Well found, Joanne.

I thought I would comment on this report.

Firstly I noticed that the introduction says:

"The clinical progression of Lyme borreliosis may be divided into early-localized, early disseminated, and late stages. During the early-localized phase, the disease's most prevalent sign is an erythematous skin rash known as erythema migrans. Subsequently, patients may develop early-disseminated disease with dermatologic, rheumatologic, cardiac, and neurologic involvement."

Progression may indeed be divided into stages as stated, but there is no scientific basis for so doing. This is only a result of an initial belief that Lyme disease was similar to syphilis as the bacterium had the same shape. This division initially was merely made as an analogy. Involvements may indeed develop, but there is no scientific basis for this development only occurring `subsequently'. This assumption has led to many of the problems in treatment as MDs do not know whether to treat for possible `subsequent' disease at once, or to wait until the patient manages to self-diagnose `subsequently', i.e. later.

In the report 'Introduction' Lyme disease is first described as a time-based or phase-based disease while it is then described as a disease based on the following categories:

a. Local or spreading, i.e. range of disease in body.
b. Skin or heart involvement, i.e. organ involvement.
c. Rheumatologic, `any disorder of the extremities or back, characterized by pain and stiffness', involvement, i.e. involvement of disorders so general that a cause could not be given. `rheum' in Greek means `stream, current'.
d. Neurologic involvement, i.e. a system involvement.

There is no mention of an infection in the brain or the casing covering the brain although this is common. It might be that this is included and implied in `neurologic involvement', but this is not what `neurologic' usually means in medicine. It is a somewhat vague term anyway.

The Introduction continues:

"The Infectious Diseases Society of America (IDSA) has issued
guidelines for Lyme borreliosis therapy [2]."

In `Background' in the IDSA it states:

"Clinical manifestations most often involve the skin, joints, nervous system, and heart. Extracutaneous manifestations are less commonly seen than in earlier years."

Here there is not only a time-basis for Lyme disease, but further types of division. `joints' are included which may perhaps be the same reference as that to `rheumatologic involvement'. Once again, there is no mention of the brain or the casing covering the brain.
IDSA then briskly moves on to describe other infectious agents transmitted by ticks.

The Rhesus Macaques study in the 'Introduction' sets out the following hypotheses:

"Signs and symptoms of putative failure of antibiotic treatment in late disease or ineffectiveness of repeated treatment in patients with PTLDS may be formally attributed to several causes, including: 1) spirochetes that persist in the tissues, likely in small numbers, inaccessible or impervious to antibiotic; 2) inflammatory responses to residual antigens from dead organisms; or 3) autoimmune responses, possibly elicited by antigenic mimicry [10]."

Putative means `supposed' and is therefore superfluous as the statements already are said to be hypotheses. Putative is perhaps written to weaken the hypothesis before it is even tested.

PTLDS stands for `post-treatment Lyme disease syndrome'. A syndrome is a condition without known cause, etiology. Hopefully, by the end of the report it will be called `too-short treatment Lyme disease progression'.

This Rhesus Macaques study first deals with `experiment 1'.

Rather oddly this experiment is about what is called `Antibiotic treatment in the late, disseminated phase of infection'. I say `oddly' as I expected the first experiment to be about the early stage of Lyme as Embers et al. introduced the disease in that order. The rationale for this order may be that the Klempner et al. study dealt directly with Lyme disease in patients where three or more treatment regimes already had failed.

24 rhesus macaques were infected with borrelia burgdorferi. 12 were treated with antibiotics, 12 were not treated. 4 animals were used as uninfected controls. 2 of these were treated with antibiotics, 2 were untreated.

This design is similar to that used in medical studies on humans.
The 24 infected animals were left for 27 weeks and checked for infection which was positive.

12 of the infected animals were treated with intra-venous, IV, ceftriaxone from week 27 to week 31, i.e. for four weeks, in fact for 30 days. From week 31 to week 39 the animals were then treated with doxycycline, for 60 days.

It is hard to see why the animals were treated for 90 days. The IDSA guidelines are 14 days of doxycyline for Lyme in the presence of an EM, and 28 days of doxycycline for neurological Lyme `without clinical evidence of neurological disease'. I have no idea how you would obtain treatment without providing clinical evidence of neurological disease. The IDSA guidelines deal with the matter of persistence after their treatment guidelines either as a co-infection or as a `rare patient'.

This Rhesus Macaques experiment 1 therefore is a study of long-term treatment and not a study of any treatment currently recommended by the IDSA. The IDSA guidelines are polemical and tendentious. It is worth repeating them as they have caused so much suffering and ill-health throughout the world:

"The etiology of residual patient complaints after treatment may include an inflammatory response unrelated to active infection or may be due to alternative disease processes. The possibility that these symptoms may have been related to a tick transmitted coinfection was not evaluated in any of the studies. Importantly, failure rates were not considered in the context of the high frequency of background complaints present in an otherwise "healthy" population. Both of these factors have likely contributed to a misconception by some that recommended treatment courses are associated with a relatively poor outcome. This has helped to foster highly speculative theories on how B.burgdorferi might survive in patients treated with a standard course of antimicrobial therapy. These issues are discussed in greater detail below in the section on post–Lyme disease syndromes."

"Background and diagnosis of patients with post–Lyme disease syndromes. Shortly after treatment with conventional courses of antibiotics for Lyme disease (tables 2 and 3), a minority of patients continue to report symptoms or signs. On the basis of numerous studies of patients with erythema migrans, it can be expected that few—if any—patients who are compliant with antibiotic therapy will have persistence or recurrence of the skin lesion. A rare patient, however, will develop an objective extracutaneous manifestation of Lyme disease, such as a new seventh nerve palsy or meningitis [138, 142]. Seventh nerve palsy typically occurs during the first week of therapy and, in most cases, appears to be benign; in an otherwise stable patient, this event does not mandate a change in treatment
[138]. In contrast, if Lyme meningitis develops during or shortly after completion of a course of oral antimicrobial therapy, the patient should be re-treated with ceftriaxone or a comparable
parenteral antibiotic (table 2) [142, 256]. In some patients treated for objective extracutaneous manifestations of Lyme disease, there will be slow or even incomplete resolution of that manifestation. This is well illustrated by the treatment of patients with neuroborreliosis who have seventh nerve palsy. A small proportion of such patients will have mild residual weakness of facial muscles [155]. A similar phenomenon can probably occur with any other site of neurologic impairment, attributable not to persistent infection but
to residual, irreversible neurologic damage. In ∼10% of patients with Lyme arthritis, joint swelling (usually of a single joint) will persist after recommended antimicrobial treatment courses (table 3) [153, 205]. Chronic joint swelling in these circumstances, if not treated with other approaches (such as synovectomy) [235], will eventually disappear, but it has lasted for up to 4–5 years in a few patients [236]. B. burgdorferi has not been demonstrated to persist in such patients. Objective clinical manifestations are uncommon after treatment of patients with Lyme disease. A much more likely scenario after treatment is the persistence or development of subjective symptoms without any residual or new objective manifestation. In patients treated for early or late Lyme disease,
the frequency of subjective symptoms is at least partially dependent
on when after treatment the patient is assessed [142,227]. On the basis of an intention-to-treat analysis of 1 study of patients treated for erythema migrans, subjective symptoms were present in 35% of patients at day 20, in 24% at 3 months, and in 17% at 12 months (P ! .002, for the comparison of the frequency of symptoms across the 3 time points) [142]. The presence of such symptoms during the first several weeks to months after treatment most often appears to be due to slow resolution of an inflammatory process associated with a highly
symptomatic or disseminated B. burgdorferi infection [257]. Furthermore, evidence from 3 randomized trials [137, 142, 227] and 1 retrospective study [144] of patients treated for either early or late Lyme disease indicates that a more prolonged initial treatment course of antibiotics does not improve the rate of resolution of symptoms (see the sections on early and late Lyme disease above for more details)."

The answer to the choice of treatment regimes in this Rhesus Macaques experiment 1 study lies in the Klempner et al. study of 2001. It was the intention of the Klempner study that "not-cured" Lyme patients be given 30 days IV cefriaxone followed by 60 days of doxycycline followed by a further 90 days of doxycyline. However, after 30 days IV ceftriaxone and 60 days of doxycyline patients appeared on median values to be no better. At that time: "However, two patients in whom a study-related serious adverse event occurred were both in the antibiotic group. During intravenous treatment, one had a life-threatening pulmonary embolism and the other had fever, anemia, and gastrointestinal bleeding." "After a planned interim analysis, the data and safety monitoring board recommended that the studies be discontinued because data … indicated that was highly unlikely that a significant difference in treatment efficacy between the groups would be observed …"

30 days of IV ceftriaxone and 60 days of doxycyline in the Rhesus Macaques study was therefore chosen to enable a comparison with the Klempner et al. study. Would there still be borrelia burgdorferi bacteria or would they all be eliminated if you killed the animals and subjected them to autopsy tests?

The ceftriaxone treatment was 25 mg/kg. Adult males weigh about 7.7 kg so this is a dose per day of 154 mg. This is a similar dose per kg to that given to humans, but the great difference in weight is a potential source of error. MIC and MBA were not measured, but by comparison with other studies it was considered that:

"Therefore, it is likely that the concentration of ceftriaxone in the rhesus circulation remained above the MIC and the MBC for a significant portion, if not all of the 24-h interval between consecutive doses of this antibiotic."

The doxycyline given was 2 mg/kg, twice a day. This was thus 30.8 mg per day for a 7.7 kg animal. MIC and MBA were noted.

The animals were killed starting at week 63. This was stated as: "Animals were kept for a minimum of 6 months after treatment termination." The reason for this is not given. It may be to allow time for any remaining bacteria to multiply, but this is speculation. In the Klempner study screening was carried out after 90 days and after 180 days, the latter perhaps because this was the period of antibiotic treatment planned before the experiment was discontinued. There was thus a period of waiting in Klempner after the end of treatment, but this was not 6 months.

Tests were carried out with five methods:

C6 ELISA; Inflammation by taking tissue samples; immunofluorescence assay; RNA; and DNA samples.

0/12 of the C6 ELISA tests were positive in no animal, 3/12 of the inflammation tests were positive in heart tissue in 3 animals, 7/12 of the IFA tests were positive in the heart and meninges, 4/12 of the RNA tests were positive in the heart and brain, and 1/12 of the tests was positive in the meninges, bladder, spleen and lung.

This demonstrates that even after 90 days of treatment borrelia bacteria remained in the heart, meninges, brain, bladder, spleen and lung, or at any rate multiplied and invaded those organs. All the organs found are in the main blood circulation path while peripheral organs might be expected to be invaded at a later time.

This also demonstrates the value of taking as many different types of test as you can, whether they be approved of or not.

The inadequacy of the advanced C6 ELISA test in Lyme disease which has been present for a while is demonstrated.

This experiment is unrealistic in that an animal cannot tell anyone that it is tired or that it has a headache or that it hurts when it urinates. On the other hand, infection in organs in Rhesus Macaques can be objectively observed as in the experiment by killing the animals while this is not ethical in humans.

Conversely if a human tells a doctor they are tired the doctor merely treats that as a subjective indication. The doctor writes; "Pat says she is tired". The patient cannot say, "Look, I think I have Lyme disease. I was bitten by a tick sixty-three weeks ago and a large, expanding, red ring appeared. I did not think much of it at the time. Can you kill me and do some tests on me, mostly on my brain and the brain cover? When you're finished please resurrect me and we will look at the results?"

The Rhesus Macaques study clearly demonstrates that bacteria are present after 90 days of antibiotics. You either believe germ theory or you don't. I believe germ theory and I therefore believe that prolonged treatment of Lyme disease is indicated by this research.
When I get the time I will look at experiment 2 as well. This deals with treatment in the early, disseminated phase of infection, as they choose to call it.

A major failing in the study regarding experiment 1 is that the hypotheses set out are not declared to be true or false.

'Explanations' are discussed, though solely in terms of the C6 ELISA test. It is as though the failure of this test must be definitive, i.e. that the C6 ELISA test is the disease. Page 8: "We therefore favor explanation #3 and seek to determine the level of transcriptional/metabolic activity, and pathogenicity of persistent organisms. If, for example, spirochetes that are recovered by xenodiagnosis from treated animals turned out to be non-pathogenic, this would validate the decline in C6 titer as a measure of successful treatment outcome." I assume #3 refers to 3) at the top of page 2.

A semantic comment on this study is that the title includes the concept: "Persistence". I hope this does not presage new IDSA guidelines such as: "Persistence of symptoms without objective signs of disease is often presented by patients. This is called Persistent Lyme Disease Syndrome, PLDS."

Peter Travis ( permission given  to re post )
The above was too long to post on the comments of my original posting about this study.