Spring has arrived, and with it, the beginning of camping and hiking season. However, something as simple as a walk in the woods can mean exposure to deer ticks, some of which carry dangerous bacteria -- and a controversial CDC recommendation against a lab test for Lyme disease may mean that many infected individuals go undiagnosed and untreated.
Commonly known as Lyme disease for the town in Connecticut whose citizens were among the first to be identified as suffering from this ailment, Borrelia burgdorferi is the most common tick-borne illness in the United States. Roughly 20,000 cases of B. burgdorferi infections are diagnosed each year, and 20 percent of these patients will continue to experience persistent symptoms known as "chronic Lyme disease." Some researchers believe that the actual number of human Lyme cases is even greater -- as many as 300,000 new cases per year, most of which go undiagnosed by currently approved testing.
One problem that can lead to persistent symptoms is delay in diagnosis and treatment. Early symptoms of Lyme disease include flu-like fever, chills, and ache, as well as a rash known as erythema migrans (EM). The rash is often described as having a "bull's-eye" appearance, but some patients (such as Discover magazine's Pamela Weintraub, who spoke at a recent IOM meeting) report that doctors' rigid adherence to a narrow definition of the rash as a diagnostic marker has cost them crucial treatment time. The CDC recommends a two-tier test for Lyme disease involving an FDA-approved enzyme-linked immunosorbent assay (ELISA) followed (if necessary) by an FDA-approved immunoblot ("Western" blot).
However, some research scientists have used a process called "xenodiagnosis" to detect spirochetes up to three months after treatment with antibiotics such as ceftriaxone or doxycycline. Xenodiagnosis is the practice of exposing healthy organism to potentially infected tissue from another organism and then examining it for evidence of infection after an incubation period. Work in animal models indicates that "low levels [of non-cultivable spirochetes] could persist [...] after antibiotic treatment for disseminated B. burgdorferi infection."
Much of the current controversy about Lyme disease centers on the question of whether chronic B. burgdorferi infection exists, and if so, whether this chronic infection is responsible for hosts' neurological and joint-related symptoms. In 2012, Dr. Linda Bockenstedt and her colleagues at the Yale University School of Medicine studied Myd88-/- mice (mice with a particular genetic variant) that they infected with B. burgdorferi and then treated with antibiotics. Nine weeks after the completion of antibiotic therapy, spirochetes were not detected in the mice either by xenodiagnosis or by culture. However, the scientists did detect B. burgdorferi DNA in the knees of these mice.
Dr. Bockenstedt and her team suggest that the chronic arthritis symptoms of human Lyme disease patients who have already been treated with antibiotics are due to the "antigenic and inflammatory debris" to which these patients continue to mount an immune response, rather than to true chronically active Lyme infection. "The multiple methods applied in this study," writes Dr. Bockenstedt, "provide a preponderance of evidence that infectious spirochetes are eliminated." Dr. Gary Wormser of New York Medical College, along with several of his colleagues, has expressed a similar viewpoint.
Other researchers disagree. According to a review of the literature conducted by Keith Berndtson of Park Ridge MultiMed in Illinois, "Lyme disease spirochetes are adapted to persist in immune competent hosts" and that these spirochetes can "remain infective despite aggressive antibiotic challenge." Raphael Stricker and Lorraine Johnson of the International Lyme and Associated Diseases Society have published a paper describing the mechanism of action of aggrecanase, an enzyme produced by B. burgdorferi that attacks joint tissue; they assert that evidence of aggrecanase activity is also evidence of the existence of chronically active Lyme infection.
In the April 18, 2014, Morbidity and Mortality Weekly Report, the CDC cautioned the public against the use of a Lyme disease test from Advanced Laboratory Services in Philadelphia, stating that mere receipt by a lab of Clinical Laboratory Improvement Amendments (CLIA) certification does not mean that all tests developed by that lab have received FDA approval. The Advanced Laboratory Services test involves sampling patients' sera, culturing it, and subsequently testing it for spirochetes. In general, the CDC does not recommend culturing or PCR to test for Lyme infection.
In order to gain a better understanding of the issues involved in Lyme infection and testing, the Allentown Family Health Examiner spoke with Dr. Philip M. Tierno, Jr., clinical professor of pathology and microbiology at NYU Langone Medical Center. The conversation is presented here.
Dr. Tierno is no stranger to controversy, having warned the CDC and Procter & Gamble about the dangers of synthetic tampons decades ago.
Q: Could you provide some information on your role in the toxic shock syndrome controversy of the 1980s?
A: In 1980, I sent an open letter addressed to the CDC, the FDA, and Procter & Gamble. In the letter I said who I was, and I said in the second paragraph that I believed I had the answer to the problem of toxic shock. They replied to me saying that the best minds are already working on the problem, and they had no funding for me. That wasn't what my letter was about. It was to give them insight into the problem so the researchers would know why the toxin is being produced.
In tampons, there were four synthetics replacing cotton, mid-1980. They used four ingredients to address women's problem of menstrual bypass [leaking]. P&G, which was never in the tampon industry, put out Rely, which was 100% synthetic. The FDA allowed that tampon, which was considered a "me, too" product. It had carboxymethyl cellulose and polyester fibers with a polyester bag -- totally synthetic. By the way, one pledget could absorb the menstruation from the entire five-day period. Other manufacturers used two other synthetics, viscose rayon and polyacrylate rayon. The best of the bad synthetics was viscose rayon, made from wood chips, basically.
The FDA responded to my letter advising me, "We don't do research. Researchers are looking at this, I'm sure." They referred my letter to CDC, which said, "We have no extramural funds. We cannot support your work." My letter had made it clear that I wasn't looking for funding.
P&G sent a scientist to my office to try to coax me into submitting a grant, which I didn't want to do -- I didn't want any strings attached. My only question to this man was, "Look, I don't want to be involved, but if I did want to, what's my freedom to publish?" They said, "You have to send us a copy so that our scientists can replicate it." In science, a second publication verifies the first and is considered fact. Long story short, I'm still involved in TSS. I still testify for women who have died or lost limbs as a result of using the last remaining synthetic product, viscose rayon. The problem is less now than before, because at least physicians are alerted to the possibility, and women use tampons differently. If a tampon is in place, and they have a toxigenic staphyloccus aureus, and they develop a constellation of symptoms, they are warned that it could be toxic shock.
CDC was rather disdainful, the way they approached the matter. Later, when my work was starting to be published, I was blocked from publication by many scientists here who worked on grants provided by manufacturers. The manufacturers had these scientists doing research, tying them up. I also wrote a letter to FDA that the Today sponge is made of a polyether polyurethane foam, and it's similar to the polyester polyurethane foam. In fact, when the nonoxynol-9 spermicide it contained wears off -- as the semen neutralizes the nonoxynol-9, so after the first intrusion -- it frees up the sponge to allow toxigenic staph to produce and release toxin. I mentioned to the FDA that if menstruation occurs during the night, these females can be subject to toxin production. The FDA said, "Well, we're not telling them to use it during menstruation, so it's not applicable." A year later, not only did my work show that the toxin is produced when blood is present, but about 16 other papers came out, and the Today sponge was pulled from the market.
Not every Lyme-associated rash shows a distinct bull's-eye pattern.
Q: Can you provide some background information on testing for Lyme disease?
A: The current testing I used in my lab at NYU (which is still being used) is the two-tier test (ELISA followed by Western blot). I used to tell my physicians that use my services that you need five of the ten bands for IgG and two of the three bands for IgM for the Western blot. The IgM usually appears first.
I used to tell some of my practitioners, it's not hard and fast. We're only talking about 50% or less of positives can be picked up by the two-tier method. It doesn't mean you don't have Lyme. I used to say, even if you have three of ten bands with symptomatology, that is proof that there is an anomaly going on, and more likely than not, it's Lyme disease. By the way, before you get to that second tier, you have to do an ELISA first; if that's positive you do the Western blot. You've got clinical signs and symptoms, with or without a rash, and you've got a positive ELISA. I used to tell them treat for Lyme at three or four bands [on the Western blot IgG].
Now there is a group that wants to use two bands, with the positive ELISA and symptomatology. That would cover about 92-93 percent of the cases. But the CDC is calling the shots to a great degree. It's like the bully in the game: they dictate, and unless you buck the bully, you'll continue to be bullied. That's the best analogy to describe the situation.
If a tick has been attached for long enough to become engorged with blood, it has been attached long enough to transmit Lyme disease.
Q: Your opinion of the likelihood of laboratory contamination in the case of the Advanced Laboratory test for Lyme disease?
A: The CDC never said or showed that there was in fact contamination. They just said they could not rule it out. To even use the word as they did in another area of the paper "probable" -- those are the strongest words that they used. They never said in fact contaminated. This is not the first time that Sanjay Gupta will have to retract his words when he looks more carefully into this. He's done that with marijuana. Then he saw some of the patients, and did further investigation -- that's what made him turn around. I want him to do the same thing here: come to his own conclusion by visiting the lab.
I have visited the Advanced Laboratory Services lab, so I can speak first-hand. I wrote a paper back in 1996, "Methods comparison for diagnosis of Lyme disease" (Lab Med. 1996; 27:542-546). I was contacted by a faculty associate of mine who said, "Hey, there's a lab in Philadelphia that could use your help in a new technique in Lyme disease." He gave them my name and we discussed things. I was amazed that they had a culture. Culturing is very tough. You can take some body fluids or use tissue from the erythema migrans and try to culture Borrelia, but with very low frequency. I was curious what they did that I didn't do. I went down there to visit and speak with the lab administration. I went through their whole facility, and if I tell you their clean rooms are clean ... I also saw firsthand the spirochetes in their cultures. They have a very intricate culture setup. It uses collagen, a whole host of things, that even though I used a similar medium, they modified this Kelly medium, and cultured for extended periods -- one month, two months, three months, four months -- and did complex subcultures. I don't think anybody really did that to the degree that these people have done, and they have perfected it.
[The first reason to believe there is no contamination in the Advanced Laboratory Services lab:] I have seen their cultures, and they verify the presence of Borrelia in the specimen. Of the 2000 they have done, they have a 38 percent positivity rate. By the way, if there were contamination, it would be across the board, and should be evidenced even here.
[They use something] called an immunostain. They have an antibody stain that glows under fluorescent microscopy. Once that's positive, they then take the material and do a PCR on it, to look at a certain segment (16S assay) of the of the genome of the bacteria, so that they can identify it as being a member of B. burgdorferi species. Now all Borrelia, by the way -- it doesn't matter what the species is, have certain conserved signature inserts and deletions (CSIs) and conserved signature proteins (CSPs) that are indigenous to all Borrelia species, and are unique in all Borrelia species. Some scientists have identified seven CSIs and 21 CSPs that are uniquely found in Lyme disease Borrelia. Then there are areas where there may be some slight differences. So you look at some of these base pairs, you amplify it so you can see it better, and it's positive or negative. So you confirm the fact that this spirochete is indeed Borrelia. And that's the process of identification.
Now the CDC comes out with a report using some methodology which shows according to their report that these might be contaminants -- that all positive cultures, or most of them, might be contaminants. If that's the case, then therefore it's an invalid test, according to them. Of course they're just going to suggest that you have the B31 control reference strain present in all of the cultures. If one wanted to be disingenuous, one could take segments that all Borrelia share -- to show complete 100% identities -- with a species of organism -- and that's basically what they did.
I read those reports from the CDC group in Fort Collins, Colorado, saying that Eve Sapi, that her work was probably contaminated. What hurt me more was these lay reporters that don't know diddly squat what they're reading, and professional medical news media that are involved, saying that it's in fact contaminated, when it was not in fact contaminated. They suggested that the PCR they did cannot rule out contamination, and I will tell you how that was ruled out, by these reports that are going to be published, one has already been accepted in the Journal of Clinical Microbiology for May, and there is a second that may come out in June. And there are others.
[The second reason to believe there is no contamination in the Advanced Laboratory Services lab:] What bothered me is these journalists reporting as a fait accompli that contamination did occur, when the CDC did not say that or prove it. None of these reporters tried to investigate further. They just took the word of CDC. I was amazed at that, and yet if contamination did occur -- and it was rampant according to them -- but not one control was positive whatsoever, that is totally not expected (by Occam's razor alone). If you're running the system and you've got -- controls that go with every specimen, so that is one thing that should send up a red flag -- no controls were positive for what they call contamination.
Another thing -- it's just a colloquial thing that we have in the field if you've done enough cases -- simple observations. When you take a reference strain like B41 (from American Type Culture & Collection, the company that sells reference strains), that reference strain will grow in about two days in your control bin. Yet the culture from the patient will grow in a week if you're lucky, but it could be up to 16 weeks. If you had contamination, that contamination would also grow quickly -- in about two days, the time it takes the reference strain to grow. It's a frame of reference that you have for the organism. All the controls came out in two days -- I think the longest was three. Microbiologists can buy any culture for reference and controls. That's the second thing. The growth of the controls was rapid, two to three days, compared to weeks or months depending upon the individual test person.
[The third reason to believe there is no contamination in the Advanced Laboratory Services lab:] Number three. If you were to do something where, of course the specimens are gone, but you do have some 16S -- some genetic markers, some PCR -- we have these in a bank called the GeneBank. In other words, there is a genome center where you can compare things, it's gene sequences in a gene bank. It's in their computer, the data on the genetics. They were sequenced. You can do something called a BLAST [Basic Local Alignment Search Tool]. It's something that you use to compare your current findings with something stored in the GeneBank. You're taking certain gene sequences. If you do a blast comparison with the GeneBank, for this B31 strain -- this is an ATC&C strain, you have that in the GeneBank -- if I run a sequence and I want to compare it to the GeneBank, I can do that.
Let's say my sequence is ABFK -- of course, it's more than that -- and the sequences I get are ABFO, then that's not identical. Or ABGHI, that's not identical. So you can take your control and see what the homology is. The CDC reported 100% homology. But they did a method where they're taking a certain number of base pairs. Remember what I said about the Borrelia species have in common 82 different signature proteins, and other inserts and deletions? Well, that occurs in all Borrelia. If I look at that subset, I get 100% homology, not only with the control, but if I ran any Borrelia, I would get that same set. The CDC says this shows 100% homology, but the BLAST analyses did not show that. It did not support 100% homology. Johnson alleges that 48 of the 51 Sapi isolates with a sequencing match perfectly the CDC GeneBank haplotypes, but when you ran a BLAST taking the actual GeneBank sequences and comparing them to see what the degree of likeness is, they did not get (on this and a second analysis) 100% likeness. They got 93%, 96% [which is what you'd expect from similar, but not identical, strains]. My point is, if there's a genetic difference in the sequences you're looking at, then it's not identical.
Then there was a second BLAST study done. Same results: non-identity. When you fact-check the assertions of contamination of patient specimen, they were not substantiated.
[The fourth reason to believe there is no contamination in the Advanced Laboratory Services lab:] The fourth thing was that the CDC claimed that one of the strains that the Advanced Labs were using was a B. garinii -- it an ATC&C strain that's also used as a control. They claimed that Advanced Labs detected a B. garinii in some of the sequences, and then they said it shows that there's contamination, because B. garinii is never found in North America -- but it turns out that CDC gave in on that point. They decided that some of the reports that came out against their comment are correct. That species has been found even in birds in the US and Mexico, so they concede that yes, there is that organism here. There is a commonality. Bottom line, all of the ATC&C strains that were tested and matched with a BLAST, showed that not one was 100% matches to 51 patient samples tested. All these people did with the BLAST was to show the difference -- they're not identifying with their technique, as it is not meant to do that -- they're only showing that the strains are different. If you say 100%, that's a pretty strong statement. I can do a sequence where I do any Borrelia and get 100% positive, if I look at a certain segment (high conserved) that is common to all of them.
Many laboratories and physicians are intimidated by pressure from the CDC regarding the types of tests they perform for patients.
Q: So it's sort of like having a room of people all wearing Gap khakis, and looking only at their pants, and saying that they are all wearing 100% the same clothes, even though their shirts may be different?
A: It's sort of like that.
My lab at NYU Medical Center was and is an FDA lab, which means that we have to use methods approved by the FDA. Home brew tests have been excepted by the FDA, but Johnson is trying to change the rule and make it so you can't use anything that's not approved by FDA. This has got to come to the light of public scrutiny. It reminds me of the tampon bullies. When you make the front page of Barron's Business Weekly, such as occurred during the TSS controversy, you're persona non grata. Nobody wants you if you're hurting the GNP. But women were being killed. I had to say something.
The CDC, until recently headed by Kathleen Sebelius, advocates a two-tier test for Lyme disease that may produce false negatives for as many as half of Lyme patients.
Q: Your view of the appropriate type of testing for Lyme disease (enzyme immunoassays, immunoblots, serum sample cultivation, etc.)?
A: Now the sensitivity of the Advanced Labs test is 94%. The sensitivity of the two-tier testing recommended by CDC is 50%. So you're missing half or maybe more of the cases. Look at the agony of these people. People send me letters and say, "My daughter is dying." I make recommendations that physicians check out that lab -- but now they've stopped doing cultures. It's such a huge ramification that this one paper by the CDC is having. I don't know how it actually got past review. Well, I guess everybody's afraid of this Fort Collins group, headed by Barbara Johnson. We used to think that if you treat with two weeks, maybe a month of therapy, that should be enough. One of the things that came out of this work by Advanced Labs is that you have to treat for longer periods, even months. We used to think two or four weeks was long enough.
I think unfortunately when you hurt these people who are looking for help, and you prevent them from getting the proper therapy, because the tools they're using do not show any active disease.
It's shocking to me what's going on. Another thing the CDC has been in print with -- they used to quote statistics of 30,000 reported cases of Lyme each year. The Advanced Labs spoke with some of the CDC people other than the Fort Collins group, and they said it's likely ten times higher. Advanced Labs said it's 300,000 cases per year, minimum. Now the CDC decided yes, it's true: the figure should be 300,000. They reversed without an apology, just as they did with the B. garinii statement.
Even if they want to allow a change in diagnostic policy -- there is another company, it's a genetic company -- that suggests two or three of the ten bands, bring down the number you need for the IgG test from five of ten to two or three of five -- they should do that immediately. But the Advanced Labs test is excellent to confirm active or chronic infection. In microbiology, there is one gold standard: the smoking gun is a live organism that is isolated from a patient. Serology is usually a retrospective look. It means at some point you were exposed. You don't know if you have the disease currently, or whether you're in the end phase of it, or whether it was in the past.
You would think that the CDC would develop their own culture system, or work to improve the Advanced Labs culture method, rather than throwing stones at it. This is an agency that has the task of protecting the health of America. They shouldn't knock a system that can help toward that goal -- and even if they felt it was in need of fixing, then they should help fix it. When I see things like the current situation, it is just frustrating, and that bothers me.
During [the] toxic shock [controversy], the manufacturers called the dean of NYU -- tampon manufacturers got an NYU alumnus who worked at the company to call NYU -- and said that NYU had a researcher who was causing trouble. I was checked out by numerous administrators. They tried to apply pressure to stop my toxic shock research. That's the length that people go to. They didn't pursue that area -- nothing happened -- because my three superiors said, "He's an upstanding faculty member," but believe me, boards of trustees of universities can be affected.