Journal of Neuro-Ophthalmology, September 1993, Volume 13, Issue 3

First isolation of Borrelia burgdorferi from an iris biopsy.

The persistence of Borrelia burgdorferi in six patients is described. Borrelia burgdorferi has been cultivated from iris biopsy, skin biopsy, and cerebrospinal fluid also after antibiotic therapy for Lyme borreliosis. Lyme Serology: IgG antibodies to B. burgdorferi were positive, IgM negative in four patients; in two patients both IgM and IgG were negative. Antibiotic therapy may abrogate the antibody response to the infection as shown by our results. Patients may have subclinical or clinical disease without diagnostic antibody titers. Persistence of B. burgdorferi cannot be excluded when the serum is negative for antibodies against it.

Journal of Clinical Neuro-ophthalmology ]3(3): 155-161, 1993. First Isolation of Borrelia burgdorferi from an Iris Biopsy V. Preac-Mursic, M.D., H. W. Pfister, M.D., H. Spiegel, M.D., R. Burk, M.D., B. Wilske, M.D., S. Reinhardt, M.D., and R. Bohmer, M.D. ([J 1993 Raven Press, Ltd., New York The persistence of Borrelia burgdorferi in six patients is described. Borrelia burgdorferi has been cultivated from iris biopsy, skin biOpsy, and cerebrospinal fluid also af­ter antibiotic therapy for Lyme borreliosis. Lyme Serology: IgG antibodies to B. burgdorferi were positive, IgM neg­ative in four patients; in two patients both IgM and IgG were negative. Antibiotic therapy may abrogate the an­tibody response to the infection as shown by our results. Patients may have subclinical or clinical disease without diagnostic antibody titers. Persistence of B. burgdorferi cannot be excluded when the serum is negative for an­tibodies against it. Key Words: Lyme borreliosis-Erytlzema migrans­Antibiotic therapy. From the Max v. Pettenkofer Institut fUr Hygiene u. Medi­zinische Mikrobiologie (V.P.-M., B.W., S.R., R.B.), Neurologi­sche Klinik (H.W.P.), Klinikum GroBhadern, and Augenkhmk (H.5.), der LM-UniversWit Miinchen; Augenklinik (R.B.), der RK-Universitat Heidelberg, Germany. Address correspondence and reprint requests to Dr. Vera Preac-Mursic, Max v. Pettenkofer InstItut, LM-Umversltat Miinchen, Pettenkoferstr 9A, W8000 Miinchen 2, Germany. 155 Lyme borreliosis, the most widespread disease transmitted by ticks, and caused by the spirochetal organism Borrelia burgdorferi (1) is characterized by various clinical stages, including dermatologic, neurologic, cardiac, rheumatologic, and ocular manifestations (2). Overlapping symptomatology of these stages is possible. Disease usually begins with the characteristic localized skin lesion Erythe­ma migrans at the site of the tick bite, whereas the later phases-weeks, months to years after the pri­mary infection-is marked by a disseminated in­fection. With respect to ocular manifestations, conjunc­tivitis, keratitis, iritis, uveitis, vitritis, endophthal­mitis, ischemic optic neuropathy, optic neuritis, oculomotor palsy, and retinal vasculitis have been reported (3-10). The diagnosis in all reported cases was made by clinical signs and serological tests for antibody to B. burgdorferi. This case report presents a patient in whom B. burgdorferi was first isolated from an iris biopsy. Additionally we report about the isolation of B. burgdorferi after corticosteroid and antibiotic therapy in patients with latent dis­seminated Lyme disease and interesting ophthal­mological findings. PATIENTS AND METHODS Patients See Table 1. Serological Tests Antibodies to B. burgdorferi in blood and cerebro­spinal fluid (CSF) were determined by indirect im­munofluorescence test (lFT) as described previ­ously (11). To avoid unspecific false positive reac­tions, the test samples were absorbed with Treponema phagedenis. Antibody titers ~1:64 were regarded as significantly elevated, titers of 1:32 as 156 V. PREAC-MURSIC ET AL. TABLE 1. Clinical and microbiological findings Antibodies to B. burgdorferi Isolation of Disease Serum CSF B. burgdorferi Patient no.lage Systemic Ocular Treatment IgM IgG IgM IgG from 1/24 None Panuveitis- Corticosteroid NE 593 Ua NO Iris biopsy iridocycl itis Doxycycline 2/55 E. migrans Iritis-uveitis Doxycycline NE NE NO Skin biopsy Corticosteroid Ceftriaxone 3/17 None None Cefotaxime NE 1:64b NE CSF 4/60 None Painful eyes Ceftriaxone NE 1:64b NE CSF 5/62 Arthralgias Conjunctivitis Penicillin NE NE NE CSF lymphadenopathy Ceftriaxone 6/25 Radicular pain Iritis Ceftriaxone NE 1:64b NE CSF NO, not done; NE, negative; CSF, cerebrospinal fluid. a ELISA (positive> 200 U). b 1FT-ASS (positive is ;;. 1:64, borderline 1:32, negative ,,;1 :16). borderline. Intrathecal production of antibodies against B. burgdorferi was assessed by comparing the CSF/serum ratio of enzyme-linked immunosor­bent assay (ELISA) IgG values (units per milliliter) with the CSF/serum ratio of total IgG (CSF/serum index). A CSF/serum index of <2 was considered normal and >2 was considered elevated. Bacteriological Examination The iris biopsy and the samples of CSF and skin biopsy were examined for B. burgdorferi by dark­field microscopy and by culture in MKP medium as previously described (12,13). The cultures were incubated at 33°C for ;;;.5 weeks and examined weekly by darkfield microscopy and subcultures. Isolates were identified with monoclonal anti­bodies L321Fll and L221F8 by Western Blot (14). The susceptibility of the strains to different antibi­otics were tested by MIC (minimal inhibitory con­centration) using in vitro test in tube (13). Tests for monoculture of the isolates were done on solid me­dia PMR agar (15). Other Laboratory Examinations The CSF was examined for white blood cells and total protein. Isoelectric focusing was used to de­termine oligoclonal IgG bands in the serum and CSF. Concentration of albumin and IgG in serum and CSF were determined by kinetic nephelome­try. Serological examinations for syphilis and rheu­matoid factor were performed. RESULTS The clinical and microbiological data are pre­sented in Table 1. I Gill Neuro-ophthalmol, Vol. 13, No.3, 1993 Spirochetes isolation was successful between 2 and 16 subcultures in MKP medium. The isolates showed typical protein pattern of B. burgdorferi in SDS-page and were identified with monoclonal an­tibodies L321Fll and L221F8 as B. burgdorferi. The in vitro susceptibility of the isolates to antibiotics was the same as in other strains tested (13,16,17). The growth of B. burgdorferi on PMR agar is shown in Fig. 1. Borreliae were isolated after antibiotic and corti­costeroid therapy, from iris biopsy of one patient with chronic recurrence uveitis and acute panuvei­tis, as well as from skin biopsy of one patient with E. migrans and ocular manifestations, and also from the CSF of patients with "latent neuroborre­liosis." However, the cell count in the CSF was normal and in all six reported patients the specific IgM antibody titers in serum were negative. Serological examinations for rheumatoid factor and syphilis were negative. FIG. 1. Borrelia burgdorferi growth on PMR-agar. BORRELIA BURGDORFERI 157 Case 1 A 24-year-old woman developed blurred vision in the right eye in 1991. She had a history of sev­eral years of chronic recurrent anterior and poste­rior uveitis. Since 1985 she had suffered from re­current bilateral iridocyclitis and had been on im­munosuppressive therapy. Lyme antibody titers had not been determined. Three years later in 1988, the IgG antibody titers against B. burgdorferi in serum were positive, while the IgM titer was negative. The patient was treated with systemic doxycycline at a dose of 200 mg/day for 4 weeks; the IgG antibody titer decreased. In 1989 the pa­tient received doxycycline, again at a dose of 200 mg daily for 4 weeks, after the Lyme IFT-IgG had been repeatedly positive. In August 1991 the pa­tient was admitted to hospital because of acute panuveitis with iridocyclitis, anterior chamber and vitreous cells, subtotal posterior synechiae, and a lens covered by a dense membrane. Fundoscopy revealed macular pucker, a cystoid macular edema, and an exudative inferior retinal detach­ment. A sector iridectomy and prepupillary mem­branectomy were performed to improve fundus vi­sualization to rule out a rhegmatogenous retinal detachment. Laboratory investigations included aqueous humor for antibody titer determination against B. burgdorferi as well as excised iris tissue for culture isolation of borreliae. The Lyme ELISA (lgG) in serum was 593 U (norm <200 U) and in aqueous humor, 42 U. B. burgdorferi was cultured from the iris excision and prepupillary membrane after prolonged in­cubation in 16 subcultures of MKP medium (13) (Fig. 2). Borreliae could be visualized in Levaditis stained biopsy (Fig. 3). Gram stains of biopsy specimens showed no organisms and bacterial cultures (aer­obic- anaerobic) showed no growth of other bacte­ria. E. migrans was not noted, although a tick bite was recalled. Case 2 A 55-year-old woman developed E. migrans, 4 weeks after a tick bite. Three days later a skin bi­opsy and Lyme 1FT and ELISA was done, and at the same time oral doxycycline 200 mg/day for 10 days was initiated. The Lyme IgM and IgG were negative; however, B. burgdorferi was isolated from the skin biopsy. E. migrans disappeared after 3 weeks. FIG. 2. Borrelia burgdorferi from iris biopsy (darkfield x600). JClit! Neuro-ophthalmol. Vol. 13. No.3. 1993 158 FIG. 3. Borrelia burgdorferi (Le­vaditi stained iris biopsy). V. PREAC-MURSIC ET AL. At the follow-up examination, 4 weeks after the antibiotic therapy, a subsequent biopsy (taken in the immediate vicinity of the prior biopsy) for cul­ture of B. burgdorferi was negative, as was the Lyme serology. The patient responded well for 1 year but then developed iritis and uveitis of the left eye. She also noted episodes of vertigo and tinnitus. Cultures and stains for bacteria and fungi were negative, the Lyme IgM and IgG were normal. For the fol­lowing 6 weeks the inflammation was treated with high doses of topical and systemic corticosteroids with moderate effect. After 1 month of therapy she developed iritis and uveitis of the right eye. Intra­venous ceftriaxone 2 g/day were administered for 3 weeks due to her Lyme history and symptomatol­ogy in both left and right eyes. The patient has remained well since, without further recurrence. Case 3 A 17-year-old man had noted several tick bites during the months of August to December after having jogged in the woods. In December (within 2 weeks) he developed a bilateral tinnitus. A com­plete EENT examination as well as neurologic ex­amination was normal. Upon physical examina­tion, the patient was afebrile and meningeal signs I C/ill Ncuro-ophthalmol. Vol. 13, No.3, 1993 were not present. Bilateral tinnitus was the only clinical symptom, Lumbar puncture revealed nor­mal cell counts (3/3), and total protein (21 mg/dl). Oligoclonal IgG bands were not detected and no intrathecal specific antibodies against B. burgdorferi could be demonstrated. Serum Lyme 1FT IgG was positive (1:64), IgM was negative «1:32). B. burgdorferi was isolated from CSF after 2 weeks incubation in MKP me­dium. The patient was treated with cefotaxime 3 x 2 g per day i.v, over 5 days followed with cepha­lexin for 8 days. Control cultures for B. burgdorferi 3 months later were negative. The same Lyme se­rological test results were obtained as those prior to therapy. Case 4 A 60-year-old otherwise healthy man developed recurrent episodes of red, painful eyes in 1990 and was treated with topical corticosteroids. In early 1991 he developed short-lived vertigo with head­aches. A tick bite or Erythema migrans had never been seen. The neurological examination was com­pletely normal. Serum Lyme IgG was 1:64 and IgM was nega­tive. Because of positive serum Lyme 1FT IgG, CSF BORRELIA BURGDORFERI 159 was investigated (see Table 2). Lumbar puncture revealed normal values for cell counts and total protein. Antibody to B. burgdorferi in CSF were not detected, however, when CSF was cultivated in MKP medium, B. burgdorferi could be isolated. There was no serological evidence for a bacterial or viral infection, except Lyme borreliosis. The cef­triaxone was administered at 2 glday for 14 days. At the follow-up examination 4 months after the antibiotic therapy, cultures for B. burgdorferi were negative and the complaints disappeared. Case 5 A 62-year-old woman had a tick bite in February 1990. Within 10 days she developed fever and cer­vicallymphadenopathy followed by conjunctivitis, arthralgias, numbness on toes and fingers, and ex­treme fatigue. The patient received oral penicillin for 12 days in February and again in May. In June 1991 the patient was referred to a neurological clinic due to persistent arthralgias and numbness. The neurological examination showed hypaesthe­sia and hypalgesia on toes and fingers of both sides as well as pallhypesthesia on malleoli left 4/8 and right 5/8. The rest of the neurological findings were normal. Lumbar puncture releaved 64 mgldl protein and 613 cells. Antibody titers to B. burgdor­feri in serum and CSF were negative, but B. burg­dorferi was isolated from CSF after 4 weeks incu­bation in MKP medium. Now ceftriaxone was given 2 glday i. v. for 14 days. Antibiotic treatment resulted in marked reduction of arthralgias and numbness. Cultures from CSF were negative. Case 6 A 25-year-old man was admitted to hospital be­cause of intensive radicular pain and blurred vi­sion. He also had minor headaches, but he denied having fever or chills. The neurologic finding was a discrete hypaesthesia on the left forearm and bi­lateral iritis was present. One year earlier he had a 2-week episode of blurred vision, which cleared with oral prednisone therapy. The patient had no history of tick bite and none of E. migrans. The 1FT IgG antibody titers against B. burgdorferi in serum were positive (1:64); anti­body titers in CSF were negative. Lumbar punc­ture revealed normal values for cell counts and to­tal protein; nevertheless, B. burgdorferi was isolated from CSF. The isolation was successful on the sec­ond subculture in MKP medium. Ceftriaxone was administered 2 g daily intravenously for 14 days. Five months after the therapy he remained well and a culture for B. burgdorferi from CSF was neg­ative. DISCUSSION The diagnosis of Lyme disease is based on clin­ical symptoms, epidemiology, specific igG and IgM antibody to B. burgdorferi in serum and CSF and isolation of borreliae. The diagnosis may be difficult in the late phase of the disease, particu­larly for ophthalmogists and rheumatologists. Characteristic of Lyme borreliosis is that its clinical picture is rarely complete and symptoms are over­lapping, which makes diagnosis more difficult. A borrelial infection is usually confirmed by deter­mining B. burgdorferi antibodies. However, inter­pretation of serological tests and results may not be straightforward. False-positive and false­negative results occur. Negative serologic results do not necessarily exclude Borrelia infection (18­20). As shown here and previously reported, anti­biotic therapy may abrogate the antibody response to the infection, but B. burgdorferi may persist. In clinically unclear cases, much greater significance is therefore attached to the isolation of B. burgdor­feri. We were able to isolate B. burgdorferi from CSF and skin biopsies months to years after the antibi­otic therapy and disappearance of Erythema mi­grans. The lack of repeated insect bite and Erythema migrans, negative AB-titers against B. burgdorferi and negative CSF examination suggest persistence of B. burgdorferi rather than reinfection. How often B. burgdorferi may persist in the CSF, skin, or other tissues after therapy or its effect in producing atypical manifestations of disease is not known. The reason for the persistence of B. burg­dorferi in patients after the treatment with antibiot­ics is not completely understood. A number of fac­tors may playa role, e.g., virulence of B. burgdor­feri, tissue penetration of antibiotics, insufficient antibiotic therapy (either duration or dose), intra­cellular localization of borreliae (21), possibility of B. burgdorferi survival in tissue and certain types of cells, and not at least the immunity of patients. The capacity of B. burgdorferi to hide in various human tissue (heart muscle, spleen, brain) (22-24) and an insufficient antibiotic tissue level are critical for the therapy. Antibiotic treatment with amoxicillin or doxycy­cline has been recommended for E. migrans, peni­cillin G, and cephalosporins, ceftriaxone, and ce­fotaxime for central nervous system infection and late stages. It is known that the therapy of late stages of the Lyme borreliosis can be complicated. JClin Neuro-ophthalmol, Vol. 13, No.3, 1993 160 V. PREAC-MURSIC ET AL. Not seldom, there are known recurrences of the disease and persistence of B. burgdorferi, also after adequate antibiotic therapy (18,25). The persistence of B. burgdorferi and clinical re­currence in E. migrans stage are rarely noted (18,20), as the therapy seems to be mostly effective and sufficient. In certain circumstances the clinical and laboratory investigations (3-4 months after the completion of antibiotics therapy), are probably too short for the enddiagnosis. Furthermore, in most E. migrans patients a control of the therapy effect is never done. However, we must take into consideration that changes in clinical symptom­atology (after months) can lead the patient to change doctors. The current antibiotic therapy (antibiotic, dose, duration) is very different, so we have very differ­ent clinical and laboratory findings. However, the randomized trials comparing various antibiotics in their clinical response, minimal inhibitory concen­tration (MIC) and the serum and CSF concentra­tion support the selection for stage-specific treat­ment. According to the data of recent clinical stud­ies, the cephalosporins are more efficient than penicillin G in late (26,27) but not in early Lyme borreliosis (28). Dattwyler et al. (27), Diringer et al. (29) and Pal et al. (30) reported that ceftriaxone and cefotaxime were effective in treating patients with meningoencephalitis and late borreliosis who did not respond to penicilin G therapy. The CSF concentrations of penicillin G, cefotax­ime, and ceftriaxone in our studies demonstrate that both cephalosporins penetrate to a greater ex­tent than penicillin. The CSF levels are evidently above the MIC 90 values for B. burgdorferi. The concentration of penicillin G did not reach the MIC 90 in any of our patients (31,32). Data from con­trolled clinical studies are still scanty, and the ob­servation period after the therapy is often too short. Furthermore, proof of a successful therapy is based not only on the disappearance of clinical symptoms but also on the elimination of B. burg­dorferi; this is difficult to achieve and seldom per­formed. However, the recurrence of the disease, longtime persistence of B. burgdorferi in untreated as well as in treated patients, unpredictable pro­gression of the disease and the isolation of B. burg­dorferi from CSF (without inflammatory signs) of patients with E. migrans (n.p.), it seems appropri­ate to treat patients in Stage I as effectively as pos­sible. The isolation of B. burgdorferi from CSF in E. migrans without inflammatory signs support an early dissemination of the borreliae. The results of randomized prospective therapy studies and case reports show that also with ade- I (lin Neuro-ophlhalmol. Vol. 13. No.3. 1993 quate antibiotic therapy cure is often impossible with one treatment course. An interval therapy with substantially larger doses of antibiotics--2 x 200 mg doxycycline, 2 x 800 mg amoxicillin for 7 days/2 times with an antibiotic-free interval of 7 days-is advisable. The patients with an active central nervous infection, carditis, or eye manifes­tations should be treated intravenously with ceftri­axone or cefotaxirne (1 x 4 g or 2 x 3 g/day, 7 days/2 times with an antibiotic-free interval of 7 days). This treatment regimen, which takes into con­sideration the long generation time of B. burgdorferi and the antibiotic mechanism of action can proba­bly be more effective than the regimen used. The higher doses of antibiotics reach correspondingly effective higher serum, CSF, and tissue antibiotic concentrations and the repeated doses of antimi­crobials killed the survivor borreliae. Likewise a combination of two antibiotics must be taken in consideration. The interval therapy and/or a com­bination therapy are often used, are obligatory in the treatment of complicated or chronical bacterial infection. However, currently recommended treat­ment regimens are inadequate for some patients; the therapy ought to be realized and controlled more individually. In conclusion, our first isolation of B. burgdorferi from eye tissue confirms invasion of the ocular space by B. burgdorferi. Furthermore, this isolate demonstrates that in eye conditions we have to think of Lyme infection-on B. burgdorferi persis­tence and on an adequate therapy with antibiotics. Further cases, with varied clinical symptoms and courses, show that negative serological tests do not exclude B. burgdorferi infection. REFERENCES 1. Burgdorfer W, Barbour AG, Hayes SF, Benach JL, Grun­wald E, Davis JP. Lyme disease-a tick-borne spirocheto­sis? Science 1982;216:1317-9. 2. Steere AC, Bartenhagen NH, Craft JE, et al. Clinical man­ifestations of Lyme disease. Zbl Bakt Hyg A 1986;263:201-5. 3. Smith JL, Parsons TM, Paris-Hamelin A1. Porshen RK. The prevalence of Lyme disease in a nonendemic area. J. Clin Neuro-oplztlzalmol 1989;9:148-55. 4. MacDonald A. Lyme disease: a neuro-ophthalmologic view. J Clin Neuroophtlzalmology 1987;7:185-90. 5. Baum 1. Barza M, Weinstein P, Groden 1. Aswad M. Bilat­eral keratitis as a manifestation of Lyme disease. Am JOph­tJwlmoI1988; 105:75. 6. Winward KE, Smith JL, Culbertson WW, Paris-Hamelin A. Ocular Lyme borreliosis. Am 1OplzthalmoI1989;108:651-7. 7. Bialasiewicz AA, Ruprecht KW, Naumann GOH, Blenk H. Bilateral diffuse chorioiditis and exsudative retinal detach­ments with evidence of Lyme disease. Am J Ophthalmol 1988;105:419-20. 8. Steere AC, Duray PH, Kaufman G, Wormser P. Unilateral BORRELIA BURGDORFERI 161 blindness caused by infection with the Lyme disease spi­rochete. Borrelia burgdorferi. Ann Intern Med 1985;103:382--4. 9. Schonherr U, Strle F. Ocular manifestations. In: Weber K, Burgdorfer W, Aspects of Lyme borreliosis. Springer, Berlin, 1993:248--58. 10. Smith JL, Winward KE, Nicholson DF, Albert DW. Retinal vasculitis in Lyme borreliosis. I Clin Neuro-ophthalmoI1991; 11:7-15. 11. Wilske B, Schierz G, Preac-Mursic V, Weber K, Pfister HW, Einhaupl K. Serological diagnosis of erythema migrans dis­ease and related disorders Infection 1984;12:331-7. 12. Preac-Mursic V, Wilske B, Schierz G. European Borrelia burgdorferi isolated from humans and ticks: culture condi­tions and antibiotic susceptibility. Zbl Bakt Hyg A 1986;263: 112-8. 13. Preac-Mursic V. Antibiotic susceptibility of Borrelia burgdor­feri: in vitro and in vivo. In: Weber K, Burgdorfer W, ed. Aspects of Lyme borreliosis Springer-Verlag, Berlin, 1993:301­11. 14. Wilske B, Preac-Mursic V, Fuchs R, et al. Immunodominant proteins of Borrelia burgdorferi: implications for improving serodiagnosis of Lyme borreliosis. In: Neu HC, ed. New Antibacterial Strategies. Churchill Livingstone, London, 1990:47-63. 15. Preac-Mursic V, Wilske B, Reinhardt S. Culture of Borrelia burgdorferi on six solid media. Eur I Microbiol Infect Dis 1991; 10:1076-9. 16. Preac-Mursic V, Wilske B, Schierz G, Holmburger M, Slil3 E. In vitro and in vivo susceptibility of Borrelia burgdorferi. Eur JClin Microbiol 1987;6:424-6. 17. Johnson RC, Kodne C, Russel M. In vitro and in vivo sus­ceptibility of the Lyme disease spirochete Borrelia burgdorferi to four antimicrobials. Antimicrob. Agents Chemother. 1987; 31:164-7. 18. Preac-Mursic V, Weber K, Pfister W, et al. Survival of Bor­relia burgdorferi in antibiotically treated patients with Lyme borreliosis. Infection 1989;17:355-9. 19. Pfister HW, Preac-Mursic V, Wilske B, Einhaupl KM, Wein­berger K, Latent Lyme neuroborreliosis: presence of Borre­lia burgdorferi in the cerebrospinal fluid without concurrent inflammatory signs. Neurology 1989;39:1118--20. 20. Liegner K, Shapiro J, Ramsey DR, Halperin AJ, Hagrefe W, Kong L. Recurrent erythema migrans despite extended an­tibiotic treatment with minocycline in a patient with per­sisting Borelia burgdorferi infection. I Am Acad Dermatol1993; 28:312--4. 21. Ma Y, Sturrock A, Weis JJ. Intracellular localization of Bor­relia burgdorferi within human endothelial cells. Infect Immu­nol 1991;59:671-8. 22. Stanek G, Klein J, Bittner R, Glogar D. Isolation of Borrelia burgdorferi from the myocardium of a patient with long­standing cardiomyopathy. N Engl I Med 1990;322:249-52. 23. Cimmino M, Azzolini A, Tobia F, Pesce C. Spirochetes in the spleen of a patient with chronic Lyme disease. Am JClin PathoI1989;91:95-7. 24. MacDonald AB, Borrelia in the brains of patients dying with dementia. lAMA 1986;256:2195-6. 25. Liegner KB, Rosenkilde CE, Cambell GL, et al. Culture­confirmed treatment failure of cefataxime and minocycline in a case of Lyme meningoencephalomyelitis in the United States. [Abstract 63]. Proceedings of the Fifth International Con­ference on Lyme Borreliosis. Arlington, VA, 1992. 26. Dattwyler RJ, Halperin JJ, Volkman DJ, Luft BJ. Treatment of Late Lyme borreliosis-randomized comparison of ceftri­axone and penicillin. Lancet 1988;1:1191--4. 27. Dattwyler RJ, Halperin JJ, Pass H, Luft BJ. Ceftriaxone as effective therapy in refractory Lyme disease. I Infect Dis 1987;155:1322-5. 28. Wilske B, Preac-Mursic V, Fuchs R, Schierz G. Diagnostik der Lyme-Borreliose. Diagnose und Labor. Laboratorium­sbliitter 1990;40:24-36. 29. Diringer MN, Halperin JJ, Dattwyler RJ.Lyme meningoen­cephalitis: report of a severe, penicillin-resistant case. Ar­thritis Rheum 1987;30:705-8. 30. Pal GS, Baker JT, Wright DJM. Penicillin-resistant borrelia encephalitis responding to cefotaxime. Lancet 1988;50-1. 31. Pfister HW, Preac-Mursic V, Einhaupl KM, Wilske B. Ce­fotaxime versus penicillin G for acute neurological manifes­tations of Lyme borreliosis: a prospective randomized study. Arch NeuroI1989;46:1190--4. 32. Pfister HW, Preac-Mursic V, Wilske B, Schielke E, Soergel F, Einhaupl. Randomized comparison of ceftriaxone and cefotaxime in Lyme neuroborreliosis. I Infect Dis 1991;163: 311-8. I Clin Nellro-ophthalmol, Vol. 13, No.3, 1993 JOllrllal of Clillical NClln1-<ll'hthal",otosy 13(3): 162, 1993. Editorial Comment First Isolation of Borrelia burgdorferi from an Iris Biopsy © 1993 Raven Press, Ltd., New York In this issue of The Journal, Dr. Vera Preac­Mursic and colleagues from the Max Pettenkofer Institute in Miinchen, Germany present a land­mark report of such magnitude that this is being published as an expedited communication. Dr. Preac-Mursic is well known on the continent for her outstanding contributions to the field of micro­biology/ and particularly with regards to the study of Borrelia burgdorferi, the spirochetal organism that causes Lyme borreliosis. Ophthalmologists who have been interested in the ocular manifestations of Lyme disease have waited for a long time for the detection of this organism within the human eye, not only by spirochetal morphology on silver stains, but for actual proof by culture that the spi­ral form being seen is truly Borrelia burgdorferi. Many ophthalmologists who have seen cases of uveitis and vitritis due to Lyme borreliosis have wondered why those who classify the manifesta­tions of Lyme disease often have neglected even the possibility that the eye may be involved in the disease, But for an infrequent comment about an 11% incidence of conjunctivitis in early stages of the disease, the medical literature, with a few ex­ceptions/ has often not even considered the possi­bility that B. burgdorferi has been causing extensive and protracted inflammatory conditions in the hu­man eye. Dr. Preac-Mursic and colleagues have put the final nail in the confirmation of ocular Lyme bor­reliosis by not only showing a positive Lyme 162 ELISA test in both serum and in aqueous humor, and by demonstrating Borrelia-like spirochetes in an iris biopsy stained with the Levaditi silver stain, but have cultured the organism from the iris exci­sion and prepupillary membrane in a young woman who had suffered from recurrent bilateral iridocyclitis since 1985 and who had been treated with antibiotics for a I-month course in 1988 and again in 1989, This shows that the organism was still present in the human eye after a 6-year course of active uveitis and also after two courses of an­tibiotics. The difficulty in obtaining this organism by culture was illustrated by requiring prolonged incubation in 16 subcultures of MKP-medium. The clinical implications of this report are obvi­ous. They not only show that B. burgdorferi is fol­lowing the same course in diagnosis and detection that T. pallidul1l has shown for many years, but emphasizes the fact that ophthalmologists must think of Lyme disease in an entirely different light than heretofore, Further research to confirm these important observations should be forthcoming from other laboratories, but this Journal is honored to have the opportunity to publish this first cul­ture- proven detection of Borrelia burgdorferi in the human eye. J. Lawton Smith, M.D. Editor Miami, Florida