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Journal of Clinical Microbiology, March 1998, p. 768-776, Vol. 36, No. 3
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
Molecular Typing of Borrelia burgdorferi
Sensu Lato by Randomly Amplified Polymorphic DNA Fingerprinting
Analysis
Guiqing
Wang,
Alje P.
van Dam,*
Lodewijk
Spanjaard, and
Jacob
Dankert
Department of Medical Microbiology, Academic
Medical Center, University of Amsterdam, Meibergdreef 15, 1105 AZ
Amsterdam, The Netherlands
Received 15 August 1997/Returned for modification 4 November
1997/Accepted 2 December 1997
 |
ABSTRACT |
To study whether pathogenic clusters of Borrelia
burgdorferi sensu lato strains occur, we typed 136 isolates,
cultured from specimens from patients (n = 49) with
various clinical entities and from ticks (n = 83) or
dogs (n = 4) from different geographic regions, by
randomly amplified polymorphic DNA (RAPD) fingerprinting with four
arbitrary primers. The RAPD patterns were reproducible up to the 95%
similarity level as shown in duplicate experiments. In these
experiments the purified DNAs prepared on different days, from
different colonies, and after various passages were used as templates.
With an intergroup difference of 55%, the 136 strains could be divided
into seven genetic clusters. Six clusters comprised and corresponded to
the established species B. burgdorferi sensu stricto
(n = 23), Borrelia garinii
(n = 39), Borrelia afzelii (n = 59), Borrelia japonica
(n = 1), Borrelia valaisiana
(n = 12), and genomic group DN127 (n = 1). One strain from a patient with erythema migrans (EM) did not
belong to any of the species or genomic groups known up to now. The
RAPD types of B. burgdorferi sensu stricto, B. garinii, and B. afzelii isolates, which may give rise
to human Lyme borreliosis (LB), were associated with their geographic
origins. A high degree of genetic diversity was observed among the 39 B. garinii strains, and six subgroups could be recognized.
One of these comprised eight isolates from patients with disseminated
LB only and no tick isolates. B. afzelii strains from
patients with EM or acrodermatitis chronica atrophicans were not
clustered in particular branches. Our study showed that RAPD analysis
is a powerful tool for discriminating different Borrelia species as well as Borrelia isolates within species.
 |
INTRODUCTION |
Lyme borreliosis (LB) is a
tick-borne spirochetal disease endemic to regions in temperate climates
throughout the world (7). The clinical spectrum of LB varies
from cutaneous erythema migrans (EM) to severe arthritis,
acrodermatitis chronica atrophicans (ACA), and cardiac and neurological
manifestations (37). Borrelia burgdorferi sensu
lato (19), the etiologic agent of LB, is genetically divergent. On the basis of DNA-DNA reassociation and the
MseI restriction enzyme patterns of the 5S-23S rRNA
intergenic spacer, B. burgdorferi sensu lato can be divided
into at least 10 different species or genomic groups: B. burgdorferi sensu stricto, B. garinii, B. afzelii (5, 11), B. japonica
(20), B. valaisiana (43), B. lusitaniae (22), B. andersonii
(25), B. tanukii, B. turdi (15,
26), and group DN127 (33). In North America, only
B. burgdorferi sensu stricto, B. andersonii, and
group DN127 have been identified (3, 5, 25), whereas
B. burgdorferi sensu stricto, B. garinii,
B. afzelii, B. valaisiana, and B. lusitaniae have been found in Europe (5, 11, 22, 43).
B. japonica, B. tanukii, and B. turdi
are limited to Japan (15, 20).
Not all strains from these species or genomic groups are pathogenic for
humans. Up to now, only B. burgdorferi sensu stricto, B. garinii, B. afzelii, and group DN127 strains
have been cultured from patients with LB (5, 32). Therefore,
it may be that B. japonica, B. valaisiana,
B. lusitaniae, B. andersonii, B. tanukii, and B. turdi are not pathogenic for humans. In
addition, different species have been associated with distinct clinical
manifestations of LB (4, 5, 11, 41). Arthritis is associated
with B. burgdorferi sensu stricto infection and
neuroborreliosis is associated with B. burgdorferi sensu
stricto and B. garinii infection (4, 41), whereas
B. afzelii has more frequently been cultured from skin
biopsy specimens from patients with EM and ACA (10, 11, 41).
However, it is not clear whether within species certain pathogenic
clusters of strains which are responsible for the particular clinical
syndromes of human LB occur and whether genetically distinguishable clusters causing EM, ACA, or neuroborreliosis can be found.
Randomly amplified polymorphic DNA (RAPD) analysis (46) or
arbitrarily primed PCR (AP-PCR) (44), both of which use
low-stringency PCR amplification with a single primer with an arbitrary
sequence to generate strain-specific arrays of anonymous DNA fragments, has been used for the molecular typing of various microorganisms (39). In two studies, this technique was also used to type
B. burgdorferi, although the procedure, including the use of
radiolabelled nucleotides and analysis of the fragments on large sodium
dodecyl sulfate-urea gels, was complex. In the first study, 29 B. burgdorferi isolates were divided by AP-PCR into three
genospecific groups (45). In the second study, reported
recently, the genetic diversity of 65 B. burgdorferi sensu
stricto strains from various geographic locations in North America and
Europe was also evaluated by AP-PCR (14).
In the present study we simplified and optimized RAPD analysis for the
typing of Borrelia strains. Subsequently, we analyzed 136 B. burgdorferi sensu lato strains by using this method. The objectives of our study were to evaluate the usefulness of RAPD analysis as a molecular typing method for Borrelia strains,
to identify pathogenic clusters of Borrelia strains causing
particular clinical syndromes in patients with LB, and to assess the
geographic diversity within different Borrelia species.
 |
MATERIALS AND METHODS |
Bacterial strains and DNA preparation.
The 136 B. burgdorferi sensu lato strains used in this study are listed in
Table
1.
Forty-nine strains were isolated from human clinical specimens (of
which 20 and 12 were cultured from skin biopsy specimens from patients
with EM and ACA, respectively; 7 were cultured from skin biopsy
specimens from patients with disseminated LB [21]; 9 were cultured from cerebrospinal fluid specimens; and 1 was from a
blood specimen). Of the remaining 87 strains, 83 were isolated from
Ixodes ticks and 4 were isolated from dogs. The origins of
the isolates covered North America, Europe, and Asia. Most of these
strains have previously been typed in our laboratory by reactivity with
monoclonal antibodies and rRNA gene restriction analysis
(41). Strains not included in previous analyses were
identified as belonging to the species listed in Table 1 by
PCR-restriction fragment length polymorphism (RFLP) analysis of the
5S-23S intergenic spacer (33, 43). Strains of B. hermsii and B. anserina were used as controls.
All spirochetal strains were grown in modified Kelly's medium
(34) at 33°C. Three B. burgdorferi strains
(strains A87S, A48T, and UK) were also incubated in solid culture
medium to obtain pure colonies (12). DNA was extracted as
described by Wilson (49), and the concentration of DNA was
determined by spectrophotometry.
RAPD-PCR amplification.
Initially, 16 arbitrary
oligonucleotide primers, synthesized by Perkin-Elmer Applied Biosystems
(Perkin-Elmer, Cheshire, United Kingdom) and available in our
laboratory, were tested for their usefulness for the typing of
Borrelia species. On the basis of the initial experiments,
four primers, primers 1254 (5'-CCGCA GCCAA-3'), 1283 (5'-GCGAT CCCCA-3'), 1247 (5'-AAGAG CCCGT-3') (1), and AP13 (5'-TTGTC TAGTG GCAAG GCT-3'),
were selected and used for the typing of the Borrelia
isolates collected.
RAPD-PCR was performed under a layer of mineral oil in a 25-µl
reaction mixture containing 20 ng of purified DNA, 10 mM Tris-HCl (pH
8.8), 50 mM KCl, 4.0 mM MgCl2, 0.1 mg of bovine serum
albumin per ml, a 200 µM concentration of each deoxynucleotide
triphosphate (Pharmacia Biotech), 1 U of AmpliTaq polymerase
(Perkin-Elmer, Gouda, The Netherlands), and a 0.4 µM concentration of
a single primer (0.8 µM for primer AP13). The PCR was carried out
with a Biometra thermocycler (Westburg B.V., Leusden, The Netherlands) by using the following steps: initial denaturation at 94°C for 2 min,
followed by 3 cycles of 94°C for 5 min, 36°C for 5 min, and 72°C
for 5 min and then 30 cycles of 94°C for 1 min, 36°C for 1 min, and
72°C for 2 min and a final incubation at 72°C for 10 min. Duplicate
experiments with either the same DNA template or DNA extracted on
different days or from different colonies or passages were performed to
assess reproducibility.
RAPD fingerprinting analysis.
The amplified DNA fragments
were separated on 1% (wt/vol) agarose gels (Boehringer, Mannheim,
Germany) containing 10 µg of ethidium bromide per ml in the gel and
in 1× Tris-acetate-EDTA buffer. For each experimental run,
bacteriophage
DNA digested with BstEII and
Neisseria meningitidis ET80 DNA amplified with primer 1254 by the same protocol were included and were used as a size marker for
the amplified fragments and as a reference for the normalization of
different gels, respectively. All pictures were digitized with an Iris
video digitizer and were analyzed with computer software (GelCompar;
Applied Math, Kortrijk, Belgium). The bands with a faint intensity
which were not reproducible in duplicate experiments were excluded in
the final analysis.
For each Borrelia strain, the DNA fingerprinting patterns
obtained with the four primers were combined. These combined patterns were used for the similarity estimation and cluster analysis, in which
the similarity among strains was estimated by means of the Dice
comparison, and the clustering of strains was determined by the
unweighted average pair group method (36) to facilitate the
plotting of the dendrogram. Isolates with a level of similarity of more
than 0.95 were assigned to the same RAPD type.
PCR amplification and sequencing of the 16S rRNA gene.
PCR
amplification and DNA sequencing of the 5' end of the 16S rRNA gene
were performed as described previously (43).
Nucleotide sequence accession numbers.
The partial 16S rRNA
gene sequences which we determined in this study have been assigned the
following GenBank accession numbers: AF010163 (strain A01C), AF010164
(strain A76S), AF010165 (strain A87S), and AF010166 (strain M63). The
accession numbers of the B. burgdorferi sensu lato strains
which we used for comparison are as follows: U03396 (B. burgdorferi B31), D67018 (B. garinii 20047), X85199
(B. garinii PBi), and U78151 (B. afzelii VS461).
 |
RESULTS |
Reproducibility.
In order to assess the reproducibility and
the day-to-day variation of RAPD fingerprinting, we performed PCR
reamplification with 54 of the 136 Borrelia strains. In
these duplicate experiments we used either the same DNA template
(n = 36) or DNA extracted on different occasions
(n = 18). The DNA fingerprints of these strains were
very reproducible. Occasionally, a discrepancy in the appearance of
faint bands was seen. Usually, the intensities of these faint bands
were below the limit for inclusion in the analysis. In addition, second
DNA samples from 10 strains were tested by one of the investigators who
had no knowledge of the origins of these samples. In these analyses,
DNA samples from the same strain showed at least 95% similarity. No
differences were seen between the RAPD patterns for two
Borrelia strains (A38S and A87S) at low passage numbers (5 and 3) and high passage numbers (25 and 27) (data not shown). The RAPD
patterns of four different colonies of strain A48T were identical to
each other, as were the RAPD patterns of 10 different colonies of
strain UK (data not shown). Four colonies of strain A87S were also
highly similar to each other; however, two of these colonies lacked one
band after amplification with primer 1247, leading to a similarity level of 95.8% (Fig. 1).

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FIG. 1.
Reproducibility of RAPD fingerprinting. The DNA
fingerprints from different passages and different colonies of B. garinii A87S were obtained by PCR amplification with primers 1254 (A), 1283 (B), 1247 (C), and AP13 (D). Lanes 1 and 6, passages 3 and
27, respectively; lanes 2 to 5, four different colonies from passage 9, respectively; lane M, BstEII-digested bacteriophage lambda
DNA. The molecular sizes (in kilobases) are indicated on the left.
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RAPD fingerprinting among species.
In the combined gels
obtained after four individual amplifications with different primers,
the DNA fingerprints of Borrelia strains comprised 20 to 35 fragments with sizes ranging from 0.3 to 4.5 kb (Fig.
2). A total of 111 RAPD types, designated
types 1 to 111, were identified for the 136 B. burgdorferi
sensu lato strains (Table 1). The discrimination index of the RAPD
technique calculated by application of the Simpson numerical index of
diversity (18) was 0.996. Phylogenetic analysis showed that
the 136 B. burgdorferi sensu lato strains used in this study
could be divided into seven genetic clusters with an intergroup
difference at least of 55% (Fig. 3). The
RAPD fingerprints for representative strains of these seven clusters
are included in Fig. 2. Clusters I, II, III, IV, and V corresponded to
the well-known species B. burgdorferi sensu stricto
(n = 23), B. garinii (n = 39), B. afzelii (n = 59), B. japonica (n = 1), and B. valaisiana
(n = 12), respectively (5, 11, 20, 43).
Cluster VI included one isolate from Borrelia genomic group
DN127. The seventh cluster, with only one Borrelia isolate
cultured from a sample from a patient in The Netherlands with EM who
developed LB, has not been described previously.

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FIG. 2.
RAPD fingerprints of the representative B. burgdorferi sensu lato strains from different species or genomic
groups (RAPD clusters I to VII) obtained by using four primers as
indicated in the legend to Fig. 1. Lanes 1 to 4, B. burgdorferi sensu stricto strains B31, A91-9, VS215, and A44S,
respectively; lanes 5 to 10, B. garinii subgroup IIa to IIf
strains NT29, PBi, HT55, HT19, M63, and 20047, respectively; lanes 11 to 15, B. afzelii VS461, A38S, A95S, A67T, and A71T,
respectively; lane 16, B. japonica HO14; lanes 17 and 18, B. valaisiana VS116 and M19, respectively; lane 19, Borrelia group DN127 strain 25015; lane 20, Borrelia sp. strain A14S; lanes 21 and 22, B. hermsii and B. anserina, respectively; lane R,
reference for normalization of different gels; lane M,
BstEII-digested bacteriophage lambda DNA. The molecular
sizes (in kilobases) are indicated on the right.
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FIG. 3.
Simplified dendrogram of B. burgdorferi sensu
lato strains. The 136 LB-associated Borrelia strains used in
this study could be divided into seven clusters with an intergroup
difference of 55%. Six of them (clusters I to VI) corresponded to the
indicated established species or genomic groups. One strain (branch
VII) could not be classified into one of the described LB-related
Borrelia species. Isolates from patients are in boldface.
The numbers in parentheses indicate the corresponding RAPD type of each
strain.
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All Borrelia strains from the three pathogenic species
B. burgdorferi sensu stricto, B. garinii, and
B. afzelii presented a 1.84-kb predominant band after
amplification with primer 1254. This band was absent from
Borrelia strains from species which were cultured only from
nonhuman sources.
RAPD fingerprinting within species.
Within the clusters of
B. burgdorferi sensu stricto, B. garinii, and
B. afzelii, a correlation between the geographic origins of
the strains and their RAPD patterns was observed. Among the B. burgdorferi sensu stricto isolates, the European and North American isolates were in different clusters (Fig.
4). B. garinii strains from
various sources exhibited high degrees of genetic diversity. At the
60% similarity level, the 39 B. garinii strains could be
divided into six subgroups. The eight B. garinii isolates from Ixodes persulcatus from the far eastern area of Russia,
Japan, and China clustered into subgroups IIa, IIc, and IId,
respectively, whereas the 30 European isolates from Ixodes
ricinus as well as from patients were clustered into subgroups IIb
and IIf (Fig. 5). Subgroup IIe contained
only one strain, strain M63, which had previously been designated as an
independent genomic group because of its unique rRNA restriction
pattern (29). The majority (95%; 56 of 59) of the B. afzelii strains showed more than 70% identity in their RAPD
fingerprints. However, strain M7C, originating from China (RAPD type
97), was rather different from the other strains, which were isolated
from The Netherlands and Germany. Two other isolates from The
Netherlands (RAPD types 98 and 99) were also distinct from the other
strains (Fig. 6). Some of the B. afzelii tick isolates that had been collected from the same sampling site showed a tendency to cluster. Of the 12 tick isolates from Santpoort, in the dunes in the western part of The Netherlands, 9 clustered together into two groups (RAPD types 50 to 55 and 59 to 61, respectively), but 3 strains were divergent. A similar result was
obtained for 13 tick isolates from a forest in Drenthe, in the northern
part of The Netherlands: 11 isolates grouped into two subclusters (RAPD
types 72 to 77 and 83 to 85, respectively) and 2 were unrelated (Fig.
6).

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FIG. 4.
Dendrogram of B. burgdorferi sensu stricto
strains (n = 23). The Borrelia isolates
derived from North America and Europe clustered into separate
branches.
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FIG. 5.
Dendrogram of B. garinii strains
(n = 39). The asterisks indicate strains from the
cerebrospinal fluid of patients. See the legend to Fig. 3 for more
information.
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FIG. 6.
Dendrogram of B. afzelii strains from
different geographic and biological sources (n = 59).
Tick isolates from two different regions in The Netherlands are
indicated. Isolates from patients with ACA are underlined. Sa
(Santpoort) and Dr (Drenthe) are two geographic regions in the western
and northern parts of The Netherlands, respectively. See the legend to
Fig. 3 for more information.
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RAPD types among isolates from patients.
Of the 49 Borrelia strains from human specimens, 48 were typed by RAPD
analysis as B. burgdorferi sensu stricto (n = 2), B. garinii (n = 16), or B. afzelii (n = 30). These results were consistent with the classification of these strains as designated in Table 1. Only
one strain, strain A14S, could not be classified by RAPD analysis into
any of the six LB-related species or genomic groups included in this
study. This strain also had a quite remarkable PCR-RFLP pattern:
instead of a 246- to 255-bp fragment, a fragment of 225 bp was
amplified. Digestion of this fragment with MseI resulted in
a unique pattern, which was designated pattern R (Table 1). This
pattern was not consistent with any pattern produced by the 10 LB-related Borrelia species or genomic groups identified up
to now (unpublished data). The 16 B. garinii strains, which were all isolated from patients with extracutaneous syndromes, were
found in subgroups IIb and IIf. Isolates from human skin biopsy
specimens and cerebrospinal fluid were evenly distributed among both
subgroups. Interestingly, subgroup IIb included only eight isolates
from patients with disseminated LB and showed little heterogeneity.
Isolates from both humans and ticks were found in subgroup IIf, with no
particular clustering for the isolates from humans. For B. afzelii, isolates from patients (n = 30) did not
differ from those from ticks (n = 29). Furthermore, no
significant subcluster was found among isolates recovered from patients
with EM (n = 18) and ACA (n = 12).
Further characterization of B. garinii subgroup
IIb.
Since B. garinii subgroup IIb only contained
isolates from humans, further characterization of this subgroup was
performed by sequence analysis of the 16S rRNA gene. Partial 16S rRNA
gene analysis of three isolates in this subgroup (isolates PBi, A01C, and A76S) showed the two conserved nucleotide substitutions at positions 469 and 635 (B. burgdorferi B31 numbering)
(17) in comparison to the B. garinii consensus
sequences (24) and to sequences from B. burgdorferi sensu stricto and B. afzelii, confirming that strains in this subgroup are genetically distinct from other B. garinii strains.
 |
DISCUSSION |
RAPD analysis has been used with increasing frequency as a method
for the molecular typing and genetic characterization of various
microorganisms (38, 39). However, considerable attention is
directed to its reliability and reproducibility, since many studies
have indicated that various factors can affect the results of RAPD
fingerprinting (8, 28, 38, 40). In our experiments, optimal
RAPD fingerprinting was found with the four primers that we selected
and purified DNA. With these four different primers, the
reproducibility of the RAPD fingerprints for a random subset of 54 of
the 136 isolates was up to at least a 95% level of similarity. The
number of passages did not affect the results of RAPD analysis. However, PCR amplification of different colonies of one strain resulted
in a difference of one band, amplified by one of the primers. This band
was absent from two colonies and was present in two other colonies.
Whether this difference is caused by the presence of a mixed population
of two related strains or by colonial variation within one strain must
be elucidated. Since these RAPD fingerprints from different colonies
still showed more than 95% similarity to each other and belonged to
the same RAPD type according to our definition, we concluded that RAPD
analysis is an appropriate method for the typing of uncloned
Borrelia strains.
By RAPD fingerprinting 135 of the 136 B. burgdorferi sensu
lato strains used in this study could be grouped into six different species or genomic groups. This result was consistent with our classification of these strains on the basis of rRNA gene restriction analysis (41) or PCR-RFLP. One strain, strain A14S, could
not be classified into one of the six species or genomic groups
included in this study and also had a highly divergent PCR-RFLP
pattern. This strain has pathogenic potential, since it was originally isolated from a patient with EM.
In our study, strains belonging to the same species but originating
from different geographical regions clustered into separate branches by
RAPD analysis. Regarding B. burgdorferi sensu stricto, North
American and European strains fell into separate subgroups. With the
exception of one B. garinii strain, B. garinii
strains from Europe clustered into two major subbranches. All eight
B. garinii strains from far east Asia were clearly different
from the European strains included in these two major subbranches. Among the B. afzelii strains, the heterogeneity was limited.
Only 2 of the 56 Dutch strains and the one Chinese strain tested were more divergent than the majority of the Dutch strains. Since only one
Chinese strain was studied, more strains from Asia should be typed by
RAPD fingerprinting before a conclusion can be drawn as to whether
B. afzelii strains from European and Asian sources differ.
Regional differences among North American B. burgdorferi sensu stricto strains were also found with the use of pulsed-field gel
electrophoresis and sequence analysis (27). Another recent study in which pulsed-field gel electrophoresis as well as the AP-PCR
technique was used showed that B. burgdorferi sensu stricto strains could be subdivided into a number of subgroups, generally consisting of only North American or only European strains
(14); however, a few North American strains, including
strain B31, clustered with the European strains and vice versa. In
contrast, in our study B31 clustered only with North American strains.
Since Foretz et al. (14) studied different European and
North American isolates, this may partly account for differences
between the studies.
B. afzelii strains grown from ticks collected in a limited
area were often quite similar to each other, although we also found some exceptions. This is in accordance with the assumption that the
migration rate of the vectors of B. afzelii, presumably
being ticks and rodents, is rather low. It would be interesting to
study a large collection of B. garinii strains in the same
way, since birds are thought to be involved in the transmission of
these spirochete species (9), and much more diversity of the
strains within one area may occur because of this route of
transmission.
Among the B. garinii strains, one cluster of eight strains
(subgroup IIb) consisted only of isolates from humans. The strains were
closely related to each other and were markedly different from the
other B. garinii strains tested. The three subgroup IIb strains for which 16S rRNA gene sequencing was performed differed from
the other B. garinii strains. All eight isolates in subgroup IIb originated from patients with disseminated disease. In another study, we showed that these strains all belonged to OspA type 4, as
defined by Wilske et al. (47), and that they were resistant to the activity of normal human serum, in contrast to other B. garinii strains (42). Interestingly, these type 4 B. garinii strains have only been recovered from human
specimens until now (48), and therefore, they may have an
increased pathogenic potential.
The RAPD patterns of B. afzelii strains from ticks and
humans were randomly distributed. In addition, strains from patients with ACA were not different from strains from patients with EM. This is
in accordance with a recent study in which pulsed-field gel
electrophoresis analysis of strains from patients with EM or ACA did
not reveal differences between these groups (10). Therefore,
those B. afzelii strains causing ACA have minor differences in their genomes in comparison with other B. afzelii
strains. Alternatively, the persistence of these spirochetes, resulting in ACA, may mainly be determined by host factors.
In conclusion, RAPD analysis is a reliable technique for identifying
the different Borrelia species, as well as for
discriminating between strains within Borrelia species.
Further use of this technique may lead to more information about the
pathways of the geographic spread of the spirochetes. In addition, if
more pathogenic subgroups exist, these may also be identified by this
technique, which can be easily and rapidly performed after the
isolation of a Borrelia strain.
 |
ACKNOWLEDGMENTS |
We thank S. J. Cutler (London, England), R. de Boer
(Amsterdam, The Netherlands), M. Fukunaga (Fukuyama, Japan), O. Péter (Sion, Switzerland), S. G. T. Rijpkema
(Bilthoven, The Netherlands), B. Wilske (Munich, Germany), and Z. F. Zhang (Beijing, People's Republic of China) for supplying
Borrelia strains. We also thank A. Oei for technical
assistance, A. van der Ende and I. Schuurman for help in the
development of RAPD analysis, and W. van Est for photography.
 |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Medical Microbiology, Academic Medical Center, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands. Phone: 31 20 566 4863. Fax:
31 20 697 9271. E-mail:
A.P.vanDam{at}amc.uva.nl.
 |
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