Unique Clinical, Immune, and Genetic Signature in Patients with Borrelial Meningoradiculoneuritis1

Abstract

Lyme neuroborreliosis (LNB) in Europe may manifest with painful meningoradiculoneuritis (also known as Bannwarth syndrome) or lymphocytic meningitis with or without cranial neuritis (peripheral facial palsy). We assessed host immune responses and the prevalence of TLR1 (toll-like receptor 1)-1805GG polymorphism to gain insights into the pathophysiology of these conditions. Regardless of LNB manifestation, most mediators associated with innate and adaptive immune responses were concentrated in cerebrospinal fluid; serum levels were unremarkable. When stratified by specific clinical manifestation, patients with meningoradiculoneuritis had higher levels of B-cell chemoattractants CXC motif chemokine ligand (CXCL) 12 and CXCL13 and T-cell-associated mediators CXCL9, CXCL10, and interleukin 17, compared with those without radicular pain. Moreover, these patients had a higher frequency of TLR1-1805GG polymorphism and more constitutional symptoms. These findings demonstrate that meningoradiculoneuritis is a distinct clinical entity with unique immune and genetic pathophysiology, providing new considerations for the study of LNB and borrelial meningoradiculitis.

Keywords: Lyme disease; Slovenia; United States; bacteria; cytokines; genetics; immune response; inflammation; meningitis/encephalitis; meningoradiculoneuritis; neuroborreliosis; peripheral facial palsy; polymorphism; vector-borne infections.

Figure 1

Frequency of individual signs and symptoms at study enrollment among patients with LNB treated in Ljubljana, Slovenia, during 2006–2013. Patients were stratified into 3 groups: meningoradiculoneuritis, PFP/meningitis without radicular pain, or patients with suspected LNB who had EM and signs and symptoms suggestive of LNB but did not meet the standard diagnostic criteria. *Meningoradiculoneuritis vs. PFP/meningitis, p<0.05; †meningoradiculoneuritis vs. suspected LNB, p<0.005. LNB, Lyme neuroborreliosis; PFP, peripheral facial palsy.

Figure 2

Heat map analysis of inflammatory mediators in CSF stratified by clinical presentation of LNB among patients with Lyme neuroborreliosis treated in Ljubljana, Slovenia, during 2006–2013. A) Levels of inflammatory mediators stratified by LNB manifestation. B) Hierarchical clustering analysis (Euclidian distance) of inflammatory mediators and CSF leukocyte counts. We assessed the levels of 17 cytokines and chemokines associated with innate and adaptive (T- and B-cell) responses in CSF of patients with meningoradiculoneuritis, PFP/meningitis, or suspected LNB. Each column represents an individual patient, with the corresponding mediators along the different rows. Heat map was constructed using Morpheus software (https://software.broadinstitute.org/morpheus). In the case of IFN-α, 3 values were exceptionally low (at lower limit of detection), resulting in disproportionately intense red coloring of other values. CSF, cerebrospinal fluid; CXCL, CXC motif chemokine ligand; GM-CSF, granulocyte macrophage colony–stimulating factor; IL, interleukin; IFN, interferon; LNB, Lyme neuroborreliosis; MIP, macrophage inflammatory protein; PFP, peripheral facial palsy; TNF, tumor necrosis factor.

Figure 3

Statistical correlation of the levels of 8 immune mediators in CSF, by clinical manifestation, among patients with LNB treated in Ljubljana, Slovenia, during 2006–2013. A) Mediators associated with innate response are IL-8, IL-10, and CCL3. B) Mediators associated with T-cell adaptive response are CXCL9, CXCL10, and IL-18. C) Mediators associated with B-cell adaptive response are CXCL12 and CXCL13. Black circles represent meningoradiculoneuritis (n = 19); white circles, PFP/meningitis (n = 42); and white squares, suspected LNB (n = 59). Horizontal lines represent median values. Statistical analyses were performed using nonparametric Mann-Whitney rank sum test. p values indicate largest differences for individual patients among groups. CCL, CC motif chemokine ligand; CSF, cerebrospinal fluid; CXCL, CXC motif chemokine ligand; IL, interleukin; LNB, Lyme neuroborreliosis; PFP, peripheral facial palsy.

Figure 4

Correlation between the levels of 5 inflammatory mediators in CSF and CSF leukocyte counts among 120 patients with Lyme neuroborreliosis treated in Ljubljana, Slovenia, during 2006–2013. A) CXCL9; B) CXCL10; C) IL-17; D) CXCL12; E) CXCL13. Solid lines inside the graph represent linear regression; dotted lines indicate 95% CIs. ρ and p values were derived using the Spearman correlation. CSF, cerebrospinal fluid.

Figure 5

Frequency of TLR1–1805GG polymorphism among patients with Lyme borreliosis treated in Ljubljana, Slovenia, during 2006–2013 (A), compared with the general population of Europe (B). A) Lyme borreliosis patients with EM vs. LNB; B) general population by female vs. male sex. The TLR1 SNP results in an exchange of thymine (T, ancestral) with a guanine (G) allele at position 1805; GG corresponds to both copies of the SNP allele (SNP), TG with one copy (heterozygous), and TT with no copies (ancestral). The information in the general population was obtained from Ensemble genome browser 104 and is based on data from the 1,000 Genomes Project (https://useast.ensembl.org/index.html). EM, erythema migrans; LNB, Lyme neuroborreliosis; SNP, single-nucleotide polymorphism.

Figure 6

Frequency of TLR1–1805 genotypes, stratified by clinical manifestations (meningoradiculoneuritis and PFP/meningitis) among patients with Lyme neuroborreliosis treated in Ljubljana, Slovenia, during 2006–2013. The frequency of TLR1–1805 genotypes was determined via PCR restriction fragment-length polymorphism. Statistical analyses were performed using Fisher exact test for categorical variables or odds ratios. PFP, peripheral facial palsy; SNP, single-nucleotide polymorphism.