Originalia C. D. R e i m e r s , U. N e u b e r t , W . K r i s t o f e r i t s c h , K. H . P f l f i g e r , W . R . M a y r
Borrelia burgdorferi Infection in Europe: An HLA-Related Disease? Summary: Various studies in the United States and Europe have established human leucocyte antigens (HLA) Cw3, DR2 and DR4 as risk factors for manifest Borrelia burgdorferi infection or the development of chronic courses of Lyme disease. Other studies failed to confirm these findings. In the present study the frequencies of H L A A, B, Cw and DR were analysed in 283 persons from Austria and Germany with manifest B. burgdorferi infection. No statistically significant differences were found between patients and the control groups with regard to the frequencies of particular HLA antigens, nor were differences in antigen frequencies in the patients with manifestations of different stages of disease significant. Furthermore, a statistical re-evaluation of all the European studies failed to confirm particular HLA antigens as risk factors for B. burgdorferi infections to become manifest or chronic.
caused by B. burgdorferi have been correlated with H L A DR2 [3]. M6jsky and co-workers [5] also found evidence of significantly increased frequencies of H L A DR2 and DR4 in 32 patients with Lyme disease. Kristoferitsch et al. [6] were unable to establish any statistically proven association between class II antigens and meningopolyneuritis, whilst the increased risk of developing acrodermatitis chronica atrophicans in H L A DR2 carriers has been demonstrated [7]. Pfliiger and colleagues [8] established the increased risk for manifest B. burgdorferi infection in carriers of H L A Cw3 and the phenotype combination H L A A2 and Cw3. The purpose of the present study was to re-examine whether the presence of particular H L A specificities, especially H L A DR2 and DR4, constitutes a prognostic factor predisposing for manifest B. burgdorferi infection or for development of late manifestations of this infectious disease in Europe.
Patients and Methods Zusammenfassung: Borrelia burgdorferi-Infektionen in Europa: HLA-assoziierte Erkrankung? Verschiedene amerikanische und europ/iische Studien wiesen auf ein erh6htes Risiko bei Tr~igern der HLA-Antigene Cw3, DR2 und DR4 hin, eine manifeste oder gar chronische Borrelia burgdorferi-Infektion zu entwickeln. Andere Studien konnten diese Ergebnisse nicht bestfitigen. Die vorliegende Untersuchung analysiert die Haufigkeiten der HLA-Antigene A, B, Cw und D R bei 283 Personen mit manifesten 13. burgdorferi-Infektionen in Deutschland und C)sterreich. Der Vergleich der Hfiufigkeiten einzelner HLA-Antigene bei den Patienten mit Normalpersonen einerseits und zwischen Antigenhfiufigkeiten bei Patienten mit verschiedenen Krankheitsstadien andererseits erbrachte keinen statistisch signifikanten Unterschied. Auch die Zusammenfassung aller bisher ver6ffentlichten europfiischen Studien zum Thema ergab keine Hinweise darauf, daB das HLA-System das Risiko einer manifesten oder chronischen B. burgdorferiInfektion beeinflu6t.
Introduction Borrelia burgdorferi causes a multisystem disease that affects the skin, the central and peripheral nervous systems, the heart and the joints. Analogous to the categorization of syphilis, B. burgdorferi infection (Lyme borreliosis) has been classified into three stages [1]. Steere et al. [2--4] reported a correlation between chronic Lyme arthritis and the human leucocyte antigens (HLA) DR2 and DR4. Furthermore, chronic neurologic diseases
Two hundred eighty-three patients (146 female, 137 male) aged 7 to 77 years with manifest B. burgdorferi infections, 47 of whom had contracted the disease before serological tests for B. burgdorferi antibodies were available, were included in the study. The latter patients were re-examined between February 1984 and December 1986. The remaining group of 236 patients was seen for the first time after September 1984. Informed consent was obtained from each patient. The frequencies of HLA A, B, Cw and DR specificities in 176 of these patients have been previously published by Pfli~ger et al. [8]. Kristoferitsch et al. [6,7] have already reported the frequencies of HLA DR specificities in 39 of the patients included in the current study. Table 1 lists the various manifestations observed. The diagnosis of erythema migrans was based on the dermatological finding of a slowly expanding, ring-shaped, red erythema and - if present - a preceding tick bite. In case of an uncertain clinical diagnosis, positive serology and possibly histopathological findings confirmed the diagnosis. A total of 65 patients with erythema migrans had elevated serum antibody titers against B. burgdorferi. In another three seronegative patients, borreliae could be Received: 16 December 1991/Revisionaccepted: 10 April 1992 Dr. med. C. D. Reimers, Friedrich-Baur-lnstitut, Medizinische Klinik Innenstadt, Ludwig-Maximilians-Universit~it,Ziemssenstr. la, W-8000 Mtinchen 2, Germany;Dr. reed. U. Neubert, DermatologischeKlinikund Poliklinik, Ludwig-Ma~imilians-Universitfit,Frauenlobstr. 9-11. W-8000 Mfinchen 2, Germany; Dr. med. W. Kristoferitsch, Neurologische Abteilung, Wilhelminenhospital, Montleartstr. 37, A-1171 Wien, Austria; Priv.-Doz. Dr. med. K. H. Pfliiger, Medizinische Klinik und Poliklinik, Schwerpunkt H/imatologie, Onkologie, Immunologie, Universit~it Marburg, Baldingerstr., W-3550 Marburg, Germany; Prof. Dr. med. W.R. &Iayr, Institut ftir Transfusionsmedizin, Rheinisch-Westf~ilischeTechnischeHochschule,Pauwelsstr.30, W-5100 Aachen, Germany. Correspondence to: C D. Reimers.
Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Mfinchen,Mtinchen 1992
197 / 21
C. D. Reimers et al.: HLA and Borrelia burgdorferi Infection Table 1 : Manifestations of Borrelia burgdorferi infection in 283 patients.
I II
IlI
I-III
Total Erythema migrans Total Lymphadenosis benigna cutis Meningopolyneuritis Myocarditis Myositis Total Acrodermatitis chronica atrophicans Arthritis Encephalomyelitis Myositis Total
91" 91 118a 3 112 3 2 89" 81 5 2 3 283a
Twenty patients presented with two different manifestations of the/3.
burgdorferi infection at examination. cultivated from skin biopsies. Nineteen patients were seronegative. Testing for antibody titers was not performed in four patients. Three patients presented with the nodular type of lymphadenosis benigna cutis and elevated serum antibody titers against B.
burgdorferi. All adult patients with meningopolyneuritis GarinBujadoux-Bannwarth complained of intense pain. A group of seven younger patients with Borrelia meningitis reported only moderate pain, and four children were without pain altogether. All of the patients with meningopolyneuritis GarinBujadoux-Bannwarth suffered from motor and/or sensory deficits of the peripheral nervous system. All patients with meningopolyneuritis and meningitis presented with a lymphocytic pleocytosis. A preceding tick or insect bite had been recognized by 39 patients (34.8%) and an erythema migrans by 43 patients (38.4%). Serological testing revealed elevated antibody titers against B. burgdorferi in the sera and/or cerebrospinal fluid (CSF) of all patients examined in the acute phase of the disease. The follow-up study revealed evidence of elevated serum antibody titers in 29 of the 44 patients who had experienced the acute phase of their disease up to I5 years prior this re-examination. In three patients serological testing was not performed. Three patients with acute atrioventricular heart block and elevated serum antibody titers against t3. burgdorferi were diagnosed with Lyme myocarditis. They were promptly cured by antibiotics. The diagnosis of acrodermatitis chronica atrophicans was based on the typical dermatological features of a skin lesion with a bluish-red discoloration with edema in the beginning or atrophy in more advanced cases, located predominantly on the extensor surface of the extremities. In case of uncertain clinical diagnosis, the detection of a lympho-plasmacellular infiltration in the upper dermis confirmed the tentative diagnosis. All patients with acrodermatitis chronica atrophicans exhibited elevated serum antibody titers against B. burgdorferi. A female patient with Borrelia encephalomyelitis presented with cerebellar signs, positive Babinski sign on both sides, areflexia and mental changes. One male patient with Borrelia encephalitis suffered from an acute paranoid-hallucinatory psychosis. In both
22 / 198
patients, the investigations of the CSF revealed a lymphoplasmocytic pleocytosis, elevated protein content and an autochthonous antibody production against B. burgdorferi. The diagnosis of Lyme arthritis was based on the finding of arthritis with elevated serum antibody titers, other origins of the arthritis having been excluded as far as possible. The diagnosis of myositis caused by B. burgdorferi was founded on clinical and myopathological features, detection of antibodies against B. burgdorferi in the sera, and staining of spirochetes in the muscle specimens in three patients or in the skin superficial to the diseased muscle. The fifth patient with myositis suffered primarily from meningopolyneuritis Garin-Bujadoux-Bannwarth. Depending on the duration of the disease and the accompanying manifestations of the B. burgdorferi infection (i.e. meningopolyneuritis or acrodermatitis chronica atrophicans), two patients with myositis were assigned to stage II, and three patients were grouped to stage III. Twenty patients presented with two different manifestations of B. burgdorferi infection on clinical examination. HLA antigens and serological testing: Employing the standard microlymphocytotoxicity test as originally described by Terasaki and McClelland [9] with slight modifications, we examined ten HLA A specificities (A1, A2, A3, A9, A10, All, Awl9, A28, Aw36, Aw43), 23 HLA B specificities (B5, B7, B8, B12, B13, B14, B15, B16, B17, B18, B21, Bw22, B27, B35, B37, B40, Bw41, Bw42, Bw46, Bw47, Bw48, Bw53, Bw59), eight HLA Cw specificities (Cwl, Cw2, Cw3, Cw4, Cw5, Cw6, Cw7, Cw8) and ten HLA DR specificities (DR1, DR2, DR3, DR4, DR5, DRw6, DR7, DRw8, DR9, DRwl0) in the typing laboratories of the Department of Haematology and Oncology of the University of Marburg (FRG) (n=232) and the Institute for Blood Group Serology of the University of Vienna (Austria) (n=51). The HLA Bw4, Bw6, DQ-, DRw52 and DRw53 specificities were also examined, but due to broad unspecificity their antigens were not included in the statistical analysis. The subjects in the control group originated from the former West Germany, the majority of whom resided in Central Hessia, or Austria. No members of either group were related. Identical techniques and sera were used for both the patients and the control group. Additionally, the data on HLA frequencies in patients with B. burgdorferi infections from all European studies were combined.
Antibody titers against 13. burgdorferi and their serological testing: Antibodies to B. butgdorferi were tested by the indirect immunofluorescence test or by enzyme-linked immunosorbent assay (ELISA) at the laboratories of Prof. Ackermann (Cologne, Germany), Dr. Neubert (Dept. of Dermatology, University of Munich, Germany), Prof. Slenczka (Hygiene Institute, University of Marburg, Germany), Dr. Stanek (Hygiene Institute, University of Vienna, Austria) and Dr. Wilske (Max yon Pettenkofer Institute, University of Munich, Germany). Statistical analysis: A comparison was made between the frequencies of individual HLA specificities in the patient and the control groups. Differences in phenotype frequencies were tested for statistical significance using the chi-squared test for 2 x 2 tables. Results were obtained by separate calculation with the data of each laboratory, the following formula being used for the combined result: n
chi2 = >
-+chi2i i=1
Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Mtinchen, Miinchen 1992
C. D, Reimers et al.: H L A and Borrelia burgdorferi Infection
Table 2: Frequencies of HLA A2, Cw3, DR2, DR3, DR4 specificities in patients with Borrelia burgdorferi infection and in normal subjects (data from the present study).
HLA A2 positive Relative frequency (%) HLA Cw3 positive Relative frequency (%) HLA DR2 positive Relative frequency (%) HLA DR3 positive Relative frequency (%) HLA DR4 positive Relative frequency (%) HLA A2 + Cw3 positive Relative frequency (%)
1921/4044 47.5 898/4044 22.2 360/1204 29.9 284/1204 23.6 327/1204 27.2 502/4044 12.4
51/91 56.0 25/91 27.5 32/91 35.2 16/91 17.6 23/91 25.3 18/91 19.8
63/118 53.4 39/118 33.1 33/118 28.0 19/118 16.1 30/118 25.4 25/118 21.2
43/89 48.3 29/89 32.6 28/89 31.5 22/89 24.7 23/89 25.8 17/89 18.4
148/2832 52.3 88/283b 31.1 92/283c 32.5 53/283d 18.7 73/283d 25.8 52/283e 18.5
C h i 2 = 6172 (degree of freedom = 2), p < 0.05. b Chi2 = 8.99 (degree of freedom = 2), p < 0.05. Chi2 = 6.04 (degree of freedom = 2), p < 0.05. d Not significant (p > 0.05). e C h i 2 = 10.28 (degree of freedom = 2), p < 0.01. Each calculation withoutcorrection for multiple comparisons (Bonferroni's adjustment [10]). After Bonferroni's adjustment no difference was significant.
(chi2i = chi 2 calculated for a single laboratory; n = number of laboratories). In case of a higher frequency of the H L A antigen in question in the patient group compared to the control group, chi 2 was positive; in the opposite case, it was negative.
Results T h e f r e q u e n c i e s of H L A A, B, Cw a n d D R specificities in o u r 283 p a t i e n t s with m a n i f e s t B. burgdorferi infections w e r e similar to t h o s e f o u n d in the c o n t r o l group. A h i g h e r f r e q u e n c y was n o t e d for H L A A2, Cw3 a n d D R 2 (p < 0.05) as well as for t h e p h e n o t y p e c o m b i n a t i o n H L A
Table 3: Combined frequencies of HLA A2, Cw3, DR2, DR3 and DR4 specificities in European Lyme borreliosis patients derived from the studies of Herzer [12], M~jsky et al. [5], Wokke et al. [13] and the present study.
HLA A2 positive (n) Relative frequency (%) HLA Cw3 positive (n) Relative frequency (%) HLA DR2 positive (n) Relative frequency (%) HLA DR3 positive (n) Relative frequency (%) HLA DR4 positive (n) Relative frequency (%)
2158/4544 47.5 1154/5109 22.6 612/2039 30.0 332/1534 21.6 383/1534 25.0
173/333" 52.0 96/318b 30.2 135/398c 33.9 72/365a 19.7 102/365d 27.9
Not significant (p > 0.05). Chi2 = 8.96 (degree of freedom = 3), p
Borrelia burgdorferi Infection in Europe: An HLA-Related Disease? Summary: Various studies in the United States and Europe have established human leucocyte antigens (HLA) Cw3, DR2 and DR4 as risk factors for manifest Borrelia burgdorferi infection or the development of chronic courses of Lyme disease. Other studies failed to confirm these findings. In the present study the frequencies of H L A A, B, Cw and DR were analysed in 283 persons from Austria and Germany with manifest B. burgdorferi infection. No statistically significant differences were found between patients and the control groups with regard to the frequencies of particular HLA antigens, nor were differences in antigen frequencies in the patients with manifestations of different stages of disease significant. Furthermore, a statistical re-evaluation of all the European studies failed to confirm particular HLA antigens as risk factors for B. burgdorferi infections to become manifest or chronic.
caused by B. burgdorferi have been correlated with H L A DR2 [3]. M6jsky and co-workers [5] also found evidence of significantly increased frequencies of H L A DR2 and DR4 in 32 patients with Lyme disease. Kristoferitsch et al. [6] were unable to establish any statistically proven association between class II antigens and meningopolyneuritis, whilst the increased risk of developing acrodermatitis chronica atrophicans in H L A DR2 carriers has been demonstrated [7]. Pfliiger and colleagues [8] established the increased risk for manifest B. burgdorferi infection in carriers of H L A Cw3 and the phenotype combination H L A A2 and Cw3. The purpose of the present study was to re-examine whether the presence of particular H L A specificities, especially H L A DR2 and DR4, constitutes a prognostic factor predisposing for manifest B. burgdorferi infection or for development of late manifestations of this infectious disease in Europe.
Patients and Methods Zusammenfassung: Borrelia burgdorferi-Infektionen in Europa: HLA-assoziierte Erkrankung? Verschiedene amerikanische und europ/iische Studien wiesen auf ein erh6htes Risiko bei Tr~igern der HLA-Antigene Cw3, DR2 und DR4 hin, eine manifeste oder gar chronische Borrelia burgdorferi-Infektion zu entwickeln. Andere Studien konnten diese Ergebnisse nicht bestfitigen. Die vorliegende Untersuchung analysiert die Haufigkeiten der HLA-Antigene A, B, Cw und D R bei 283 Personen mit manifesten 13. burgdorferi-Infektionen in Deutschland und C)sterreich. Der Vergleich der Hfiufigkeiten einzelner HLA-Antigene bei den Patienten mit Normalpersonen einerseits und zwischen Antigenhfiufigkeiten bei Patienten mit verschiedenen Krankheitsstadien andererseits erbrachte keinen statistisch signifikanten Unterschied. Auch die Zusammenfassung aller bisher ver6ffentlichten europfiischen Studien zum Thema ergab keine Hinweise darauf, daB das HLA-System das Risiko einer manifesten oder chronischen B. burgdorferiInfektion beeinflu6t.
Introduction Borrelia burgdorferi causes a multisystem disease that affects the skin, the central and peripheral nervous systems, the heart and the joints. Analogous to the categorization of syphilis, B. burgdorferi infection (Lyme borreliosis) has been classified into three stages [1]. Steere et al. [2--4] reported a correlation between chronic Lyme arthritis and the human leucocyte antigens (HLA) DR2 and DR4. Furthermore, chronic neurologic diseases
Two hundred eighty-three patients (146 female, 137 male) aged 7 to 77 years with manifest B. burgdorferi infections, 47 of whom had contracted the disease before serological tests for B. burgdorferi antibodies were available, were included in the study. The latter patients were re-examined between February 1984 and December 1986. The remaining group of 236 patients was seen for the first time after September 1984. Informed consent was obtained from each patient. The frequencies of HLA A, B, Cw and DR specificities in 176 of these patients have been previously published by Pfli~ger et al. [8]. Kristoferitsch et al. [6,7] have already reported the frequencies of HLA DR specificities in 39 of the patients included in the current study. Table 1 lists the various manifestations observed. The diagnosis of erythema migrans was based on the dermatological finding of a slowly expanding, ring-shaped, red erythema and - if present - a preceding tick bite. In case of an uncertain clinical diagnosis, positive serology and possibly histopathological findings confirmed the diagnosis. A total of 65 patients with erythema migrans had elevated serum antibody titers against B. burgdorferi. In another three seronegative patients, borreliae could be Received: 16 December 1991/Revisionaccepted: 10 April 1992 Dr. med. C. D. Reimers, Friedrich-Baur-lnstitut, Medizinische Klinik Innenstadt, Ludwig-Maximilians-Universit~it,Ziemssenstr. la, W-8000 Mtinchen 2, Germany;Dr. reed. U. Neubert, DermatologischeKlinikund Poliklinik, Ludwig-Ma~imilians-Universitfit,Frauenlobstr. 9-11. W-8000 Mfinchen 2, Germany; Dr. med. W. Kristoferitsch, Neurologische Abteilung, Wilhelminenhospital, Montleartstr. 37, A-1171 Wien, Austria; Priv.-Doz. Dr. med. K. H. Pfliiger, Medizinische Klinik und Poliklinik, Schwerpunkt H/imatologie, Onkologie, Immunologie, Universit~it Marburg, Baldingerstr., W-3550 Marburg, Germany; Prof. Dr. med. W.R. &Iayr, Institut ftir Transfusionsmedizin, Rheinisch-Westf~ilischeTechnischeHochschule,Pauwelsstr.30, W-5100 Aachen, Germany. Correspondence to: C D. Reimers.
Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Mfinchen,Mtinchen 1992
197 / 21
C. D. Reimers et al.: HLA and Borrelia burgdorferi Infection Table 1 : Manifestations of Borrelia burgdorferi infection in 283 patients.
I II
IlI
I-III
Total Erythema migrans Total Lymphadenosis benigna cutis Meningopolyneuritis Myocarditis Myositis Total Acrodermatitis chronica atrophicans Arthritis Encephalomyelitis Myositis Total
91" 91 118a 3 112 3 2 89" 81 5 2 3 283a
Twenty patients presented with two different manifestations of the/3.
burgdorferi infection at examination. cultivated from skin biopsies. Nineteen patients were seronegative. Testing for antibody titers was not performed in four patients. Three patients presented with the nodular type of lymphadenosis benigna cutis and elevated serum antibody titers against B.
burgdorferi. All adult patients with meningopolyneuritis GarinBujadoux-Bannwarth complained of intense pain. A group of seven younger patients with Borrelia meningitis reported only moderate pain, and four children were without pain altogether. All of the patients with meningopolyneuritis GarinBujadoux-Bannwarth suffered from motor and/or sensory deficits of the peripheral nervous system. All patients with meningopolyneuritis and meningitis presented with a lymphocytic pleocytosis. A preceding tick or insect bite had been recognized by 39 patients (34.8%) and an erythema migrans by 43 patients (38.4%). Serological testing revealed elevated antibody titers against B. burgdorferi in the sera and/or cerebrospinal fluid (CSF) of all patients examined in the acute phase of the disease. The follow-up study revealed evidence of elevated serum antibody titers in 29 of the 44 patients who had experienced the acute phase of their disease up to I5 years prior this re-examination. In three patients serological testing was not performed. Three patients with acute atrioventricular heart block and elevated serum antibody titers against t3. burgdorferi were diagnosed with Lyme myocarditis. They were promptly cured by antibiotics. The diagnosis of acrodermatitis chronica atrophicans was based on the typical dermatological features of a skin lesion with a bluish-red discoloration with edema in the beginning or atrophy in more advanced cases, located predominantly on the extensor surface of the extremities. In case of uncertain clinical diagnosis, the detection of a lympho-plasmacellular infiltration in the upper dermis confirmed the tentative diagnosis. All patients with acrodermatitis chronica atrophicans exhibited elevated serum antibody titers against B. burgdorferi. A female patient with Borrelia encephalomyelitis presented with cerebellar signs, positive Babinski sign on both sides, areflexia and mental changes. One male patient with Borrelia encephalitis suffered from an acute paranoid-hallucinatory psychosis. In both
22 / 198
patients, the investigations of the CSF revealed a lymphoplasmocytic pleocytosis, elevated protein content and an autochthonous antibody production against B. burgdorferi. The diagnosis of Lyme arthritis was based on the finding of arthritis with elevated serum antibody titers, other origins of the arthritis having been excluded as far as possible. The diagnosis of myositis caused by B. burgdorferi was founded on clinical and myopathological features, detection of antibodies against B. burgdorferi in the sera, and staining of spirochetes in the muscle specimens in three patients or in the skin superficial to the diseased muscle. The fifth patient with myositis suffered primarily from meningopolyneuritis Garin-Bujadoux-Bannwarth. Depending on the duration of the disease and the accompanying manifestations of the B. burgdorferi infection (i.e. meningopolyneuritis or acrodermatitis chronica atrophicans), two patients with myositis were assigned to stage II, and three patients were grouped to stage III. Twenty patients presented with two different manifestations of B. burgdorferi infection on clinical examination. HLA antigens and serological testing: Employing the standard microlymphocytotoxicity test as originally described by Terasaki and McClelland [9] with slight modifications, we examined ten HLA A specificities (A1, A2, A3, A9, A10, All, Awl9, A28, Aw36, Aw43), 23 HLA B specificities (B5, B7, B8, B12, B13, B14, B15, B16, B17, B18, B21, Bw22, B27, B35, B37, B40, Bw41, Bw42, Bw46, Bw47, Bw48, Bw53, Bw59), eight HLA Cw specificities (Cwl, Cw2, Cw3, Cw4, Cw5, Cw6, Cw7, Cw8) and ten HLA DR specificities (DR1, DR2, DR3, DR4, DR5, DRw6, DR7, DRw8, DR9, DRwl0) in the typing laboratories of the Department of Haematology and Oncology of the University of Marburg (FRG) (n=232) and the Institute for Blood Group Serology of the University of Vienna (Austria) (n=51). The HLA Bw4, Bw6, DQ-, DRw52 and DRw53 specificities were also examined, but due to broad unspecificity their antigens were not included in the statistical analysis. The subjects in the control group originated from the former West Germany, the majority of whom resided in Central Hessia, or Austria. No members of either group were related. Identical techniques and sera were used for both the patients and the control group. Additionally, the data on HLA frequencies in patients with B. burgdorferi infections from all European studies were combined.
Antibody titers against 13. burgdorferi and their serological testing: Antibodies to B. butgdorferi were tested by the indirect immunofluorescence test or by enzyme-linked immunosorbent assay (ELISA) at the laboratories of Prof. Ackermann (Cologne, Germany), Dr. Neubert (Dept. of Dermatology, University of Munich, Germany), Prof. Slenczka (Hygiene Institute, University of Marburg, Germany), Dr. Stanek (Hygiene Institute, University of Vienna, Austria) and Dr. Wilske (Max yon Pettenkofer Institute, University of Munich, Germany). Statistical analysis: A comparison was made between the frequencies of individual HLA specificities in the patient and the control groups. Differences in phenotype frequencies were tested for statistical significance using the chi-squared test for 2 x 2 tables. Results were obtained by separate calculation with the data of each laboratory, the following formula being used for the combined result: n
chi2 = >
-+chi2i i=1
Infection 20 (1992) No. 4 © MMV Medizin Verlag GmbH Mtinchen, Miinchen 1992
C. D, Reimers et al.: H L A and Borrelia burgdorferi Infection
Table 2: Frequencies of HLA A2, Cw3, DR2, DR3, DR4 specificities in patients with Borrelia burgdorferi infection and in normal subjects (data from the present study).
HLA A2 positive Relative frequency (%) HLA Cw3 positive Relative frequency (%) HLA DR2 positive Relative frequency (%) HLA DR3 positive Relative frequency (%) HLA DR4 positive Relative frequency (%) HLA A2 + Cw3 positive Relative frequency (%)
1921/4044 47.5 898/4044 22.2 360/1204 29.9 284/1204 23.6 327/1204 27.2 502/4044 12.4
51/91 56.0 25/91 27.5 32/91 35.2 16/91 17.6 23/91 25.3 18/91 19.8
63/118 53.4 39/118 33.1 33/118 28.0 19/118 16.1 30/118 25.4 25/118 21.2
43/89 48.3 29/89 32.6 28/89 31.5 22/89 24.7 23/89 25.8 17/89 18.4
148/2832 52.3 88/283b 31.1 92/283c 32.5 53/283d 18.7 73/283d 25.8 52/283e 18.5
C h i 2 = 6172 (degree of freedom = 2), p < 0.05. b Chi2 = 8.99 (degree of freedom = 2), p < 0.05. Chi2 = 6.04 (degree of freedom = 2), p < 0.05. d Not significant (p > 0.05). e C h i 2 = 10.28 (degree of freedom = 2), p < 0.01. Each calculation withoutcorrection for multiple comparisons (Bonferroni's adjustment [10]). After Bonferroni's adjustment no difference was significant.
(chi2i = chi 2 calculated for a single laboratory; n = number of laboratories). In case of a higher frequency of the H L A antigen in question in the patient group compared to the control group, chi 2 was positive; in the opposite case, it was negative.
Results T h e f r e q u e n c i e s of H L A A, B, Cw a n d D R specificities in o u r 283 p a t i e n t s with m a n i f e s t B. burgdorferi infections w e r e similar to t h o s e f o u n d in the c o n t r o l group. A h i g h e r f r e q u e n c y was n o t e d for H L A A2, Cw3 a n d D R 2 (p < 0.05) as well as for t h e p h e n o t y p e c o m b i n a t i o n H L A
Table 3: Combined frequencies of HLA A2, Cw3, DR2, DR3 and DR4 specificities in European Lyme borreliosis patients derived from the studies of Herzer [12], M~jsky et al. [5], Wokke et al. [13] and the present study.
HLA A2 positive (n) Relative frequency (%) HLA Cw3 positive (n) Relative frequency (%) HLA DR2 positive (n) Relative frequency (%) HLA DR3 positive (n) Relative frequency (%) HLA DR4 positive (n) Relative frequency (%)
2158/4544 47.5 1154/5109 22.6 612/2039 30.0 332/1534 21.6 383/1534 25.0
173/333" 52.0 96/318b 30.2 135/398c 33.9 72/365a 19.7 102/365d 27.9
Not significant (p > 0.05). Chi2 = 8.96 (degree of freedom = 3), p
