BIGGER PICTURE! TICK-BORNE DISEASE DIAGNOSIS SHOULD NOT BE LIMITED TO JUST LYME DISEASE A LOOK AT THE

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1 TICK-BORNE DISEASE DIAGNOSIS SHOULD NOT BE LIMITED TO JUST LYME DISEASE A LOOK AT THE BIGGER PICTURE! KUNAL GARG, M.Sc. Ph.D. STUDENT UNIVERSITY OF JYVÄSKYLÄ FINLAND. kugarg@jyu.fi

2 OPEN notjustlyme

3 Periodontal diseases % Global population 500 Microbial species % Risk cardiovascular 1 1 1

4 Respiratory diseases Million worldwide Microbial species 90 % 4 Risk diabetes 2 3

5 Mosquito - borne % Global population Symbiosis 5, 6 Same microbial species Immunosuppression Meningitis 7 8

6 Tick - borne Million worldwide? Microbial spectrum? Likelihood 9

7 Borrelia spirochete species Borrelia burgdorferi Borrelia afzelii Borrelia garinii Tick-borne co-infections Babesia microti Bartonella henselae Brucella abortus Ehrlichia chaffeensis Rickettsia akari Tick-borne encephalitis virus

8 Borrelia spirochete species Borrelia burgdorferi Borrelia afzelii Borrelia garinii 4 to 60 % Co-infection rate Tick-borne co-infections Babesia microti 10, 11, Bartonella 12 henselae Brucella abortus Ehrlichia chaffeensis Rickettsia akari Tick-borne encephalitis virus

9 Borrelia spirochete species Borrelia burgdorferi Borrelia afzelii Borrelia garinii 4 to 60 % Co-infection rate Tick-borne co-infections Babesia microti Bartonella henselae Brucella abortus Ehrlichia chaffeensis Rickettsia akari Tick-borne encephalitis virus Borrelia species persistent forms Borrelia burgdorferi Borrelia afzelii Borrelia garinii Opportunistic microbes Chlamydia pneumoniae Chlamydia trachomatis Coxsackievirus Cytomegalovirus Epstein-Barr virus Human parvovirus B19 Mycoplasma pneumoniae Mycoplasma fermentans

Borrelia spirochete species Borrelia burgdorferi Borrelia afzelii Borrelia garinii 4 to 60 % Co-infection rate Tick-borne co-infections Babesia microti Bartonella henselae Brucella abortus Ehrlichia

10 Borrelia spirochete species Borrelia burgdorferi Borrelia afzelii Borrelia garinii 4 to 60 % Co-infection rate Tick-borne co-infections Babesia microti Bartonella henselae Brucella abortus Ehrlichia chaffeensis Rickettsia akari Tick-borne encephalitis virus Borrelia species persistent forms Borrelia burgdorferi Borrelia afzelii Borrelia garinii Opportunistic microbes Chlamydia pneumoniae Chlamydia trachomatis Coxsackievirus Cytomegalovirus Tick-borne diseases are exceptionally polymicrobial in nature? Epstein-Barr virus Human parvovirus B19 Mycoplasma pneumoniae Mycoplasma fermentans

11 20 Microbes 432 Patients 80 % 20 % ELISA IgM IgG

12 *Centers for Disease Control and Prevention (CDC) **Infectious Disease Society of America (IDSA) *** CE/ IVD/FDA marked test kits for non-borrelia microbes 432 Patients 80 % 20 % *** * * CDC Acute * CDC Late CDC Negative PTLDS Immunocompromised * *** ** Unspecific * *** Healthy

13 IgM response to More than 1 microbe Only 1 microbe No response IgG response to More than 1 microbe Only 1 microbe No response * * 51 % 65 % 9 % 16 % 40 % 19 %

14 IgM response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response IgG response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response * * 26 % 18 % 29 % 13 % 2 % 40 % 22 % 13 % 7 % 19 %

15 IgM response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response IgG response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response * 26 % 18 % 13 % 2 % 40 % * 29 % 22 % 13 % 7 % 19 %

16 IgM response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response IgG response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response 13 % 2 % 13 % 7 %

No response IgG response to Borrelia spirochete and persistent

Borrelia persistent forms over 22 % Borrelia spirochete forms 13

17 IgM response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response IgG response to Borrelia spirochete and persistent forms Other TBD microbes Borrelia spirochete form Borrelia persistent form No response 26 % 18 % 13 % 2 % 40 % 80 / % Borrelia persistent forms over 22 % Borrelia spirochete forms 13 % 7 % 19 %

18 Research outcome 1 Response to Borrelia antigens by CDC Acute and CDC Late patients

19 Research outcome 2 Response to Borrelia antigens by CDC Negative patients

20 Research outcome 2 Response to Borrelia antigens by CDC Negative patients 3 / 4 CDC Negative patients are positive for Borrelia persistent forms

21 Research outcome 3 Response to Borrelia antigens by PTLDS patients

22 Research outcome 3 Response to Borrelia antigens by PTLDS patients 95 / 100 PTLDS patients are positive for Borrelia persistent forms

23 Research outcome 4 Outstanding co-infections and opportunistic microbes

24 Bartonella henselae Differential diagnosis examples Chlamydia pneumoniae Chlamydia trachomatis 67.5 % Chronic fatigue syndrome 48.3 % Juvenile idiopathic arthritis 6-50 % reactive arthritis Epstein- Barr virus Mycoplasma pneumoniae Mycoplasma fermentans 95 % Multiple sclerosis 59.3 % Chronic fatigue syndrome 48 % Chronic fatigue syndrome

25 Only Borrelia IgM response to Borrelia and other TBD microbes Only other TBD microbes Only Borrelia IgG response to Borrelia and other TBD microbes Only other TBD microbes * * 61 % 61 % 8 % 31 % 12 % 27 %

26 Only Borrelia IgM response to Borrelia and other TBD microbes Only other TBD microbes Only Borrelia IgG response to Borrelia and other TBD microbes Only other TBD microbes 61 % % Random Lyme disease patients 8 % 31 % 12 % 27 %

27 Only Borrelia IgM response to Borrelia and other TBD microbes Only other TBD microbes Only Borrelia IgG response to Borrelia and other TBD microbes Only other TBD microbes 61 % 85 / % 8 % 31 % Lyme Disease and multiple microbes associated with tickborne diseases 12 % 27 %

28 CDC and IDSA guidelines became the status-quo Correlation between deer tick and Lyme disease by Dr. Willy Burgdorfer Commercially available tests are only Lyme disease oriented with no change in 23, 24 sensitivity Tick-borne diseases are exceptionally polymicrobial % global population will be effected by tick-borne diseases 9

29 Schwartz Foundation Non-profit philanthropic foundation

31 notjustlyme Thank you!

32 References 1.Nazir, A Muhammad. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim). 2017;11(2): Filkins LM, O Toole GA (2015). Cystic Fibrosis Lung Infections: Polymicrobial, Complex, and Hard to Treat. PLoS Pathog 11(12): e Buchanan, Paul. Microbial infection in cystic fibrosis ( 5.World Health Organisation (WHO; 6.World Mosquito program ( 7.Ramiro RS, Pollitt LC, Mideo N, Reece SE. Facilitation through altered resource availability in a mixed-species rodent malaria infection. Ecol Lett. 2016;19(9): Marinho P, Bretas de Oliveira D, Candiani T, Crispim A, Alvarenga P, Castro F, et al. Meningitis Associated with Simultaneous Infection by Multiple Dengue Virus Serotypes in Children, Brazil. Emerg Infect Dis. 2017;23(1): Davidsson, M. The Financial Implications of a Well-Hidden and Ignored Chronic Lyme Disease Pandemic. Healthcare. 6, 16 (2018). 10.Koetsveld, J., Tijsse-Klasen, E., Herremans, T., Hovius, J. W. & Sprong, H. Serological and molecular evidence for spotted fever group Rickettsia and Borrelia burgdorferi sensu lato co-infections in The Netherlands. Ticks Tick Borne Dis. 7, (2016). 11.Krause, P. et al. Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. JAMA. 275, (1996). 12.Steere, A. et al. Prospective study of coinfection in patients with erythema migrans. Clin Infect Dis. 36, (2003). 13.Maggi RG, Mozayeni BR, Pultorak EL, et al. Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. Emerg Infect Dis. 2012;18(5): Altun S, Kasapcopur O, Aslan M, Karaarslan S, Koksal V, Saribas S, Ergin S, Arisoy N, Kocazeybek B. J. Med. Microbiol. 53(8): doi: /jmm Schumacher Jr. Chlamydia trachomatis nucleic acids can be found in the synovium of some asymptomatic subjects Arthritis & Rheumatism 16.Donatella Donati and Steven Jacobson. Polymicrobial Diseases ( 17.Nasralla M1, Haier J, Nicolson GL. Multiple mycoplasmal infections detected in blood of patients with chronic fatigue syndrome and/or fibromyalgia syndrome. Eur J Clin Microbiol Infect Dis Dec;18(12): Centers for Disease Control and Prevention (CDC), Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR. 44, (1995). 19.Halperin, J. J. Lyme Disease: An Evidence-based Approach. 296 (CABI 2011). 20.Aguero-Rosenfeld, M. E., Wang, G., Schwartz, I. & Wormser, G. P. Diagnosis of lyme borreliosis. Clin Microbiol Rev. 18, (2005). 21.Nemeth, J. et al. Update of the Swiss guidelines on post-treatment Lyme disease syndrome. Swiss Med Wkly. 146, w14353 (2016). 22.Wormser, G. P. et al. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 43, (2006). 23.Connally, N. et al. Testing practices and volume of non-lyme tickborne diseases in the United States. Ticks Tick Borne Dis. 7, (2016). 24.Cook, M. & Puri, B. Commercial test kits for detection of Lyme borreliosis: a meta-analysis of test accuracy. Int J Gen Medicine. 9, (2016).

Panel & Test Price List

Panel & Test Price List Effective October 16, 2017 we are offering our new tests for Lyme IGXSpot, Lyme Borreliosis, and Tick-borne Relapsing Fever Borreliosis The new ImmunoBlot tests have replaced the original Western Blot