Getting false negative for lyme in stage III is something of the worst which could happen to someone, as many never get a second test, and go on either undiagnosed, or with a wrong symptom based diagnose.
So here's my thought of how a test could be done, which could give a sensitivity of way over 90%, and also a very high specificity. Perhaps also way over 90%.
This could (theoretically) become a method for people who are very sick, have tested negative for lyme, but have good reason to suspect that they have it. And it could also be a method used in studies to prove that 1) The bacteria survives treatment 2) That many with symptom based diagnosis in fact have lyme.
Here's the method: Take a blood sample from the sick person, inject it into a mouse. If the ELISA negative mouse begins producing antibodies after the injection, then that's a pretty strong indication that the blood injected into the mouse contained Borrelia. I.e. the sick person have lyme in their blood...
If mice who are injected with blood without Borrelia don't get antibodies against Borrelia (which there's no reason to suspect they would) then we'd have a really high specificity.
The reason why this would work is because mice have no problems whatsoever to produce antibodies against Borrelia. And it happens quickly.
Could this be used to prove that large portions of those with symptom diagnosis (such as Fibromyalgia) really have a lyme infection?
Would getting the fibro community, and the fibro patients to team up with us, help with getting the truth about lyme out?
[ 07-12-2010, 05:52 PM: Message edited by: peter j ]
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seekhelp
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posted
Poor mouse. We can't do them like that.
The IDSA would just say the mouse caught it in between the time the shot was injected and testing. Seriously, sounds like an interesting idea.
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TerryK
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Borrelia don't generally live in the blood. It is a deep tissue infection.
Terry
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massman
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posted
Excellent point Terry. It may get in through the blood but doesn't stay there.
In stage I and II Borrelia lives in larger numbers in the blood. And the lousy PCR tests the IDSA use in their studies, have a sensitivity of some 30% on blood in stage I and II.
In stage III the same PCRs have a sensitivity of around 0%.
But with good PCRs you can find Borrelia in the blood even in stage III, and with Borrelia in the blood, you could infect others via blood transfusion. Meaning a test such as described above would work.
If Borrelia were to be found in e.g. a third of fibro sufferers, wouldn't that be enough to get a lyme to become one of the highest research priorities in the country? Leading to research for better cures? (right now, how we find cures are mostly trial and error...). It wouldn't be easy, but would it be worst a try? Does anyone know of a person who could do research on this, would could get the tip?
@seekhelp, so true, so true. It's funny yet tragic that they'd claim something like that. And they probably would.
Dostoyevsky has a great quote, which I find to fit perfectly well on how the IDSA operates:
"I have decided long ago to not understand. If I wish to understand something, I immediately begin fudging the facts, and I have decided to stick to the facts".
Posts: 275 | From Home | Registered: May 2007
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posted
Cure Unknown describes how this is done in several of the studies that have been conducted, not for purposes of diagnosing lyme, but to confirm presence of lyme for purposes of the research. This was done just for research and there was/is a group of lyme rats that were confirmed lyme free prior to the testing.
I'm not sure how realistic it is for diagnostic purposes, given the numbers of humans we're talking about.
Posts: 252 | From New York | Registered: Apr 2010
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I hope they could do the same with humans. Draw blood after the so called 'sufficient' treatment. Inject mice. See that the previously healthy mice get Borrelia.
The same scientists as did the study mentioned above could do that. All they would need would be some blood from a stage III lyme patient who have got the 4 weeks of ceftriaxone, which the IDSA considers a "overkill".
Wouldn't this be a giant leap forward? Anyone who could write to the scientists and suggest something like that? Their email is there if you click the link...
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massman
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peter where did you learn about the stages of lyme ? I was exposed to that by a RN about 5 years ago.
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nenet
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posted
I have a couple of concerns with your design as you've laid it out here.
One of my concerns is a problem that comes up again and again in current research, which is the circular logic applied when determining who has Lyme, and who doesn't, to establish who is infected, and who are the healthy controls.
This circular logic is applied in the foundational studies upon which the IDSA base their testing and treatment guidelines.
Currently, all of the modes of research testing (Lyme WB, ELISA, and PCR) have major weaknesses which build in inherent flaws in Lyme research/testing designs from the beginning.
How would you test to be sure that the "healthy" human controls do not have asymptomatic or undiagnosed Lyme infection?
We currently have no way to prove absence of infection. Which brings me to my second point:
Lack of an immune response in the mouse to the human's blood could mean more than lack of the organism in the human.
As we have seen, PCR tests are highly useful and accurate when positive, but are only as accurate as the blood or CSF sample being drawn. Blood or CSF is not going to carry a high-concentration of Lyme bacteria, and in many cases may not have a single viable organism.
PCR has a better chance of detection since it only looks for the DNA, and can amplify that DNA. It does not need a whole, viable organism to work.
Trying to find a viable, infectious spirochete in a fluid sample, and infect another organism, would be even more difficult than getting a positive PCR.
From memory, I recall that PCR testing has about a 3% success-rate of detecting otherwise-proven cases of Lyme disease.
Then we get into other possibilities for lack of antibody response in the mouse - off the top of my head: type of strain, OSP mutation, antibody response too low for detection due to tiny number of infectious spirochetes in the human sample, lack of any Lyme in the sample (which is highly likely), or the human sample only containing cystic of other Lyme forms which will not induce an antibody response.
My suggestion would be that one way to detect Lyme in the injected mouse might be repeated injections of human sera samples over time, and then killing the mouse and applying intensive PCR testing of every tissue and fluid in the mouse. Even then, spirochetes, cyst forms, or L- and other bodies could be missed, making it still far from accurate.
Another point not directly related to your test design - as I understand it, Lyme Disease is currently no longer being characterized as having defined stages (I, II, and III), because it is misleading.
Lyme can invade the CNS and brain of lab mice within 12-48 hours of infection. So symptoms are more useful an indicator of involvement, but even then they do not rule out asymptomatic or missed neurological infection.
Clinical practitioners and researchers generally now recognize that a patient can have neurological Lyme involvement within the first several days or weeks of initial infection, making the stages previously used obsolete.
posted
@massman: "I was exposed to that by a RN about 5 years ago?". Can you explain what you mean by this? (and what's a RN?). How I learned that about the stages and sensitivity? Reading studies, both meta studies and original studies. And seeing how long they've been infected and how many positives there are etc.
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There's several studies I suggest in the posts, and I am not quite sure which of them you're referring to. But, anyway, I agree that it's a huge problem the way the IDSA defines who have lyme, and who hasn't. And also how they use absence of proof, as proof of absence (if you see the study with people who's got a month of treatment, no-one tests positive on PCR, and they use it as evidence that no-one have borreliosis, but IMO that doesn't prove anything. They can't even get the PCR working on non-treated stage III patients...).
The problem this would solve (the one suggestion about using the test method on people who have undergone treatment) would be to show them that the bacteria is still there. If we could show that it survives a month of treatment, just like in the mice (see study above), then it would be much easier to argue for the rationale for trying other treatments then the monotherapy of ceftriaxone (which IMO is pretty worthless). And if the IDSA would accept it (which they probably wouldn't at first) they would have to take a deep hard look at their own practice.
I have to agree that it's a huge problem to find healthy controls who are truly healthy (and not just feel healthy), because I think that a double digit number of people in exposed counties have a latent infection (or asymptomatic if you will). The best way to get truly 'healthy blood' would be to use blood from the very north of Alaska, where ticks don't live.
I see you worry about the consequences of lack of an immune response in the mouse after being injected with the human's blood. Well, I think that absence of proof, is not equal to proof of absence, so I really don't think that's a big issue. But I see how it could be misused, especially be the IDSA. They seem to live by the Dostoyevsky quote. But that said, I feel pretty certain, almost absolute, that the mice would get borreliosis from such an injection, and that the antibody response would arise. I know of people who have been infected from human blood (and not by a tick bite). So if small amounts of human blood is enough to infect humans, I guess large amounts would be enough to infect mice.
"or the human sample only containing cystic of other Lyme forms which will not induce an antibody response." This is a very valid point. If you haven't read the study above ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2346637/ ) then I highly recommend reading it. At least the abstract. As you can see there, the treated mice's blood made the other mice PCR positive, but culture negative. They weren't able to culture after treatment. That may very well indicate that the borrelia has formed cysts, and thereby don't grow the same way in the medium. Cystic borrelia may naturally also work in a different way in the mouse execpt for the hardship of culturing it. That said, I think that it would invoke an antibody response.
"Another point not directly related to your test design - as I understand it, Lyme Disease is currently no longer being characterized as having defined stages (I, II, and III), because it is misleading."
I can see that you don't like the stage definition. But I do.
I didn't know you didn't define it that way in the US. Many European countries do.
I like it. Mostly because it circumvents much of the chronic or not debate. If you have chronic lyme, stage III lyme is a much less controversial term.
The stage list below is how it's normally defined (untreated lyme)... Stage I is days to a month after infection. Stage II is months after a infection. Stage III is at least six months to a year after infection.
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posted
The three stage definition is far from perfect. But I think it's better to have it than to not have it.
Personally I see the stages like this: First stage, very soon after the bite. May or may not get some initial symptoms. Second stage. Some symptoms, or you could go through this asymptomatic. Third stage: When the immune system caves for the lyme. Many remain unsymptomatic in the second stage, and never come to this stage. But it's in this stage the symptoms become the most intense.
Anyway, back to topic. Do you guys and girls think such a study as proposed above could be feasible? Should it get done? Could you d something to help it get done? (pull some strings, or email some well meaning scientists?)
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massman
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posted
peter - RN = Registered Nurse.
She felt (summer 2005) that many of the "autoimmune" diseases were / are actually different stages of lyme.
Many other "autoimmune" diseases were also listed in the stages. I am a tired fuzzy thinker today so I don't remember it all.
Many of these are difficult to diagnose
She also realized that many organs and systems could be affected so each case had some shared problems but also individual expressions.
She worked in central PA with lots of Amish patients, point being Amish are very straightforward no BS people. No imaginary diseases.
The more I studied and treated lyme, the more sense her opinions and conclusions made. I was fortunate to work with Amish patients from OH and learned from them too.
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Fibromyalgia and Chronic Fatigue Immune Dysfunction Syndrome (or M.E. as it's called in Europe) are NOT Stage 1 Lyme.
IF (and this is a BIG "if") those illnesses are Lyme at all, they are certainly Stage 3. If you don't understand CFIDS, please do some reading and educate yourself. CFIDS is NOT just feeling fatigued. It's not just having some pain. It is a whole body disorder, affecting every system, and it is highly disabling (and does lead to premature death, usually from either a heart condition or cancer).
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massman
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posted
Well, Marritt, I guess that RN must be wrong, having only treared thousands of patients.
I have worked with many patients with many of these diagnoses.
How many patients have you treated ?
None of this is set in stone. Are your opinions primarily from reading ? _______________________________________________ DISCLAIMER: only honest questions for honest answers. No sarcasm.
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nenet
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posted
Ok there are lots of different definitions being talked about here, and that can make for some confusion and miscommunication.
There is the old, outdated in the US, 3-stage definition of Lyme pathogenesis (the development of a disease state over time), which is laid out as:
Stage I: early, localized/non-disseminated, "mild" symptoms (with the arbitrary 1 to 4 weeks timeline of infection)
Stage II: intermediary, early disseminated, more systems affected, heart or neurological symptoms (with an arbitrary 1 to 4-months timeline of infection)
Stage III: late persistent infection, fully disseminated. Strong neurological and multi-system involvement, damage to joints, nerves, or brain, etc.. (with an arbitrary 4-month to indefinite timeline of infection)
This definition is outdated because it has since been better understood that any of the symptoms and system involvement can occur at any time during infection.
Practically-speaking, treatment would have to be the same for whatever type of symptoms have been observed - for at least 2-3 months after the last symptom is gone.
Animal studies have shown that it can take as little as a day to begin having brain/CNS/neurological, or heart infection, after a bite. People can often get VERY sick with neurological and/or heart symptoms within a day or two of infection.
I know of cases of heart and neurological symptoms starting within a day of the bite, even in my small circle of non-Lyme-community family and friends.
This definition is useless in my opinion, in any kind of practical sense - for clinical practice, or for research purposes. Yet, the 3-stage definition is still used on some websites, in some research studies, and in some clinical practices. WebMD is one example of being behind the times:
The layout of stages massman posted is not the same definition that used to be used in the general medical industry. I've never heard of it before, and don't agree with it, but to each their own.
In light of IDSA's constant denial of the existence of Lyme infection that does not respond to their guidelines, the term "Chronic Lyme" has come into wide use, in order to describe pathology that is resistant to typical IDSA guidelines-recommended treatment.
I also think that the term "Chronic Lyme" is a two-edged sword. Tuberculosis - which requires upwards of 18 months of multi-antibiotic treatment - is not called "chronic". It is just understood medically that it takes a long time to treat, and that it ALSO may relapse over a person's lifetime, in times of stress or other illnesses, etc.
Adding the term "Chronic" creates an imaginary new category for Lyme patients that don't respond to the IDSA treatment guidelines, when those guidelines are what is at fault - the Lyme is the same Lyme, before, during, and after IDSA-based treatment.
I think it's more helpful to see Lyme that IS effectively treated by IDSA standards as the exception to the rule, and to call it something like "Atypical Lyme". It might be unrealistic to have that as a goal, but it's a good way to think about the situation in a new, non-IDSA-defined way.
'Kete-tracker
Frequent Contributor (1K+ posts)
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posted
You might have a good chance of sucking up some viable 'ketes if the blood is drawn from a person with acute, active infection. But once you start on antibiotics, the likelyhood of these 'ketes being successfully "drawn" quickly drops to near zero, as the blood-borne 'ketes are all killed off & the pieces drawn out of the body by the immune system. Interesting... but I doutbt it would have predictable enough results (quantified mouse anti-body generation) to be used as a diagnostic tool.
Not to mention that all the testing labs would be put into an unprecedented position of having to be supplied "standardized" mice... on a large scale!
And the chances of FDA approval of the equipment needed? A better chance that the Guidelines for Lyme disease treatment will be re-written next year. Posts: 1233 | From Dover, NH | Registered: Sep 2008
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massman
Unregistered
posted
The stages I mentioned are not a direct progression.
But as said in some other posts (not sure if in this thread) using antibiotics definitely helped some patients with these supposed "autoimmune" diseases.
The word autoimmune always bugged the _____ out of me. I always wondered WHY the body attacked itself, sometimes very savagely. I felt it just did not "happen".
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Just saw your response to me. My *opinion* is from real life experience. I have been sick with CFIDS for ~ 15 years.
Further, I've had a lot of time to research. RN's and doctors seeing patients do not have time to research even if they would. I've read kazillions of research papers through the years for my own benefit and tried to stay current on the latest.
Neither being an RN nor a doctor treating patients makes one an expert. No one knows it all, and there is a great deal of speculation by everyone about these "new" and emerging diseases.
I am waiting now for XMRV to be resolved. Latest developments:
Blood Products Advisory Committee Mulls XMRV Information
Fran Lowry
July 27, 2010 -- The US Food and Drug Administration (FDA) Blood Products Advisory Committee yesterday heard briefings from a number of public health agencies and other experts on whether the recently discovered human retrovirus xenotropic murine leukemia virus-related virus (XMRV) poses a threat to the nation's blood supply.
The committee also heard how laboratories from the National Cancer Institute (NCI), the Centers for Disease Control and Prevention (CDC), the Blood Systems Research Institute, and the FDA are working to develop state-of-the-art assays to speed recognition of the virus and facilitate screening of potential blood donors.
The panel was treated to a rehash of conflicting studies -- some showing an association with XMRV and prostate cancer and chronic fatigue syndrome (CFS), and others showing zero association between the gammaretrovirus and these diseases.
Indira Hewlett, PhD, from the FDA's Division of Emerging and Transfusion Transmitted Diseases, Office of Blood Research and Review, briefed the panel on the conflicting studies that linked -- or did not link -- XMRV with prostate cancer and CFS.
In one study, XMRV was detected in 7 of 11 prostate cancer patients with a genetic predisposition for prostate cancer; in another, 6% of 334 prostate cancer patients were found to be positive for XMRV by polymerase chain reaction (PCR), and 23% were found to be positive for XMRV by immunohistochemistry. "Taken together, these findings suggest an association of XMRV with prostate cancer," Dr. Hewlett said.
In CFS, one study (Science. 2009;326:585-589) showed that XMRV could be detected in 67% of patients with CFS vs 3.7% of healthy control patients, using PCR and serology testing.
Horns of a Dilemma
However, other studies have yielded negative results for both prostate cancer and CFS, and these have placed researchers and policy makers on the horns of a dilemma.
The possibility of potential transfusion transmission of XMRV comes from experiments with rhesus macaque monkeys -- intravenous inoculation showed disseminated infection and low but detectable transient viremia between 4 and 14 days, Dr. Hewlett told the committee. Seroconversion occurred between 11 and 14 days, with titers peaking around day 95. In addition, XMRV was isolated from lymphoid cells, reproductive tissue, and a number of organs.
"These findings lend support to potential transfusion transmission of XMRV and suggests that there is a need for additional studies using well-standardized assays," Dr. Hewlett said.
Because of the potential for transmission of XMRV during blood transfusions, the Canadian government has decided to err on the side of caution by mandating that all patients with CFS refrain from donating blood, Peter Ganz, MD, from Health Canada, Ottawa, told the panel.
Caution in Canada
The Canadians have been ultracautious ever since the "tainted blood" scandal of the mid-1980s, which saw a number of people become infected with HIV through blood transfusions, Dr. Ganz said.
Blood from donors with CFS who were asymptomatic was accepted in Canada until April 2010, but now 90% of these would-be donors are indefinitely referred. The remaining 10% are from the province of Quebec, which still allows donors to give blood as long as they feel well.
"In Canada, one of our overarching guiding principles with regard to blood safety is the precautionary principle, which means that authorities must act, even if there is only a theoretical risk of harm," he said.
Robert Silverman, PhD, who was part of the team that first reported the potential link between XMRV and prostate cancer and CFS, presented those data again and also told the panel about possible ways that the virus infects humans.
Dr. Silverman told the panel that XMRV is found in semen and that its infectivity is enhanced by androgen and inhibited by antiandrogens.
Evidence Mixed for Disease Links
Of the 12 studies on XMRV and prostate cancer, 9 found evidence of the virus at some level. In CFS, the evidence has been less: Only 1 study of the 5 that have been done found a link between XMRV and this debilitating disease.
Dr. Silverman suggested that laboratory contamination, geographical distribution, sequence variants, clinical criteria for patient selection (particularly with CFS), and lack of standardized screening methods and positive control human participants are factors that could be responsible for large differences in the detection rate.
"XMRV is associated with prostate cancer and CSF in humans in some, but not all, studies. All individuals are at risk, regardless of the RNA cell genotype. XMRV establishes both acute and chronic persistent disseminated infection in primates -- the prostate epithelium is an early target, the stroma a late target, CD4 and other blood cell types are infected," he told the panel.
In addition, "XMRV growth is fueled by androgen, which is a possible oncogenic mechanism, XMRV might be transmitted by blood transfusion, and there is now donor deferral for people with CFS in 3 countries," he said.
Knowledge Still Emerging
In spite of these observations, Dr. Silverman cautioned that knowledge about the infectious nature of XMRV is still emerging. "We need to let science do its work. Any causal link to human disease remains to be established."
R. Michael Hendry, DSC, from the CDC in Atlanta, Georgia, followed Dr. Silverman's presentation. He told the panel that, in direct and complete contrast to Dr. Silverman's experience, the CDC was unable to find any evidence of infection with XMRV in their population of CFS patients by any means, including using Western blot or ultrasensitive PCR assays.
"Many people have alluded to differences in patient population, complexities of defining [CFS], lab methods, and strain differences, to explain the contrasting results; however, our results do not support an association of XMRV with the majority of [CFS] patients," he said.
Stuart Le Grice, PhD, from the NCI Frederick Laboratory, Frederick, Maryland, described how he and his colleagues have been working to develop a single-copy assay for XMRV DNA, RNA, and serology, based on the assay that was developed for HIV.
"The HIV single copy that was developed at the NCI is regarded as the gold standard assay. We now believe that we have an equivalent assay for XMRV."
Dr. Le Grice and his team have also developed a cell line, dubbed the Derse cell line, which can detect XMRV in as little as 3 days.
He said that the XMRV assay that his lab has developed has been transferred to labs in Sweden, Australia, Vietnam, and South Africa to prove its utility. "Developing an assay is one thing, but transferring it to a laboratory where it can be reproduced is clearly important when we are talking about single copy assay. Contamination is a huge problem, and the ability to transfer these reagents is very important," he noted.
Dr. Le Grice added that the aim of the NCI is to make sure that the assays they have developed are as valid as possible. "Our goal is to develop a series of assays that we feel confident in and to test those head to head with other assays. I think that is really important at the moment. We should start with 6 assays in house, and if we have a problem, I think it is important to sit amongst ourselves and try to understand where those problems are before we disagree with anybody else's assay."
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