Aberer E, Kersten
A, Klade H, Poitschek C, Jurecka W
Heterogeneity of Borrelia burgdorferi
in the skin.
Am J Dermatopathol 1996 Dec; 18(6):
571-9
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8989928
The reliability of various in vitro techniques
to identify Borrelia burgdorferi infection is still unsatisfactory. Using a
high-power resolution videomicroscope and staining with the borrelia
genus-specific monoclonal flagellar antibody H9724, we identified borrelial
structures in skin biopsies of erythema chronicum migrans (from which borrelia
later was cultured), of acrodermatitis chronica atrophicans, and of morphea. In
addition to typical borreliae, we noted stained structures of varying shapes
identical to borreliae found in a "borrelia-injected skin" model;
identical to agar-embedded borreliae; and identical to cultured borreliae
following exposure to hyperimmune sera and/or antibiotics. We conclude that the
H9724-reactive structures represent various forms of B. burgdorferi rather than
staining artifacts. These "atypical" forms of B. burgdorferi may
represent in vivo morphologic variants of this bacterium.
Excerpts:
p. 573
Studies with antibiotics revealed similar morphologic changes
although the formation of granules of a much larger size (spheroblast-like
structures) was obvious (fig. 5a).
Vibrio-like forms associated with granules were visualized in
the epidermis (Fig. 3b) or short rods in perineural spaces.
Bizarre, heavily stained borreliae were visualized on serial sections (Fig.
9a-d), intracellularly in a macrophage (Fig 4b.), or in the epidermis
(Fig. 3b). Large granules or spherical bodies ("gemmae") 1-3 µm were
detected among collagen fibers (Fig. 5b) comparable to cysts arising after
culture experiments (Fig. 5a).
p. 574
The morphological forms of borreliae seen in biopsies were correlated with
clinical findings. Seropositive patients showed clumped and agglutinated
borreliae in tissue (Fig. 4b), whereas seronegative patients exhibited
borreliae colony formation (n=2) (Figs. 7b,8b). Neuralgies arising 6 months
after ECM in spite of antibiotic therapy were evident in a seronegative patient
who showed perineural rod-like borrelia structures. In ACA samples we
identified agglutinated, intertwined spirochetal forms that resembled the
clumped, dying borreliae seen in our culture experiments. In areas with
inflammatory infiltrates, delicate dispersed, serpentine organisms were seen in
degenerating collagen fibers. Also, small granular structures were evident
among collagen fibers (Fig. 6b).
In biopsy sections from morphea patients, the number of borreliae was low. Yet,
heavily stained intertwined forms and, in one case, clusters of delicate
borreliae were seen within collagen fibers (Fig. 2d). Similarly, variant
spirochetal forms were present in biopsies of three patients with plaque-like
and papular eruptions arising at previous ECM sites. Histologically, two of
these biopsies revealed epitheloid cell granulomas: skin sarcoidosis in one and
cheilitis granulomatosa in the other patient. The third case represented
lymphocytoma of the skin.
p. 576-78
The extracellular location of typical borreliae was not necessarily associated
with the presence of an inflammatory infiltrate. Rather, these borrelia forms
were seen in seronegative patients with uncomplicated ECM. If the extracellular
borreliae were accompanied by an inflammatory infiltrate, the bacteria
exhibited a heterogeneous morphology. Heavily stained, clumped, and
aggregated borreliae and granules, formed by action of hyperimmune sera, were
evident as were degererative changes in the connective tissue.
Whether borreliae can be located intracellularly has been heavily debated.
In vitro studies demonstrated that borreliae actively penetrate endothelial
cells (31) and fibroblasts, where they apparently evade eradication by
antibiotics (32). The presence of borreliae
in macrophages and keratinocytes, as shown in our studies and also in Berger's
silver staining studies, supports the hitherto unproven concept that borreliae
may survive intracellularly (33). Whether
borreliae are also present in Langerhans cells could not be elucidated by this
technique, although recent data suggest that borreliae invade and selectively
damage them, as shown ultrastructurally (2).
The conditions necessary for the development of borrelia granules and their
function are still unclear. The granules, which do not typically form under
short-term culture conditions, do evolve in solid media (21),
as well as in oral spirochetes (20,24),
T. pallidum (23), and old acidic cultures of B. burgdorferi
(34). Cystic borrelia forms have also been reported in
tissue imprints of patients with Alzheimer disease (35). The
development of spherical bodies or "gemmae" had been repeatedly
observed in meticulous studies of spirochetal organisms over 40 years ago (20,23,24), as well as
recently under varying culture conditions (26,36),
in skin tissue (1,2), and after exposure to
antibiotics (25,37).
Our results lead to several conclusions. First, the
videomicroscopy technique described here has made possible the identification
of borreliae in situ. Second, the behavior of borreliae within collagen fibers
is strongly influenced by immune recognition by the patient. Borreliae may
escape immune surveillance by colony formation and masking within collagen,
resulting in seroregativity. Furthermore, the bacteria can survive in collagen
fibers and cause tissue damage resulting in Iong-standing ACA, even in the
presence of anti-Bb antibodies, which are known to kill B. burgdorferi (38). Third, whether the formation of granules or cysts
represents a mode of degeneration of borreliae or their persistence is not yet
clear. Nevertheless, simply knowing that B. burgdorferi are morphologically
diverse may explain the large spectrum of Bb-associated diseases, may indicate
a heterogenous immune responses in individuals, and may enhance future
immunohistochemical studies of borreliae in animal models.
Selected
References
1 Hulinska
D, Jirous J, Valesova M, Herzogova J. Ultrastructure of Borrelia
burgdorferi in tissues of patients with Lyme disease. J Basic Microbiol
1989; 29(2): 73-83
2 Hulinska
D, Bartak P, Hercogova J, Hancil J, Basta J, Schramlova J. Electron
microscopy of Langerhans cells and Borrelia burgdorferi in Lyme disease
patients. Int J Med Microbiol Virol Parasitol Infect Dis 1994 Jan; 280(3):
348-59
20 Hampp EG, Scott DB, Wyckoff RWG. Morphologic characteristics of
certain cultured strains of oral spirochetes and Treponema pallidum as revealed
by the electron microscope. J Bacteriol 1948;56:755-69. Excerpt
21 Kurtti
TJ, Munderloh UG, Johnson RC, Ahlstrand GG. Colony formation and
morphology in Borrelia burgdorferi. J Clin Microbiol 1987 Nov; 25(11): 2054-8
23 Mudd S, Polevitzky K, Anderson
TF. Bacterial morphology as shown by the electron microscope. J Bact
1943, 46:15-24
24 De Lamater ED, Haanes M, Wiggall RH, Pillsbury DM. Studies on the
life cycle of spirochetes. J Invest Dermatol 1951; 16:231-56
25 Barbour
AG, Todd WJ, Stoenner HG. Action of penicillin on Borrelia hermsii. Antimicrob
Agents Chemother 1982 May; 21(5): 823-9
26 Barbour
AG, Hayes SF. Biology of Borrelia species. Microbiol Rev 1986 Dec;
50(4): 381-400
32 Georgilis
K, Peacocke M, Klempner MS. Fibroblasts protect the Lyme disease
spirochete, Borrelia burgdorferi, from ceftriaxone in vitro. J Infect Dis
1992 Aug; 166(2): 440-4
33 Berger
BW, Clemmensen OJ, Ackerman AB. Lyme disease is a spirochetosis. A
review of the disease and evidence for its cause. Am J Dermatopathol 1983
Apr; 5(2): 111-24
34 Pillot
J, Ryter A. Structure des spirochetes. 1. Etude des genres treponema,
borrelia et leptospira au microscope electronique. Ann Inst Pasteur Paris
1965 Jun; 108(6): 791-804
35 MacDonald
AB. Concurrent neocortical borreliosis and Alzheimer's disease. Demonstration
of a Spirochetal Cyst Form. Ann N Y Acad Sci 1988:468-70
36 Hayes
SF, Burgdorfer W, Barbour AG. Bacteriophage in the Ixodes dammini spirochete,
etiological agent of Lyme disease. J Bacteriol 1983 Jun; 154(3): 1436-9
37 Kersten
A, Poitschek C, Rauch S, Aberer E. Effects of penicillin, ceftriaxone, and doxycycline on morphology of
Borrelia burgdorferi. Antimicrob Agents Chemother 1995 May; 39(5): 1127-33.
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38 Kochi
SK, Johnson RC. Role of immunoglobulin G in killing of Borrelia
burgdorferi by the classical complement pathway. Infect Immun 1988 Feb;
56(2): 314-21