This presentation tackles the controversy regarding Lyme disease by reviewing the evidence for immune evasion and persistent infection by the Lyme spiorchete, Borrelia burgdorferi. The evidence shows that physicians called upon to assist patients with this potential diagnosis should be open to the possibility of persistent infection even in patients who have already received antibiotic treatment for their condition. Lacking evidence on how best to treat a chronic infection of this kind, physicians should be allowed to rely on their experience and to exercise their best clinical judgment in managing patients with Lyme disease.

1. Lyme Disease
A Systems Medicine Approach
Keith Berndtson, MD

2. Lyme Wars, circa 2013
ILADS
Is not a persistent infection! vs. Is so a persistent infection!

3. The 2011 Institute of Medicine Report
Underpowered studies that purport to
demonstrate universal efficacy must be
viewed with circumspection.
Everyone is studying the early stage of this
infection; no one is studying the persistent
phase of the disease. It is important that 2011
those studies occur.
All the bitterness of the debate does not
serve the science or the patient...[it]
drowns out the complexity and nuance of
the work that needs to be done.

4. What is the physician’s duty
when assisting patients with Lyme disease?
Know and teach the evidence for
immune evasion and persistent
infection in Lyme disease.
Learn the varied clinical
presentations of Lyme disease.
Apply evidence-based care strategies
within a shared decision-making
model that respects patient values.
Monitor and document clinical
outcomes.
Hippocratic Oath
on papyrus, 200 AD

5. 2012 Yale Lyme Risk Map
• Map produced by the Yale
School of Public Health
• Released February, 2012
• Includes a high risk “sliver”
in Northern Illinois
• Most of Northern Illinois
considered a transitional
area

6. July 2012 Illinois Tick survey
56.4% of over 1,067 ticks collected from 17 sites in Cook,
Lake, McHenry, and DuPage counties were deer ticks.

7. Bloated tick on a Cedar Waxwing
Dispersal of Borrelia burgdorferi
by songbirds can help account
for the dramatic increase in the
incidence of tick-borne diseases
in North America and Europe
over the past 16 years.

8. Research shows a 7 to 10-
fold increase in Chicago
area Bb-infected deer ticks
between 2005 and 2007.
In a 2007 tick survey of Lake and Cook Questing Deer tick
counties, 37% of adult deer ticks collected
were + for Borrelia burgdorferi. (1)
A 2006 report by this team found that Borrelia burgdorferi
only 3-5% of adult deer ticks in Cook and
DuPage counties were + for Bb. (2)
(1) Jobe DA, Nelson JA, Adam MD, Martin SA.
Lyme disease in urban areas, Chicago. Emerging
Infectious Diseases. 2007;13(11):1799-1800.
(2) Jobe DA, Lovrich SD, Nelson JA, et al. Borrelia
burgoderferi in Ixodes scapularis ticks, Chicago
area. Emerging Infectious Diseases.
2006;12:1039-1041.

9. Evidence for Immune
Evasion in Lyme Disease
Cross-disciplinary studies

10. Evidence for Immune Evasion in Lyme Disease
A Flexibly Adaptive Genome
“Borrelia species may well have the most
unusual genomes on the planet. No other
bacteria have such a large complement of
extra-chromosomal elements. They
perform an uncommon process known as
telomere resolution that can explain the
wide-ranging variability in linear plasmid
size, content, and sequence scrambling.”
- George Chaconas, the Canadian Society for
Microbiology Murray Lecture
Canadian Journal Microbiology 2011;58(3):236-48.

11. Evidence for Immune Evasion in Lyme Disease
Bb Commandeers Tick Salivary Protein
Tick salivary protein (Salp-15) binds to CD4 on T helper cells and to OspC on
Bb, which delays the humoral response to Bb, allowing early dissemination
into connective tissue and the central nervous system. Salp-15 and OspC
collaborate to enhance the virulence of Bb during the early stages of infection.
Hovius J, et. al. Tick-host-pathogen interactions in Lyme borreliosis. Trends in Parasitology 2007;23(9):434-438.
Ramamoorthi N, et al. The Lyme disease antigen exploits a tick protein to infect the mammalian host. Nature 2005;436(7050):573-7.

12. Evidence for Immune Evasion in Lyme Disease
Antigen Masking
Kurtenbach K, et al. Host
association of Bb sensu
lato - the key role of host
complement. Trends in
Microbiology. 2002;10(2):
74-9.
Bb’s Factor H
“hall pass”
Bb evades complement-mediated killing by interacting with complement regulators through
distinct complement regulator-acquiring surface proteins (CRASPs). CRASP-1 is a multifunctional
protein of Bb that binds to several human extracellular matrix proteins and plasminogen. These
interactions contribute to adhesion, bacterial colonization, and organ tropism and assist with
dissemination of Bb in the host.
Kraiczy P, Stevenson B. Complement regulator-acquiring surface proteins of Bb: structure, function, and
regulation of gene expression. Ticks and Tick Borne Diseases. 2013 Feb;4(1-2):26-34.

13. Evidence for Immune Evasion in Lyme Disease
Bb Usurps the Host’s Plasminogen Activating System
The Blood-Brain Barrier
Plasmin + MMPs
Bb spirochete able to disrupt
tight junctions causing a leaky
blood-brain barrier and a
portal of entry into the brain.
Bb’s outer membrane protein, OspC, binds to plasminogen, activating the serine
protease, plasmin. Plasmin induces the release of collagenases and MMPs (matrix
metallproteinases), which enhance Bb’s ability to pass through tight junctions. Bb
thus usurps the fibrinolytic pathways of its host to help it penetrate otherwise
impermeable tissue barriers. The result: rapid deep tissue invasion.
Hu LT, et al. Binding of human plasminogen to Borrelia burgdorferi. Infection and Immunity. 1995 Sep;63(9):3491-6.
Toledo A, et al. The enolase of Borrelia burgdorferi is a plasminogen receptor
released in outer membrane vesicles. Infection and Immunity. 2012 Jan;80(1):359-68.

14. Evidence for Immune Evasion in Lyme Disease
Bb Encodes for “Best in Class” Antigenic Variation
15
silent
vls
casse-es expressed
vlsE
casse-e
The VlsE sequence variants produce different antigen epitopes. Recombination occurs continuously during
mammalian infection and plays a key role in immune evasion and the long-term survival of Bb in humans.
Norris SJ. How do Lyme Borrelia organisms cause disease? The quest for virulence
determinants. Open Neurology Journal. 2012;6(Suppl 1-M8):119-123.
Ongoing antigenic variation frustrates the host’s antibody response to Borrelia burgdorferi. B-cells become
confused, causing excess B-cell traffic in lymph nodes and a weak and delayed marrow plasma cell response.
Hastey CJ, et al. Delays and diversions mark the development of B cell responses
to Borrelia burgdorferi infections. Journal of Immunology 2012;188(11):5612-22.

15. Sources of Immune Evasion in Lyme Disease
Atypical Forms
Rolled forms A cystic form.
Bb strain ADBI thickened
membrane
Bb strain B31
The results indicate that atypical extra- and intracellular pleomorphic and cystic forms of Borrelia
burgdorferi and local neuroinflammation occur in the brain in chronic Lyme neuroborreliosis.
The persistence of these more resistant spirochete forms, and their intracellular location in
neurons and glial cells, may explain the long latent stage and persistence of Borrelia infection.
Mikossly J, et al. Persisting atypical and cystic forms of Borrelia burgdorferi
and local inflammation in Lyme borreliosis. J Neuroinflammation 2008;5:40.

16. Sources of Immune Evasion in Lyme Disease
Atypical Forms
Rolled forms of Bb
Cystic forms of Bb. Plasma membrane Cystic forms of Bb.
inside cystic structure (i) thinner than
extracystic plasma membrane (e).
Brorsson O, Brorsson SH. Transformation of cystic forms of Miklossy J, et al. Persisting atypical and cystic forms of
Borrleia burgdorferi to normal, mobile spirochetes. Infection Borrelia burgdorferi and local inflammation in Lyme
1997;4:241-46. borreliosis. J Neuroinflammation 2008;5:40.

17. Sources of Immune Evasion in Lyme Disease
Horizontal Gene Transfer
Conjugation Transformation
Gene transfer by bacterial conjugation and by DNA transformation happens
efficiently in biofilms, and this process helps stabilize the biofilm structure.
Molin S. Gene transfer occurs with enhanced efficiency in biofilms and induces enhanced
stabilization of the biofilm structure. Curremt OPinions in Biotechnology. 2003;14:255-261.

18. Evidence for Immune Evasion in Lyme Disease
Advanced Motility Capabilities

19. Evidence for Immune Evasion in Lyme Disease
High Performance Flagellar Motors

20. Evidence for Immune Evasion in Lyme Disease
Elite Flagellar Design

21. Evidence for Immune Evasion in Lyme Disease
Advanced Flagellar Maneuverability

22. Evidence for Immune Evasion in Lyme Disease
Evasive Chemotaxis and Niche-Seeking Behavior
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).

23. Evidence for Immune Evasion in Lyme Disease
Movement through Vascular Walls
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).

24. Evidence for Immune Evasion in Lyme Disease
Rapid Escape from Vascular Compartment
into the Extracellular Matrix
Spirochetes would transmigrate through the venule wall, typically at the endothelial
cell junctions, and escape into the surrounding extracellular matrix in a process that
averaged 10.8 minutes. The speed of the final escape yielded images in which
spirochetes appeared to burst away from the vessel. The matrix is like a sanctuary
from immune traffic, and Bb escapes to it in a hurry.
Moriarty TJ, et al. Real-time high resolution 3D imaging of the Lyme disease spirochete
adhering to and escaping from the vasculature of the living host. PLoS Pathogen 2008;4(6).

25. Evidence for Immune Evasion in Lyme Disease
Bb Quorum Sensing and Biofilm-Like Behavior
Sapi E, et al. Characterization of biofilm formation by Borrelia burgdorferi In Vitro. PLoS ONE;7(10):e48277.
Bb respond to AI-2 by expressing factor H-binding protein to enhance immune evasion.
Babb K, et al. Synthesis of autoinducer-2 by the Lyme disease spirochete. Journal of Bacteriology 2005;187:3079-87.
Stevenson B, et al. LuxS-mediated quorum sensing in the Lyme disease spirochete. Infection and Immunity 2002;70:4099-4105.

26. Evidence for Immune Evasion in Lyme Disease
Biofilm-Like Aggregations
Bb-induced effects included multilevel arrangements of alginates, calcium, and
extracellular DNA, highly consistent with biofilm. Bb grown on agarose-coated mica
discs. Imaged by atomic force microscopy, measurements made with Nanorule software.
Sapi E, et al. Characterization of biofilm formation by Borrelia burgdorferi In Vitro. PLoS ONE;7(10):e48277.

27. Evidence for Persistent
Infection in Lyme Disease
Definitive studies

28. Evidence for Persistent Infection in Lyme Disease
Barthold, 2010 Forms of proof
given for
post-antibiotic
persistence of
viable and
infective Bb
in this study:
Allograft
-transmissible Bb
Xenodiagnosis
-Bb acquisition
by ticks
-Bb transmission
by ticks
-Bb survival
through tick
life cycle
..
..
RNA transcripts
..
..
.. - showing
metabolically
..
..
.. active, viable Bb
..

29. Evidence for Persistent Infection in Lyme Disease
Yrjanainen, 2010
Forms of proof
given for
post-antibiotic
persistence of
viable Bb
in this study:
.. Culture
.. from tissue samples
.. of mice treated with
anti-TNFa 4 weeks
post antibiotic
treatment
..
..
..

30. Evidence for Persistent Infection in Lyme Disease
Embers, 2012 Forms of proof
given for
post-antibiotic
persistence of
viable and
infective Bb
in this study:
Xenodiagnosis
acquisition
transmission
Culture
Immunofluorescence
PCR
C6 antibody
.. Bb antigen
..
..
..
.. RNA transcripts

31. Conclusions
1. Bb has an unusually adaptive combined genome that encodes for a
powerful set of immune evasion capabilities.
2. Bb exploits tick and host proteins, antigen masking and variation, elite
motility skills, strategic niche-seeking, horizontal gene transfer, atypical
forms, biofilm-like behavior, and antibiotic tolerance to help it persist
within mammalian hosts.
3. In mice and primates, Bb subsets are proven to remain viable and
infective despite culture negativity following antibiotic challenge.
4. Immune suppressed mice are more susceptible to the reactivation of
viable Bb that persist despite antibiotic challenge.
5. Solid evidence supports the existence of persistent Lyme disease. Health
care policy needs to accommodate efforts to prevent, detect, and treat it.

32. Added Sources of
Complexity in Lyme Disease
Clinical Considerations

33. Sources of Added Complexity in Lyme Disease
Co-infections
Anaplasmosis Babesiosis Bartonella Ehrlichiosis
Granulocytes Red blood cells Red blood cells Monocytes
WBCs, RBCs, platelets Fever, chills, sweats Endothelial cells Fever, chills, body aches
Elevated liver enzymes Headache, fatigue Fever, rash, headache Confusion, GI
Fever, chills, aches Ring forms, Maltese cross Fatigue, brain fog disturbance
Headache, diarrhea Howell-Jolly bodies Endocarditis, sore soles Headache
Morula (colony) forms
Borrelia
burgdorferi (124 strains), afzellii, garinii (European forms)
50+ symptoms reported, invasion of most tissues documented, primarily connective tissue, synovium, liver,
testes, pelvic organs, central, peripheral, and autonomic nervous system cells, heart cells, and immune cells.
A new breed of polymicrobial, polyphasic infection?

34. Sources of Added Complexity in Lyme Disease
Deer Tick Co-infection Rates
Among 286 Ixodes scapularis ticks collected in this study:
Borrelia +
Borrelia + Borrelia +
Borrelia Anaplasma Babesia Anaplasma+
Anaplasma Babesia
Babesia
% positive
182 (64%) 56 (20%) 58 (20%) 45 (16%) 48 (17%) 14 (5%)
ticks
Assessment of polymicrobial infections in ticks in New York
State. Vector Borne Zoonotic Diseases. 2010 Apr;10(3):217-221.

35. Sources of Added Complexity in Chronic Lyme Disease
Co-morbid Conditions in the Host
Autoimmune
Disease
Chronic Allergic
Toxicity Sensitivities
Psychosocial Degenerative
Stresses Lyme Disease
Mood or
Metabolic
Cognitive
Disease
Disorders
Co-infections

36. Sources of Added Complexity in Chronic Lyme Disease
Host Genetic Variations
The influence of tumor necrosis factor alpha (TNFa) in Bb infection is well documented.
There seems to be a polarity in host reactions, perhaps related to gene polymorphisms in
TNFa or in promoter genes for the pro-inflammatory cytokines. This results in weaker or
stronger cell-mediated immune responses.
In pathology studies of neurological Lyme disease, the following polarity is seen:
Infiltrative Atrophic
cerebral vasculitis frontotemporal atrophy
multi-infarct dementia
white matter lesions hypoperfusion
inflammation apoptosis
Miklossy J. Biology and neuropathology of dementia in syphilis and Lyme disease. In Handbook of Clinical
Neurology, vol. 89, 2008, Elsevier: New York.

37. Sources of Added Complexity in Chronic Lyme Disease
The Limits of Diagnostic Testing
ILADS
• Prefers higher sensitivity on Western Blot • Prefers higher specificity on Western Blot
• Tolerates a higher false positive rate • Tolerates a higher false negative rate
The search is on for biomarkers with better abilities to rule in (ILADS)
and rule out (IDSA) cases of persistent Lyme and associated diseases.

38. Sources of Added Complexity in Chronic Lyme Disease
The Limits of Therapy
There is to date no known therapy for the post-Lyme residual
autoimmune condition postulated by IDSA-aligned researchers.
NIH-sponsored clinical trials were underpowered and likely
ILADS underestimate the benefits of antibiotic therapy in chronic Lyme
patients. There is no surefire way of proving total eradication of
viable Lyme spirochetes.
Guidelines for selecting therapies for patients with chronic Lyme
continues to rest on a weak evidence base. For this reason, physicians
should be allowed to select therapies based on pathophysiologic
rationales supported by clinical experience and judgment, with
decisions that reflect patient values and preferences.

39. Sources of Added Complexity in Chronic Lyme Disease
Patients Caught in the Crossfire
Given the lack of reliable biomarkers for use in monitoring responses
to therapy for chronic Lyme disease, outcomes evaluation must rely
on methods for assessing the subjective dimensions of the patient’s
experience with therapy.
Who will help me?
Overall
The Rationalists Function The Empiricists
Physical Symptoms
? ?
Mental Outlook
Social
ILADS
Finding reasons Finding reasons
not to treat to treat

40. Dimensional
Outcomes Assessments
Dimensional assessment tools used
in NIH-funded chronic Lyme
treatment studies:*
• Quality of Life Score (SF-36)
• Fibromyalgia Impact Questionnaire (FIQ)
• Fatigue Severity Scale (FSS)
• Neurocognitive Dysfunction Index (NDI)
• McGill Pain Questionnaire (MPQ)
• Medical Outcome Scale (MOS)
* Klempner, Krupp, and Fallon
Visual analog scale for practice-based
outcomes monitoring
• Review of Systems Scale (ROSS)

41. We Need a More
Integrative
Medical Model
• Evidence-based medicine 2.0
• Built to handle complexity
• Patient values respected
• Shared decision-making
• Clinical experience valued
• Empirical trials encouraged
• Dimensional outcome tracking
• Biopsychosocial awareness
• Systems theory and practice
A Systems Medicine Model

42. Repairing the Broken Bridge
All the bitterness of the debate does not serve the science or the patient...all the
shouting drowns out the complexity and nuance of the work that needs to be done.
- Institute of Medicine Lyme Report, 2011
Physicians must be allowed to use current evidence, experience, and clinical judgment
to address the complexity of patients with tick-borne illness.
- Keith Berndtson, MD

43. Patient-centered
systems medicine.
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