Could a urine test to detect cancer biomarkers help drive new breakthroughs in Lyme disease diagnostics? Driven by her family’s experience with Lyme disease, a high school intern posed that question to a George Mason University lab. Now, the team is one of 10 Phase 1 winners that have advanced to Phase 2 of the LymeX Diagnostics Prize, a prize competition to accelerate the development of Lyme disease diagnostics.

Through September 2023, the Phase 2 cohort is participating in a virtual accelerator designed to help them refine their concepts for detecting active Lyme disease infections in people. The goal of the multiphase LymeX Innovation Accelerator (LymeX) competition is to nurture the development of diagnostics toward Food and Drug Administration (FDA) review.

We spoke with George Mason University’s Dr. Alessandra Luchini and Dr. Lance Liotta to understand how their test could utilize the unique benefits of urine diagnostics, identify new biomarkers for key insights into disease progression, and improve ease of testing for patients.

You’re tackling a biofluid not everyone thinks of when it comes to Lyme disease diagnostics: urine. What insights have you discovered, and how have you applied them to your concept for a Lyme disease test?
Luchini: “Urine is a fluid that has a lot of advantages versus analyzing serum. It’s non-invasive, simpler from the analytical point of view, and physiologically integrates the molecular information in the blood.

Liotta: “Data from our clinical studies shows that our test can pick up Lyme disease even at the time—or even maybe before—a rash develops after a tick bite, because you immediately see products of the Borrelia burgdorferi [the bacteria most commonly responsible for Lyme disease] in the urine.

Blood is constantly circulating through the kidneys. In the several hours of time between urination, you’ve gotten an integration of diagnostic information. We’ve previously shown that markers for other infectious diseases like tuberculosis, Chagas disease, or even drugs of abuse are in higher concentration in the urine.

There’s hardly any B. burgdorferi that you can see in the blood after infection. We look at urine proteins because one B. burgdorferi can make thousands and thousands of proteins. So it’s a built-in amplification. The type of markers that we look at tell you what metabolism the B. burgdorferi is using, whether it’s living, dying, whether it’s active, or whether it’s maybe even resisting the immune system.”

With an estimated 476,000 Americans diagnosed and treated for Lyme disease each year, ensuring widespread availability of future diagnostics will be critical to expanding access to treatment. How will the patient of the future take your test?
Liotta: “The goal is to have the patient collect their urine at home in our collapsible urine collection cup. So they do not have to send in a liquid cup of urine; they urinate into this special cup, dump it out, collapse it, and put it in the mail in an envelope and send it to the lab. And then we can assay it for different types of tick-borne disease.”

Luchini: “After discarding the liquid part of the urine, the collapsed cup only carries the urine’s molecular or bacterial content. This cup will address the issue of collecting the samples at home and then shipping them to a central lab without the requirement of the cold chain. The cup will also eliminate the necessity of storing large volumes of urine, which is currently one of the main obstacles for including urine in biospecimen repositories. 

We are interested in streamlining the test and offering the test to as many patients as possible—with an emphasis on dark-skinned individuals—in collaboration with clinics that are here managed by the university.”

Liotta: “We’re meeting with a local clinic that serves immigrants and underserved populations. They provide care to many outdoor workers who are at higher risk of getting tick bites. Workers who have a dark skin tone are less likely to be screened for tick bites, and are at higher risk of late diagnosis, delayed treatment, and progression to disseminated disease. Skin manifestations are one of the main clinical signs used to diagnose Lyme disease, and US physicians are insufficiently trained to recognize dermatological manifestations in patients with black or dark skin tones because of dark skinned patients’ under-representation in medical books. The local clinic thinks that they have hundreds of patients a month who are worried about catching tick-borne diseases. We’re going to be doing surveillance with our methodology using these patient samples.”

The LymeX Diagnostics Prize uses an open innovation structure to accelerate diagnostics development and stimulate the market. Unlike a grant, this model allows the competition to offer cash prizes alongside a range of non-monetary resources—as you’re experiencing now in the Phase 2 virtual accelerator. What has been most helpful to your team?
Luchini: “It’s been a great opportunity and my colleagues and I are extremely honored to be part of this selected number of teams. What we appreciated very much was the personal interaction with subject matter experts and the LymeX team. The scientific conversation on the feedback that the judges had was extremely interesting and very helpful. 

One aspect that is different from another HHS or NIH grant is that there is a personal relationship with the program. And it’s been very helpful. And then we had the chance to have very targeted, one-on-one focus conversations with internationally renowned Lyme scientists. We are in the very beginning, but we had the chance to speak to experts on issues with biobanking—urine being a biofluid that is not commonly used in biorepositories because there is a lot of it.”

The genome of Borrelia burgdorferi has been described as the most complex of all bacteria, and developing direct diagnostic tests is extremely difficult. What is keeping you excited as you look to the months ahead?
Luchini: B. burgdorferi certainly has a very interesting and unique way of escaping the immune response. And then from the very beginning of the interaction with the human host, once it overcomes the immune response of the skin, then it goes into the lymph node. And in the lymph node—again, not much is known—but it appears to even destroy the architecture of the lymph node. Therefore, the Lyme bacterium has a very impactful effect on the immune response of the patient. And then it disseminates and it hides in immunological sanctuaries.

Once we have a good diagnostic test to know that we have B. burgdorferi, how are we going to treat it? Once the bacterium is hidden in body sites that are so hard to reach, how are we going to be able to approach that? And so there are so many challenges that are still open with B. burgdorferi. And then of course it’s an organism that is extremely hard to culture, so the staple of the microbiology diagnostic is very hard to accomplish. Thus, it is a very stimulating topic, both from the diagnostic and the research points of view.”

Your concept was inspired by prior work in cancer diagnostics. With so much left to uncover about Lyme disease, how could your findings help address Lyme disease treatment?
Luchini: “Lyme disease is largely unknown. What we are learning from the many patient samples is that we almost have a chance to eavesdrop on what’s going on in the body at the molecular level. So we have now studied and sequenced almost 300 proteins that derive from B. burgdorferi and which we see in the urine of patients. And these proteins are involved in many physiological functions for B. burgdorferi—cell wall remodeling, metabolism, phospholipids metabolisms. And this can become information about metabolic weaknesses for B. burgdorferi and in the future become useful for creating new targets, like drug targets for new therapies. They can also be useful to study from the immunological point of view for new vaccines.”

Liotta: “The specificity and the functional information that we get from this test is why we think it’s hopefully going to be very effective to help individuals and design treatments—and maybe even new vaccines or drug strategies too.

The approach we’re currently working on is capable of identifying and detecting many strains of B. burgdorferi and many species, including U.S. species, European species, and worldwide species. So we can detect all pathogenic Borrelia species for which we have a database.”

Looking ahead: Expert judging panel to convene in October 2023

Following the accelerator, the cohort will submit concept papers that detail solution refinement, clinical and patient input, and a roadmap from lab to market. The competition judging panel—composed of experts across biology, clinical and technology translation, patient experience and advocacy, diagnostic science and technology, exponential innovation, and ethics—will evaluate eligible submissions according to official Phase 2 evaluation criteria. Based on the judges’ evaluations, the panel will recommend up to five Phase 2 winners of the LymeX Diagnostics Prize.

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