Understanding Lyme borreliosis

How can the history of Lyme borreliosis over the past 40 years be divided into stages?

This disease has apparently been known for a long time, but even today, this pathogen can cause unexpected situations and serious professional debates. This applies to diagnosis as well as treatment and prevention of infection. As a pathologist, my job has always been to conduct fact-based investigations and research. Later, the experience I gained at the serological laboratory of the Johan Béla National Institute of Public Health helped me first in diagnostics and then in the maze of treatment and prevention.

In the early 1980s, it still took time to recognise the connections between symptoms, and case reports sent by the best specialists from across the country and consultations based on knowledge of serological reactivity were a great help in this. However, identifying, naming and culturing the pathogen, developing appropriate diagnostic methods and recognising their limitations were also serious challenges. Unfortunately, the problem of cross-reactions, which were only suspected at the beginning, still makes it difficult to apply the known pathomechanism in treatment regimens. Without this, the necessary application of the appropriate dose and duration of antibiotic treatment was a particularly challenging task for specialists.

Later, the development of combined antibiotic treatment was a real revolution. Every discovery, every modification, laboratory and clinical testing, the identification of possible inhibitory effects, the recognition of the development of autoimmunity, and the identification of Lyme borreliosis alongside tick-borne diseases (Morbus ixodicus, Tick illness), Febris ixodica, and the associated complex tick-borne disease. Despite this, or perhaps because of it, continuous scientific progress based on pathogenesis is a great research task.

Lyme borreliosis can be most accurately identified through direct diagnostic methods. Why is a special culture medium important for direct diagnostics?

During the diagnosis, I quickly realised that direct detection of the pathogen was unavoidable. This required the use of new procedures: a special culture medium protects the condition of the pathogen and the blood sample, prevents the destruction of the pathogen and ensures its movement. While aiding diagnosis, it allows the life of the pathogen Borrelia burgdorferi sensu lato to be followed almost in vivo, providing a deeper understanding of the disease process. Without the DualDur® reagent, decomposition products often form in the blood sample, even with the usual anticoagulants, making it impossible to test. This applies to both genetic and visual testing, which is why, for example, many people have published images that actually show pseudo-spirochetes rather than Borrelia, the causative agent of Lyme disease. The pathogen itself is very sensitive outside the human body, so without protection it decomposes in seconds without a trace. As there has been no reliable direct test to date, it is very difficult to determine the number of pathogens in a Borrelia infection, and even more difficult to objectively assess the effect of treatment. However, it is generally accepted that the bacterium is found in the blood, through which it reaches various parts of the body. It is also assumed, and can be proven by experiments, that the number of pathogens in the blood varies and is sometimes very low. It is therefore important to examine a sufficient amount of blood, not just a single drop. The right culture medium also helps to ensure that the pathogen is still viable after a series of concentration steps, after which it can be identified based on its unique movement, specific genetics or surface proteins. This makes the test objective: either there is a pathogen in the sample or there is not, and it is even possible to calculate the amount per 4 ml of blood, which is concentrated into a single drop during the highly repeatable testing process. If we want to examine a smaller amount, say for cultivation, it is worth knowing that the pathogen reproduces slowly compared to other bacteria, even under special conditions: due to the short examination time, we can only strive to “keep alive” and examine existing pathogens.

How does the automatic dark-field AI microscope help with proper diagnosis? How does artificial intelligence help?

The automatic dark-field AI microscope automates the previously manual half-hour tests and converts qualitative determination into quantitative determination. In order for an examination to be repeatable not only at a leading research institute such as the Johan Béla National Institute of Public Health (currently NNK), but in any laboratory, it is essential to objectify it and eliminate the possibility of human error. Human operators can become tired, may not always find suspicious formations, and cannot document and record everything they see in a live, continuously moving sample. Artificial intelligence is not smarter than humans, as we have taught it with human knowledge, but it is more tireless and objective. Specifically, we use it to select suspicious patterns and then filter out false positives from them. This is where humans come into the picture, as they only need to validate a representative sample. The machine calculates statistics, draws correlations, and runs through the decision tree. But the key question is whether the laboratory results match the reference and the symptoms. Does it give the same result for the same sample, for two samples from the same person, even a week after sampling?

What is the current sensitivity of direct diagnostics? Can the methodology be further developed?

Of course, everything can be further developed. Of the many indicators, one is important for doctors encountering suspected Lyme disease cases: the proportion of patients detected by the test. Contrary to diagnostic “clichés”, this is not represented by sensitivity, but by positive predictive value (PPV), which is 96% with automated testing. Lyme testing already allows for evaluation based on data that can be used to recommend individual treatment regimens – this is also worth further development.

With special sampling using the DualDur® reagent, we can detect not only Borrelia, but also other intracellular pathogens, Bartonella, Babesia, and two forms of Anaplasma, as well as patterns characteristic of Mycoplasma and Chlamydia. For the time being, only Borrelia can be tested in any laboratory. Further experiments are needed to test for tick-borne disease (Morbus ixodicus, Tick illness), Febris ixodica, and the associated complex tick-borne disease.

What is special about Lyme borreliosis?

Bedside medical care, diagnosis and therapy for patients. When the world’s best clinicians were unable to decide whether doxycycline or penicillin derivatives were more effective in treatment, and when new fluoroquinolones were not really effective according to laboratory tests, it was necessary to return to the analysis of the known characteristics of Borrelia burgdorferi sensu lato.

Over the past decades, we have learned that this pathogen is incredibly versatile. Its genetic makeup and the proteins it produces can change so much that the body recognises it as a new infection, a new bacterium. Therefore, during therapy, not only is a drug appropriate for the antibiotic sensitivity of the strain causing the current infection required, but the variability must also be inhibited (e.g., ciprofloxacin fluoroquinolone). Since we have identified more than a hundred strains of the pathogen and the symptoms it causes, we have come to understand that the reason for the therapeutic difficulties is also the different antibiotic sensitivity of the strains. In other words, treatment tailored to the individual and the pathogen must be used to achieve a lasting effect. It should be noted here that we treat the patient, we want to eliminate or alleviate their symptoms, and not normalise laboratory values: after treatment, weeks are needed for regeneration, and even longer may be needed for serological reactivity to decrease. In addition, the body’s defences, which have been damaged by the pathogens, must be rebuilt so that a complete immune and organisational response can develop.

What developments would be worthwhile in the fight against Lyme borreliosis over a longer period of decades?

Research into tick control methods, the use of microscopic fungi, further research, and the destruction of the pathogen in ticks or small mammals are the right direction to take. However, this is a very long process, so for now, we must rely on the most accurate and rapid direct diagnostics possible to combat the infections that have developed.