,568 pg/mL; for PFP/meningitis, 1,170 pg/mL; for suspected LNB, 819 pg/mL) and CXCL13 (meningoradiculoneuritis, 1,000 pg/mL; PFP/meningitis, 53 pg/mL; suspected LNB, 1 pg/mL) and for T-cell chemoattractants CXCL9 (meningoradiculoneuritis, 680 pg/mL; PFP/meningitis, 252 pg/mL; suspected LNB 15 pg/mL) and CXCL10 (meningoradiculoneuritis, 5,159 pg/mL; PFP/meningitis, 4,087 pg/mL; suspected LNB, 236 pg/mL). These mediators correlated strongly with leukocyte counts in CSF (p<0.001) (Figure 4), implying the predominance of CSF-localized T- and B-cell responses in meningoradiculoneuritis.
Frequency of TLR1–1805GG Polymorphism in LNB
We previously demonstrated that the TLR1–1805GG SNP is associated with excessive immune responses, more symptomatic early infection, and a heightened risk for chronic inflammatory (antibiotic-refractory) Lyme arthritis, thereby linking host genetic variation with dysregulated immunity and severe Lyme borreliosis (12). Herein, we extended these findings to LNB (Figures 5, 6). As reported previously (12), 49% of the general population of Europe had both copies of the SNP (GG); distribution was similar in female and male patients. Similarly, 51% of patients with EM had both copies of the SNP, whereas the frequency was slightly higher in patients with LNB (57%), but these differences were not statistically significant (Figure 5). However, when we subcategorized LNB patients by clinical presentation, patients with meningoradiculoneuritis had a significantly higher frequency of TLR1–1805GG SNP compared to patients with PFP/meningitis (68% vs. 40%; odds ratio 3.1; p = 0.04) (Figure 6). Consent for genetic studies was not obtained from patients with suspected LNB, and they were not included in these analyses.
CNS involvement is a common manifestation of Lyme borreliosis in Europe. Although distinct manifestations of LNB are well described clinically, the reasons for these differences are not well understood. Herein, we demonstrated that LNB patients with meningoradiculoneuritis have a different immune signature than LNB patients without radiculoneuritis. Although both LNB groups (patients with meningoradiculoneuritis and PFP/meningitis) have broadly elevated innate and adaptive inflammatory immune response that the suspected LNB group does not, we observed the most dramatic differences for cytokines and chemokines associated with adaptive T- and B-cell immune responses in CSF. In particular, patients with meningoradiculoneuritis had the highest CSF levels of B-cell chemoattractants CXCL12 and CXCL13, as well as T-cell chemoattractants CXCL9 and CXCL10, and a potent Th17 cytokine, IL-17. These inflammatory mediators were often concentrated 10- to 50-fold in CSF, the site of the disease, and correlated strongly with lymphocyte counts (p<0.001), implying a role in CNS inflammation and disease pathogenesis. In contrast, cytokine and chemokine levels did not correlate with symptom duration, implying that greater immune responses are not caused simply by the longer disease duration in patients with meningoradiculoneuritis. Rather, we postulate that these site-specific T- and B-cell responses likely play a direct role in the pathophysiology of meningoradiculoneuritis and the higher prevalence of systemic symptoms in this condition. T- and B-cell mediators, namely IL-17 and CXCL13, have been implicated in disease pathogenesis in a recent study of patients with LNB or suspected LNB in Sweden (32), although that study did not compare patients with distinct manifestations of LNB. In contrast to findings for CSF, we observed low levels of most of the immune mediators in serum in LNB patients that were comparable to the levels in healthy persons (data not shown). Collectively, these findings support the role of site-specific T- and B-cell responses in the pathogenesis of borrelial meningoradiculoneuritis.
Because the clinical manifestation of LNB is largely attributable to host immune responses, immune mediators in CSF offer attractive targets as biomarkers for diagnosis as well as markers of disease activity and resolution. LNB diagnosis is limited because CSF pleocytosis and clinical signs and symptoms of disease overlap with other neurologic conditions and are thus not unique to LNB. Moreover, borrelia-IT-Abs, although highly specific, take weeks to develop and thus offer limited sensitivity during early infection. In addition, once elevated, antibodies against borrelia can persist for years and may not be able to distinguish previous from current infection. Immune mediators such as CXCL13, which are presumably elevated before demonstratable cellular influx necessary for CSF pleocytosis and borrelia-IT-Ab-S, and decrease dramatically after antimicrobial therapy, appear to address these diagnostic limitations (20). Indeed, CXCL13 has been proposed as an adjunct diagnostic marker for LNB (19–26). However, studies in the United States and Europe have demonstrated that the diagnostic utility of CXCL13 is primarily limited to patients with definitive LNB who already meet the standard diagnostic criteria (CSF pleocytosis, Borrelia IT-Bb-Ab-S) (18,33,34). Our findings underscore this point by demonstrating that CSF levels of CXCL13 are below the proposed 162 pg/mL diagnostic cutoff (26) in most patients with suspected LNB (median CXCL13 levels 1 pg/mL) and even in many patients with PFP/meningitis (median CXCL13 levels 53 pg/mL). Our results suggest that CXCL13 diagnostic utility may be constrained to patients with meningoradiculoneuritis, a clinically identifiable condition. Nevertheless, because of their role in pathogenesis, immune mediators remain attractive targets as biomarkers, and new cytokines with greater discriminatory power than CXCL13 have been proposed in LNB (16). As we have demonstrated, diagnostic suitability of these factors will require detailed studies of LNB patients with a range of well-defined clinical manifestations.
In addition to elevated immune responses, patients with borrelial meningoradiculoneuritis had a greater frequency and longer duration of constitutional symptoms than patients without radiculoneuritis. The most prevalent symptoms were sleep disturbance/insomnia, followed by fatigue, concentration disturbance, and memory disturbance, all of which could be attributed to sleeplessness resulting from pronounced radicular pain. However, these patients also had several other symptoms, such as low back pain, arthralgia, myalgia, and paresthesia, that are likely to have other causes, unrelated to sleeplessness. In contrast, patients with suspected LNB more often sought care for nonspecific symptoms such as headache, nausea, malaise, and vertigo. Thus, meningoradiculoneuritis is a distinct clinical entity distinguished not only by radicular pain but also by prevalence of several constitutional symptoms.
Alterations in the human genome have been implicated in maladaptive immune responses and severe Lyme borreliosis (9–12). We previously demonstrated that a SNP (1805GG) in TLR1, a major sensor for Borrelia, alters host immune responses to infection and thereby the clinical course and outcome of Lyme borreliosis (12). This SNP results in a transversion of thymine to guanine (1805T>1805G), causing an amino acid exchange of isoleucine for serine at position 602 in the transmembrane domain of the receptor, a constrained region likely to affect function. Indeed, the SNP results in decreased expression of TLR1 on cell surface and diminished downstream cytokine signaling in response to Pam3CSK4, a specific TLR1/2 agonist (35–37). Paradoxically, in response to B. burgdorferi infection, this SNP is associated with excessive immune responses with marked levels of IFN-γ and IFN-γ–inducible chemokines CXCL9 and CXCL10 in serum of patients with EM and even higher levels in joint fluid of those with postantibiotic (postinfectious) Lyme arthritis. This excessive inflammatory immune response was associated with highly symptomatic early infection in EM patients and with an elevated risk for postantibiotic chronic inflammatory Lyme arthritis (12). In this study, we extended these concepts to patients with various manifestations of LNB. We show that patients with meningoradiculoneuritis have a significantly higher frequency of the TLR1–1805GG SNP (OR = 3.1; p = 0.03) and more symptoms (p<0.001) than those with other LNB manifestations. Moreover, patients with meningoradiculoneuritis also have heightened T-cell (namely Th1) and B-cell immune responses, consistent with the role of this SNP in excessive Th1 inflammation and more symptomatic disease in patients with EM or Lyme arthritis.
A limitation of this work is that, because genetic studies require separate consent, the TLR1–1805GG analyses were performed in a different cohort of patients than those in whom the immune responses were tested; thus, we could not directly correlate the SNP genotype with the immune phenotype. Moreover, we based our study on a relatively small number of patients in each group. However, we should point out that this is an initial analysis of these concepts in LNB, and although small, these patient cohorts are well defined and are among the largest available. Finally, although the immune responses were elevated in CSF in patients with meningoradiculoneuritis as a group compared with those with PFP/meningitis, the levels of immune mediators varied in individual patients, and thus not every patient with radiculitis had higher CSF immune responses than did every patient with PFP/meningitis. Despite these limitations, these data support a link between TLR1–1805GG SNP, maladaptive Th1 immunity, and disadvantageous clinical outcomes in several manifestations of Lyme borreliosis, including LNB. An effort is now underway to recruit additional patients to validate these genetic and immunologic results.
In summary, our study demonstrates that meningoradiculoneuritis is a distinct clinical entity with unique immune and genetic pathophysiology. In future studies, we hope to establish the functional link between the TLR1–1805GG SNP, excessive site-specific T- and B-cell immune responses in CSF, and painful meningoradiculoneuritis. The findings from this study provide new considerations for the study of patients with meningoradiculoneuritis and LNB in general; further studies may help to improve accuracy of laboratory diagnosis.
We thank Graham Willsey for help with TLR1 genotyping.
This work was supported by the US National Institutes of Health (NIAID no. R21AI144916, and NIAMS no. K01AR062098) and the Massachusetts General Hospital Executive Committee on Research Interim Support Fund to K.S.; and by the Slovenian Research Agency (P3-0296, J3-1744, and J3-8195) to F.S. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funding agencies. Funding agencies were not involved in the design, conduct, or interpretation of the findings.
Author contributions: K.S., F.S., and K.O. designed the study. K.S., S.H., and M.K. conducted the experiments and the data analyses for this study. K.O., F.S., P.B., and T.R. examined patients with Lyme neuroborreliosis, made diagnoses, and collected clinical samples and clinical information. S.H., K.S., F.S., and K.O. wrote the manuscript. S.H., G.C., M.K., K.S., and L.L. performed the statistical analyses, contributed to generation of tables, and helped with the interpretation of the data. All authors reviewed and approved the manuscript.
- Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet. 2012;379:461–73.
- Steere AC, Strle F, Wormser GP, Hu LT, Branda JA, Hovius JW, et al. Lyme borreliosis. Nat Rev Dis Primers. 2016;2:16090.
- Ogrinc K, Lusa L, Lotrič-Furlan S, Bogovič P, Stupica D, Cerar T, et al. Course and outcome of early European Lyme neuroborreliosis (Bannwarth syndrome): clinical and laboratory findings. Clin Infect Dis. 2016;63:346–53.
- Stanek G, Strle F. Lyme borreliosis-from tick bite to diagnosis and treatment. FEMS Microbiol Rev. 2018;42:233–58.
- Mygland A, Ljostad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I. EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Eur J Neurol. 2010;17:8–16, e1–4.
- Ogrinc K, Lotrič-Furlan S, Maraspin V, Lusa L, Cerar T, Ružič-Sabljič E, et al. Suspected early Lyme neuroborreliosis in patients with erythema migrans. Clin Infect Dis. 2013;57:501–9.
- Cerar T, Strle F, Stupica D, Ruzic-Sabljic E, McHugh G, Steere AC, et al. Differences in genotype, clinical features, and inflammatory potential of Borrelia burgdorferi sensu stricto strains from Europe and the United States. Emerg Infect Dis. 2016;22:818–27.
- Grillon A, Scherlinger M, Boyer PH, De Martino S, Perdriger A, Blasquez A, et al. Characteristics and clinical outcomes after treatment of a national cohort of PCR-positive Lyme arthritis. Semin Arthritis Rheum. 2019;48:1105–12.
- Oosting M, Ter Hofstede H, Sturm P, Adema GJ, Kullberg BJ, van der Meer JW, et al. TLR1/TLR2 heterodimers play an important role in the recognition of Borrelia spirochetes. PLoS One. 2011;6:
- Steere AC, Dwyer E, Winchester R. Association of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles. N Engl J Med. 1990;323:219–23.
- Steere AC, Klitz W, Drouin EE, Falk BA, Kwok WW, Nepom GT, et al. Antibiotic-refractory Lyme arthritis is associated with HLA-DR molecules that bind a Borrelia burgdorferi peptide. J Exp Med. 2006;203:961–71.
- Strle K, Shin JJ, Glickstein LJ, Steere AC. Association of a Toll-like receptor 1 polymorphism with heightened Th1 inflammatory responses and antibiotic-refractory Lyme arthritis. Arthritis Rheum. 2012;64:1497–507.
- Lochhead RB, Strle K, Arvikar SL, Weis JJ, Steere AC. Lyme arthritis: linking infection, inflammation and autoimmunity. Nat Rev Rheumatol. 2021;17:449–61.
- Sellati TJ, Sahay B, Wormser GP. The Toll of a TLR1 polymorphism in lyme disease: a tale of mice and men. Arthritis Rheum. 2012;64:1311–5.
- Eckman EA, Pacheco-Quinto J, Herdt AR, Halperin JJ. Neuroimmunomodulators in neuroborreliosis and Lyme encephalopathy. Clin Infect Dis. 2018;67:80–8.
- Skogman BH, Lager M, Brudin L, Jenmalm MC, Tjernberg I, Henningsson AJ. Cytokines and chemokines in cerebrospinal fluid in relation to diagnosis, clinical presentation and recovery in children being evaluated for Lyme neuroborreliosis. Ticks Tick Borne Dis. 2020;11:
- Henningsson AJ, Tjernberg I, Malmvall BE, Forsberg P, Ernerudh J. Indications of Th1 and Th17 responses in cerebrospinal fluid from patients with Lyme neuroborreliosis: a large retrospective study. J Neuroinflammation. 2011;8:36.
- Markowicz M, Schötta AM, Kundi M, Bogovič P, Ogrinc K, Strle F, et al. CXCL13 concentrations in cerebrospinal fluid of patients with Lyme neuroborreliosis and other neurological disorders determined by Luminex and ELISA. Ticks Tick Borne Dis. 2018;9:1137–42.
- Hytönen J, Kortela E, Waris M, Puustinen J, Salo J, Oksi J. CXCL13 and neopterin concentrations in cerebrospinal fluid of patients with Lyme neuroborreliosis and other diseases that cause neuroinflammation. J Neuroinflammation. 2014;11:103.
- Strle F, Henningsson AJ, Strle K. Diagnostic utility of CXCL13 in Lyme neuroborreliosis. Clin Infect Dis. 2021;72:1727–9.
- Skogman BH, Lager M, Henningsson AJ, Tjernberg I. The recomBead Borrelia antibody index, CXCL13 and total IgM index for laboratory diagnosis of Lyme neuroborreliosis in children. Eur J Clin Microbiol Infect Dis. 2017;36:2221–9.
- Henningsson AJ, Gyllemark P, Lager M, Skogman BH, Tjernberg I. Evaluation of two assays for CXCL13 analysis in cerebrospinal fluid for laboratory diagnosis of Lyme neuroborreliosis. APMIS. 2016;124:985–90.
- Tjernberg I, Henningsson AJ, Eliasson I, Forsberg P, Ernerudh J. Diagnostic performance of cerebrospinal fluid chemokine CXCL13 and antibodies to the C6-peptide in Lyme neuroborreliosis. J Infect. 2011;62:149–58.
- Borde JP, Meier S, Fingerle V, Klier C, Hübner J, Kern WV. CXCL13 may improve diagnosis in early neuroborreliosis with atypical laboratory findings. BMC Infect Dis. 2012;12:344.
- Ljøstad U, Mygland Å. CSF B - lymphocyte chemoattractant (CXCL13) in the early diagnosis of acute Lyme neuroborreliosis. J Neurol. 2008;255:782.
- Rupprecht TA, Manz KM, Fingerle V, Lechner C, Klein M, Pfirrmann M, et al. Diagnostic value of cerebrospinal fluid CXCL13 for acute Lyme neuroborreliosis. A systematic review and meta-analysis. Clin Microbiol Infect. 2018;24:1234–40.
- Stanek G, Fingerle V, Hunfeld KP, Jaulhac B, Kaiser R, Krause A, et al. Lyme borreliosis: clinical case definitions for diagnosis and management in Europe. Clin Microbiol Infect. 2011;17:69–79.
- Reiber H, Peter JB. Cerebrospinal fluid analysis: disease-related data patterns and evaluation programs. J Neurol Sci. 2001;184:101–22.
- Postic D, Assous MV, Grimont PA, Baranton G. Diversity of Borrelia burgdorferi sensu lato evidenced by restriction fragment length polymorphism of rrf (5S)-rrl (23S) intergenic spacer amplicons. Int J Syst Bacteriol. 1994;44:743–52.
- Ruzić-Sabljić E, Maraspin V, Lotric-Furlan S, Jurca T, Logar M, Pikelj-Pecnik A, et al. Characterization of Borrelia burgdorferi sensu lato strains isolated from human material in Slovenia. Wien Klin Wochenschr. 2002;114:544–50.
- Ruzić-Sabljić E, Zore A, Strle F. Characterization of Borrelia burgdorferi sensu lato isolates by pulsed-field gel electrophoresis after MluI restriction of genomic DNA. Res Microbiol. 2008;159:441–8.
- Gyllemark P, Forsberg P, Ernerudh J, Henningsson AJ. Intrathecal Th17- and B cell-associated cytokine and chemokine responses in relation to clinical outcome in Lyme neuroborreliosis: a large retrospective study. J Neuroinflammation. 2017;14:27.
- Eckman EA, Clausen DM, Herdt AR, Pacheco-Quinto J, Halperin JJ. Specificity and diagnostic utility of cerebrospinal fluid CXCL13 in Lyme neuroborreliosis. Clin Infect Dis. 2021;72:1719–26.
- Cerar T, Ogrinc K, Lotric-Furlan S, Kobal J, Levicnik-Stezinar S, Strle F, et al. Diagnostic value of cytokines and chemokines in lyme neuroborreliosis. Clin Vaccine Immunol. 2013;20:1578–84.
- Hawn TR, Misch EA, Dunstan SJ, Thwaites GE, Lan NT, Quy HT, et al. A common human TLR1 polymorphism regulates the innate immune response to lipopeptides. Eur J Immunol. 2007;37:2280–9.
- Misch EA, Hawn TR. Toll-like receptor polymorphisms and susceptibility to human disease. Clin Sci (Lond). 2008;114:347–60.
- Johnson CM, Lyle EA, Omueti KO, Stepensky VA, Yegin O, Alpsoy E, et al. Cutting edge: A common polymorphism impairs cell surface trafficking and functional responses of TLR1 but protects against leprosy. J Immunol. 2007;178:7520–4.
TablesCite This Article
Original Publication Date: March 22, 2022
1Part of the research reported here was presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases (online), July 9–12, 2021.
2These first authors contributed equally to this article.
3These senior authors contributed equally to this article.