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From CDC Expert Commentary
Testing for Lyme Disease: Follow the Steps
Barbara J.B. Johnson, PhD
Authors and Disclosures
Hello, I am Dr. Barbara Johnson. I am a microbiologist with the Centers for Disease Control and Prevention, and I am pleased to speak with you today as part of the CDC Expert Commentary Series on Medscape about serologic testing for Lyme disease. Serology is currently the only type of diagnostic test for Lyme disease approved by the US Food and Drug Administration.
Serologic tests are designed to detect antibodies that the immune system makes in response to an infectious organism, in this case the spirochete Borrelia burgdorferi. Before testing a patient for Lyme disease, it is important to consider the likelihood that a patient is infected. Factors to consider are:
Symptoms: Does the patient have signs and symptoms consistent with the disease?
Geography: Has the patient been in an area where the disease occurs?
Behaviors: Does the patient have risk factors for exposure to ticks?
If you decide there is a reasonable chance that your patient has Lyme disease, serologic testing may be helpful. Remember, however, that it can take several weeks after infection for a serologic test to become positive. This means that patients with early stages of Lyme disease, such as erythema migrans, may have a negative serologic test when first seen. For this reason, it is recommended that such patients be diagnosed and treated immediately, without serologic testing. In contrast, patients who have been ill for 4 weeks or longer will almost always have antibodies, if infected. Consequently, serologic testing is very useful for diagnosing patients with later stages of disease, such as Lyme arthritis.
When testing for antibodies for Lyme disease, CDC recommends a 2-step testing process. In the first step, serum is tested using a highly sensitive but inadequately specific quantitative assay, most commonly an enzyme immunoassay, such as an ELISA. If this first test is negative, no further testing is indicated. If the first test is positive or indeterminate (also called "equivocal" or "borderline"), a second-step test should be performed.
In the second step, serum is tested by immunoblotting, either with Western or striped blots, to identify IgM and IgG antibodies against several different B. burgdorferi antigens. Some of these antigens are recognized by antibodies to other common organisms, so even uninfected patients will usually have at least 1 reactive band. The important issue is the number of bands. To be considered positive, the serum should react with at least 5 of 10 scored bands on the IgG assay and with 2 of 3 scored bands on the IgM assay.
Two important caveats:
Do not skip steps in the 2-step process. Skipping steps, for example performing a Western blot alone, increases the chances of a false-positive result. The higher false-positive rate has ranged from 1.5%-8%, depending on the population studied.
A positive IgM immunoblot is only meaningful during the first 4-6 weeks of illness. After that time, an infected patient should have a positive IgG immunoblot as well. If they don't, it strongly suggests that the IgM result is a false positive.
Unfortunately, there is a lot of misinformation about Lyme disease testing, most notably that the first-step tests are insensitive. This myth is based on tests that are no longer in use and inappropriately expecting positive results for patients who are in the early stages of infection, for whom serologic testing is not recommended. In truth, first-tier tests for Lyme disease are quite sensitive -- sensitive enough to react in some patients with other spirochetal diseases, such as tick-borne relapsing fever, syphilis, or leptospirosis, as well as with other infectious and noninfectious conditions.
For more information about Lyme disease, the geographic areas of risk, and appropriate laboratory testing procedures, please consult the CDC Website list below. Thank you.
Aguero-Rosenfeld ME, Wang G, Schwartz I, Wormser GP. Diagnosis of Lyme borreliosis. Clin Microbiol Rev. 2005;18:484-509.
CDC. Lyme Disease
CDC. Lyme Disease: Laboratory Testing
CDC. Notice to readers: caution regarding testing for Lyme disease. MMWR Morb Mortal Wkly Rep. 2005;54:125.
CDC. Notice to readers: recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR Morb Mortal Wkly Rep.1995;44:590-591.
Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43:1089-1134.
United Kingdom Health Protection Agency. Diagnosis and Treatment of Lyme borreliosis.
Barbara J. B. Johnson, PhD, is a supervisory research microbiologist with the US Centers for Disease Control and Prevention, Division of Vector-Borne Diseases, in Fort Collins, Colorado. She conducts research to improve the laboratory diagnosis of Lyme disease and other tick-borne illnesses, prevent Lyme disease by vaccination, and understand the pathogenesis of Borrelia burgdorferi infection. Dr. Johnson holds a doctoral degree in biochemistry from the University of Wisconsin, Madison.
Once again, the emphasis is on how to avoid, and deal with, false positive test results. No mention whatsoever is made about even the potential for false negative test results and any possible reasons for them.
My hypothetical question is this:
If a patient has had a known tick exposure and subsequently develops classic signs of Lyme disease, but only 4 out of the 5 required bands show up on a Western Blot IgG, where does that leave the patient and his or her doctor?
I think this question is especially difficult to answer when a physician has exercised due diligence and already ruled out other possible causes for that patient's ill health as part of a complete diagnostic work-up. Based on the CDC's stringent requirements (that were initially intended for surveillance purposes, but are now apparently also being used for diagnostic purposes), that person would NOT have Lyme disease and theoretically wouldn't qualify for any kind of treatment.
Maybe it's just me, but I think it would be entirely reasonable to treat that patient as if he or she had Lyme disease just to be on the safe side. What if -- as has been shown in a recently published European article -- that patient's antibody levels are in flux? At the very least, I think repeat testing would be warranted.
Also, does every species/strain of Borrelia react the same on a Western Blot test? Something tells me they might not. If that's the case, how is any doctor expected to recognize a potentially new/mutated strain of Lyme disease through current testing methods? I'm guessing the short answer is "They aren't".