Discovery and Targeted Proteomics on Cutaneous Biopsies Infected by Borrelia to Investigate Lyme Disease

Lyme disease is the most important vector-borne disease in the Northern hemisphere and represents a major public health challenge with insufficient means of reliable diagnosis. Skin is rarely investigated in proteomics but constitutes in the case of Lyme disease the key interface where the pathogens can enter, persist, and multiply. Therefore, we investigated proteomics on skin samples to detect Borrelia proteins directly in cutaneous biopsies in a robust and specific way. We first set up a discovery gel prefractionation-LC-MS/MS approach on a murine model infected by Borrelia burgdorferi sensu stricto that allowed the identification of 25 Borrelia proteins among more than 1300 mouse proteins. Then we developed a targeted gel prefractionation-LC-selected reaction monitoring (SRM) assay to detect 9/33 Borrelia proteins/peptides in mouse skin tissue samples using heavy labeled synthetic peptides. We successfully transferred this assay from the mouse model to human skin biopsies (naturally infected by Borrelia), and we were able to detect two Borrelia proteins: OspC and flagellin. Considering the extreme variability of OspC, we developed an extended SRM assay to target a large set of variants. This assay afforded the detection of nine peptides belonging to either OspC or flagellin in human skin biopsies. We further shortened the sample preparation and showed that Borrelia is detectable in mouse and human skin biopsies by directly using a liquid digestion followed by LC-SRM analysis without any prefractionation. This study thus shows that a targeted SRM approach is a promising tool for the early direct diagnosis of Lyme disease with high sensitivity (<10 fmol of OspC/mg of human skin biopsy).Lyme borreliosis is an arthropod-borne disease transmitted by hard ticks (Ixodes spp.). The causative agents are bacteria belonging to the Borrelia burgdorferi sensu lato group. In the United States, more than 30,000 cases have been reported to the Centers for Disease Control and Prevention in 2012. There, the unique pathogenic species of Borrelia is B. burgdorferi sensu stricto (s.s.). In Europe, between 65,000 and 85,000 cases are reported depending on the epidemiological study (1, 2), and the three most prevalent pathogenic species of Borrelia are Borrelia afzelii, Borrelia garinii, and B. burgdorferi s.s. The disease in both Europe and the United States is first characterized in most patients by an inflammatory skin lesion, erythema migrans (EM),¹ which is the most frequent manifestation of the disease. Dissemination to other sites occurs secondarily and can involve among others articulation, nervous system, heart, and skin at other sites (3, 4). The diagnosis can be a real challenge because of the proteiform clinical manifestations. When an EM is present, which is the case for 80% of patients (3), early diagnosis is facilitated. However, EM presentation can be clinically atypical, making the recognition of this manifestation of Lyme borreliosis difficult (5). Later on, when Borrelia has disseminated to the target organs, biological diagnosis is based either on the direct detection of the pathogen in different patient body fluids and biopsies by means of culture and/or PCR or on the indirect demonstration of presence of Borrelia by detection of anti-pathogen-directed IgM and IgG antibodies (enzyme-linked immunosorbent assay (ELISA) and Western blot) (6).Concerning the direct detection of Borrelia, culture of the bacteria has allowed the spirochete isolation since the 80s in different specific Barbour-Stoenner-Kelly-based media by using skin biopsies or biological fluids such as blood or cerebrospinal fluid (7, 8). However, Borrelia culture is not routinely used as a diagnostic test because the bacterial growth takes several weeks and does not yield timely results. Indeed, it requires the use of the specific and expensive Barbour-Stoenner-Kelly medium and a dark field microscope to detect, frequently after at least 2 weeks of incubation, the presence of Borrelia in tissues or biological fluids. When performed from patients with EM, only 40–80% of the cultures are positive (6). In addition, the success of culture varies greatly according to the Borrelia species. PCR is quicker and generally more sensitive than culture with a range of 36–88%, although the success of bacterial detection varies with the gene selected for the assay (6). PCR is efficient for Borrelia detection in synovial liquid (60–85% of the cases) in the case of arthritis (9, 10) but less sensitive in cases of neuroborreliosis in cerebrospinal fluid (<20–40% of the cases) (9, 11). Moreover, PCR detects DNA and not proteins and therefore prevents the detection of active infection. As far as the skin biopsies are concerned, the sensitivity of detection is variable in cases of EM or acrodermatitis chronica atrophicans (12). Conversely, indirect detection using serological tests is not adapted to the early diagnosis as it relies on antibodies only detectable after at least 4–6 weeks after the infectious tick bite. These tests also suffer from lack of specificity (13). New diagnostic approaches are therefore required. Selected reaction monitoring (SRM) has been recognized as an efficient mass spectrometry-based technique for the biomarker verification and validation in several biological fluids (blood, plasma, and urine) (14–18). The demonstrated specificity, selectivity, and high sensitivity (low attomole range) of the technique (19) makes it promising for the development of an SRM-based method for early diagnosis of Lyme disease. To our knowledge, this strategy has only rarely been used on skin tissue (20). It would allow the direct and rapid detection of Borrelia proteins in the skin, demonstrating the presence of an active infection very early after the tick transmission.In the present study, we set up a workflow to develop a robust and sensitive SRM assay to detect Borrelia in human skin samples (Fig. 1). First, we looked for Borrelia proteins in infected mouse skin samples by using a classical shotgun/discovery strategy. This experiment afforded a list of bacterial proteins that are expressed in vivo in the skin of an infected mammalian host. Then, we selected protein targets and optimized a Ge-LC-SRM assay to specifically detect and quantify these proteins in mouse skin samples. We demonstrated the transferability of the SRM assay for the detection of the targeted proteins in human skin samples naturally infected with Borrelia. Finally, we improved the experimental protocol to avoid gel prefractionation.Open in a separate windowFig. 1.Summary of the experimental workflow. Experimentally infected mouse skin biopsies were analyzed by a shotgun Ge-LC-MS/MS strategy to identify Borrelia target proteins. Then we developed targeted LC-SRM assays with or without gel prefractionation. Finally, these targeted methods were transferred on tick-infected human skin samples.