In Strasbourg I have arranged a visit to the Institute of Bacteriology, parasitology and Virology at 3 Rue Koerberle.
Louis Pasteur who made some of the greatest breakthroughs in modern medicine in his era and is known for his work on the principles of vaccination, microbial fermentation and pasteurisation. He is remembered for his breakthroughs in the causes and prevention of disease and he created the first vaccine for anthrax and rabies, he worked within the institution I visited . The picture below is displayed within the building and it is a well known painting of Rabies vaccination in Pasteur’s clinic in Paris.
Nathalie is a pharmacist and works as a medical Entomologist, Nathalie also teaches at the school of pharmacy, she has been working on ticks and tick borne disease within France since 2001-2002, since the France national plan in 2016 there is a large increase in the amount of people who now work in different aspects of ticks and tick borne disease and in particular on Lyme disease.
Nathalie spoke about how she has been involved in the field work of collecting ticks and this has been important over the years to generate the data, particularly when considering emerging pathogens and how they have increased over the years. Nathalie has also spent years working in the laboratory progressing the knowledge on the importance of the skin, and the reaction that occurs following a tick bite. Nathalie also spoke about the importance of speaking to people about ticks and tick borne disease, and particularly the primary prevention actions she shared some of the resources she uses to educate people. But it is difficult for researchers to balance the time to teach, undertake research and also to speak to the public as well as time to apply for grants to continue with the research.
Nathalie introduced me to one of her PhD students Pierre Boyer, he works as a Microbiologist and his Phd study is looking at proteomics to identify ticks, most researchers use looking under the microscope to identify ticks. Looking at proteins appears to be more accurate, rapid and low cost he is about to publish his results. He is also looking at emerging pathogens, particularly Borrelia miyamotoi and rickettsia. The 3rd aspect of his Phd is to develop a new tool to diagnose Borrelia, by looking at the proteins present in Erythema migrans skin biopsy samples, these studies have the potential to improve diagnoses and testing.
Nathalie has always been interested in research of the skin and the area around the tick bites as this does appear to be a very important factor and the main interface between tick and host and has recently published a book on the topic:
Nathalie is involved in collaborative groups that develop resources and undertake the awareness raising on ticks and tick borne diseases.
Professor Benoit Jaulhac
Professor Benoit Jaulhac is a clinical Microbiologist, who has a clinical role as well as Director of the reference laboratory.
He developed an interest at the end of the 1980’s when as a medical student he worked with people who were starting to look at the serology of a new bacteria, this bacteria was present in Austria and Germany he was then working in the laboratory to look at this bacteria using molecular biology and he suggested to his boss that it would be interesting to look using PCR, he has extensive experience and has been involved in many research publications. During our discussion he made some recommendations for articles to read regarding the characteristics and clinical outcomes of a national cohort of PCR-positive Lyme arthritis. I asked him about the diagnostic accuracy of serological tests which is frequently criticised and he emphasises as others have done that the results cannot be interpreted in isolation, history, symptoms and the patients presentation have all to be considered. If the conclusion is that it is not Lyme disease other investigations should be undertaken. Prof Jaulhac told me about a study published in 2018 in France that demonstrated only 10% of patients with ongoing symptoms had Lyme disease and the concerns that exist around over-diagnosis and over treatment of Lyme disease is increasing.
Link to article: https://www.ncbi.nlm.nih.gov/pubmed/30239603
Reference Lab visit: CNR Borrelia Centre National de Reference-Borrelia
Laurence Filliax is a laboratory engineer and Marine Engel is a laboratory technician and both work in the CNR Strasbourg laboratory and are involved in projects where ticks are collected regularly in locations across the region since 2014. Although in the next year the sites for sampling is being reduced.
This has helped to identify the ticks that are present in France and the pathogens that they carry.
The ticks most commonly found in France are Rhipicephalus, Ixodes ricinus, and Dermacentor- images below
The laboratory is currently participating in a study with the dermatology department, patients that agree to enroll have biopsies taken of acrodermatitis rash and the sample is analysed for the presence of Borrelia. A questionnaire is completed with the usual patient details but also includes details of the bite. Photographs are taken of the rash.
Some of the rash’s do not test positive for Borrelia and some do, on the day I attended one of the samples was positive and I was able to see live Borrelia under the microscope. In the picture circled in red are the Borrelia, the video shows them clearly moving. I have permission from the ‘CNR Borrelia–Centre National de Reference-Borrelia” to use the picture and video I recorded while on my visit there.
The reference lab test all the serology samples for the three hospitals in Strasbourg.
Testing for Lyme disease receives criticism for its accuracy and reliability, each practitioner I speak too emphasises that it is important when testing patients to consider everything, the patients symptoms, history of tick exposure and also general risk of tick exposure ( where people go, what activities they participate in etc), presence of erythema migrans ( acknowledging that sometimes patients may not have seen the rash) and the results of blood tests. The ELISA test and the Western blot are the two commonly used tests.
The ELISA ( enzyme-linked immunosorbent assay)test is used to detect antibodies against Borrelia burgdorferi.
The Western blot can be used to confirm a positive ELISA test. It checks for the presence of antibodies to specific B.burgdorferi proteins.
Polymerase chain reaction (PCR) is used to evaluate people with persistent Lyme arthritis or nervous system symptoms. It is performed on joint fluid or spinal fluid
This a picture of the Western blot results
Basically the 3 strips on the left are the controls and the strips further on the right have to present darker than the controls to offer a positive result, if the strips further to the right are lighter in colour than the controls the result is negative, if the reaction is darker they are positive, the colours change in reaction to IGG and IGM in the samples being tested.
Strasbourg for the tourist in me was lovely, many old beautiful buildings and the city is interwoven with rivers. There were some remnants of the Xmas markets to be seen around the city and I found the Xmas shop::
As always I managed to have a look at the local area, Strasbourg was a lovely city with some beautiful architecture: