Guidelines for Diagnosis and Treatment German Borreliosis So

Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
Cobwebby
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Cobwebby » Fri 5 Oct 2012 20:17

Well-beginning at the beginning - I see the first challenge as:
Challenge to Lab Diagnostic Test Requirement--Page 1090 :“Diagnostic testing performed in laboratories with excellent quality-control procedures is required for confirmation of extracutaneous Lyme disease….”
In my case, fortunately I was positive as tested by a mainstream (in the US) lab through QUEST.
However, when I spoke to our pediatrician at the time about having my daughter tested by Igenex she called it a 'rogue lab'. To my knowledge , Igenex does have excellent quality controlled procedures-yet mainstream dr.s consider it bogus.
Of course the real challenge is to the necessity of lab confirmation.

edited to erase too many beginnings.
Also to add that several other hard hitting diseases, such as Alzheimers, Parkinsons, Crohn's, IBD, are diagnosed clinically .Clinical diagnosis of Lyme Disease gets no respect.
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Lorima
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Lorima » Sat 6 Oct 2012 18:14

Yes, testing is key. The IDSA language about "laboratories with excellent quality-control procedures" is code for the two-tier test interpreted by CDC criteria (= Steere/Dressler 5 band criteria). In real life, one needs both IgG and IgM, with ALL BANDS REPORTED. These can be obtained from one of the specialty labs such as Igenex, which I agree is good. But if I thought I'd need to argue with someone who wouldn't accept a test from one of the specialty labs, I'd get it from State University of New York at Stoneybrook. They will report all bands, though only ON REQUEST. Of course, even with a blot from Stoneybrook, IDSA followers will still say it's invalid unless it uses all their interpretation criteria, including the Dressler 5 band standard, and the discounting of IgM entirely in disease later than a month.

The DBG guidelines don't say anything about the importance of getting all bands reported (maybe they don't censor the bands, in Germany). The DBG does give the essential information as to which bands are specific for Bb, and which are not. (Is it too much to ask that a doctor use that table to judge whether his patient is likely to have a Bb infection? Maybe radicale or Dr. MacDonald could say.)

In sum, the DBG advice sounds right to me:
http://www.borreliose-gesellschaft.de/T ... elines.pdf

2.5.2 Borrelia serology

Borrelia serology is the basic diagnostic tool to answer the question whether a Borrelia infection might be present.

The test systems on the market (ELISA, immunoblotting) are not standardised. Therefore, findings from different laboratories can be compared to only a limited degree. Testing for the presence of Borrelia-specific antibodies is possible only with an immunoblot. If a Borrelia infection is suspected, an IgG and IgM immunoblot for Borrelia should be carried out in all cases. The request note to the laboratory must therefore state the request for:

Borrelia serology inc. immunoblotting for Borrelia

In addition, the clinical diagnosis or suspected diagnosis (CD or SD) at least should be given: Lyme borreliosis.
The procedure recommended by the Robert Koch Institute (RKI) and prescribed by the Association of Health Insurance Funds [Kassenärztliche Vereinigung (KV)], to conduct immunoblotting as well as a confirmatory test only if the ELISA is abnormal (or other so-called exploratory tests) (a process known as stepwise diagnostics), must be rejected because this leads to serologically false-negative results in up to a further 15% of patients.(7/81/154) The reason for this is that the antigen spectrum present in the immunoblot (see Table 1) is usually not identical to that included in the (ELISA) exploratory test. An ELISA and an immunoblot for Borrelia are two different test methods which can yield differing results in the individual case, even though they correlate with each other to a high degree.(131)

Image


A negative serological finding does not rule out Lyme borreliosis.(7/115/118/154) There may be a disease requiring treatment even without the detection of antibodies. (Causes: e. g. antibiotic treatment starting early but inadequate with immunodepressants, including cortisone, exhaustion of the immune system, masking of the causative agents, genetic disposition.)

A positive serological finding means that the patient has acquired a Borrelia infection at some point in time. With a single serological test it is not possible to decide whether this infection is active or latent; at best this can be decided by the attending physician on the basis of its clinical development. It is not within the remit of a laboratory physician to evaluate a positive finding as a “serological relic” i.e. antibodies evidential of an earlier infection.

2.5.3 Examination of the CSF
Diagnostic testing of the CSF is indicated in cases of acute inflammation of the nervous system:

• meningitis, meningo-encephalitis, encephalomyelitis, acute encephalitis,
• acute meningoradiculitis (Bannwarth’s syndrome),(88) Guillain-Barré syndrome,
• cerebral vasculitis, myelitis,
• neuritis of cranial nerves (especially facial nerve paresis),
• acute polyneuropathy.

Testing of the CSF is not indicated in the following disease states in relation to Lyme neuroborreliosis, because pathological results are not to be expected:

• encephalopathy in chronic Lyme borreliosis,
• chronic polyneuropathy in the late stage,(66)
• cerebro-organic psychosyndrome.(44/78/82/90)


Pleocytosis (cell count over 5/μL), elevated protein level and evidence of the intrathecal synthesis of Borrelia-specific antibodies (serum/CSF ratio) are indications of acute neuroborreliosis.

However, if the neuroborreliosis occurs very soon after Borrelia infection and with late manifestations, Borrelia-specific antibodies will be absent from both the serum and the CSF or will appear sooner in the CSF than in the serum and vice versa.
"I have to understand the world, you see."
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duncan
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by duncan » Sat 6 Oct 2012 19:09

Hmmm...The DBG bands (IgG) differ a bit from those specified by the CDC. For instance, bands 28,30 and 45, which are on the CDC's list, are not on the one Lorima was kind enough to post above from the DBG. Is that because different types of Bb are involved, or is this indicative of differing opinions between the two bodies as to which bands are significant?

X-member
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by X-member » Sun 7 Oct 2012 1:58

Maybe Eucalb can give us some answers.

http://www.eucalb.com/

A quote (from "Tests in use"):
Immunoblot, also known as Western blot, which should have a specificity of at least 95%, is important in the characterisation of immune responses to specific Borrelia burgdorferi s.l. proteins and is generally used in a two-test procedure, the first test of which is a sensitive assay such as ELISA or IFA. Currently, the interpretation criteria of Engstrom et al., (J. Clin. Microbiol. 1995, 33 419) are recommended for IgM blots and those of Dressler et al., (J. Infect. Dis. 1993, 167 392) for IgG. These rules, however, are not universally applicable to immunoblots across Europe. Interpretation criteria depend on the strain or species used as source of antigen (Hauser et al., J. Clin. Microbiol 1997 35 1433) and it is necessary to characterise diagnostic antigens with monoclonal antibodies for proper subsequent identification of immunoblot bands.

Standardisation of criteria for interpretation of immunoblot in Europe was the subject of a study by EUCALB (Robertson et al.,2000, J. Clin. Microbiol, 38, 2097-2102). This multicentre study, involving six European laboratories using different immunoblot protocols, identified eight bands that were discriminatory in all the laboratories, though with variations in significance. From these bands, five closely related European rules were formulated giving acceptable sensitivity and specificity though there was no single rule that could be applied in all laboratories. This panel of European rules provides a framework for immunoblot interpretation that may be adapted in relation to the characteristics of LB in local areas.

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panda
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by panda » Sun 7 Oct 2012 2:21

Concerning band criteria in immunoblot

@ Lorima, duncan

In earlier years (eighties, beginning nineties) the serological test-kits in Germany and other European countries were composed mostly as the US model; the antigen spectrum in IFT, EIA, ELISA and various blots was very limited and contained the American strain B31 of Bbss, although other strains are prevalent here, with local shifts.

The majority of infections are caused by B. afzelii and B. garinii, as far as we know today. Beyond this, there is an increasing number of other human pathogen species, for example B. spielmanii, B. bavariensis, B. valaisiana, B. lusitaniae, and B. bissetti. All these species show a great genetic diversity, splitting into various strains, OspA-serotypes, genotypes.

Since 2005 there exists a German Industrial Standard (DIN 58969-44): “Medical microbiology – Diagnostics of infectious diseases in serology and molecular biology – Part 44: Immunoblot (IB); Special requirements for the detection of antibodies against Borrelia burgdorferi”. Test manufacturer are required to meet these norms.

In spite of the multiple human pathogen species and strains it is possible to use only one strain; this could also be the American strain B31. It is recommended to use a B. afzelii-strain in Germany. “An antigen preparation for IB shall either contain diagnostically relevant protein antigens of one strain of Borrelia burgdorferi or of more than one strain in order to demonstrate such a high antigenic homology to native Borrelia strains prevalent in the area of testing assuring that Borrelia infections will be detected with a high degree of sensitivity. For example, the B. afzelii strain pKo is suited as an antigen in Germany.” (DIN 58969-44)

So, many test-kits contain antigens of only one species which is not typical for the area of infection. To test against a greater number of species there is a need to prepare a greater number of antigens for the test-kit. Therefore here are used less bands, but only those which are considered highly specific.

“A minimum of the following antigens shall be contained in the antigen preparation for IB: p83/p100, p58, p39, OspC, DbpA=Osp17. Additionally, whole-cell lysate-blot shall contain p41, p30, and p21, for recombinant blot: truncated p41 (p41int). VlsE may replace this, or it may be used in addition.” (DIN 58969-44)

The minimum of tested bands are the five mentioned ones. And the test is valuated positive if two of the highly specific bands are visible.

Most test-kits capture only one species of Borrelia burgdorferi s.l., better ones the three universally known B. burgdorferi sensu stricto, B. afzelii, and B. garinii. Rarely also B. spielmanii antibodies are tested, for example: http://www.mikrogen.de/uploads/tx_oemik ... IRLBBE.pdf
But this is a matter of money, not of science.

Of course, other bands could be specific, in a less intensity, compare the table here:
http://www.laborlexikon.de/Lexikon/Tabe ... n-Blot.htm


I am sorry that I cannot provide the whole DIN-text because of copyright, one has to buy it.

http://www.named.din.de/cmd?level=tpl-a ... guageid=en

http://www.en-standard.eu/de/din-58969- ... rgdorferi/


Best wishes,
Panda

Lorima
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by Lorima » Sun 7 Oct 2012 4:53

Thanks Carina and Panda!

With regard to thinking about which bands are specific,
the link Panda gave, http://www.laborlexikon.de/Lexikon/Tabe ... n-Blot.htm
is nice. See the third column, with the plus signs. More plus signs means "more specific".

I was digging through the Steere literature to find out where the CDC got its particular list of 10 bands, and while I was at it I found something interesting which I hadn't noticed: in 2010, he published at least two papers saying that the CDC's stricture against using IgM blots in infections of greater than one month, has been leaving as many as 33% of acute neuritis and carditis Lyme patients with disease of 5-16 weeks duration undiagnosed, because they don't (yet) have 5 bands on IgG, and their IgMs are disallowed by CDC criteria. See http://cid.oxfordjournals.org/content/50/1/20.full.pdf :
Approximately two-thirds of patients with acute neuroborreliosis or carditis (stage 2 LD), who had been symptomatic for 1–16 weeks, were seropositive by 2-tiered testing, but positivity still depended largely on IgM results. Of the
27 patients with stage 2 LD, 16 (59%) had a positive IgM blot only, 9 (33%) had both positive IgM and IgG blots, 1 (4%) had only a positive IgG blot, and 1 (4%), a patient with EM and facial palsy, had neither a positive IgM nor a positive IgG blot. However, 9 of the 16 patients who had only a positive IgM blot were considered negative by 2-tiered criteria, because they had been ill >1 month (5–16 weeks) at the time of collection of serum samples. Even though they did not yet have the 5 bands required for a positive IgG blot, both their IgM and IgG blots typically showed reactivity with the 23-kD, 39- kD, and 41-kD spirochetal proteins, which are common early responses.
Stage 2 LD is "neuritis or carditis". So these patients have extracutaneous Lyme disease, and are "required" to have a positive CDC two-tier test to be diagnosed and treated, according to IDSA guidelines. But they don't, so they can't. Scary. Around here, that's the law. The CDC says follow the steps, and that's what they do, as if they're following a checklist.

Here's my go-to figure for remembering specificity of Lyme Western blot bands. It's from the US, so not strictly applicable to Europe, but I appreciate its simplicity. See the bar graph here:

http://www.ncbi.nlm.nih.gov/pmc/article ... 62/?page=4

Best wishes, Lorima

PS: Carina, I'm starting to look at EUCALB material. Later 8-)
"I have to understand the world, you see."
Richard Feynman

duncan
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by duncan » Sun 7 Oct 2012 13:14

Thank you, Carina, panda, and Lorima.

Can you believe I think I have numbers that aren't on one of those lists? :) I must have goofed; I will have to go double check this.

Lorima, I have confidence that apparent contradictions will not deter the evangelism of either the CDC or IDSA.

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panda
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by panda » Thu 11 Oct 2012 0:11

Found another one for the US:
Westernblot_USA.jpg
Maiella 2012
Westernblot_USA.jpg (152.45 KiB) Viewed 2005 times
http://www.valleynaturopathicfamilymedi ... n-2012.ppt

ChuckG
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by ChuckG » Thu 11 Oct 2012 3:11

panda

Ma (1992) used a combined IgG/IgM blot
DISCUSSION
A visually distinguishable band pattern in our Western blot was achieved by use of a nonradioactive alkaline phosphatase-conjugated goat anti-human IgG-IgM antibody.
The protein bands regularly detected by 186 serum samples from patients with Lyme borreliosis were those with the molecular masses of 94, 83, 75, 66, 60, 55, 46, 41, 39, 34, 31, 29, 22, and 17 kDa (Fig. 3).
What the chart shows is IGeneX . Can't find the whole article now.

Comparison of specificity and sensitivity of IGeneX Lyme Western Blots using IGeneX criteria and CDC criteria for a positive Western Blot
Townsend Letter for Doctors and Patients, April, 2007 by Jyotsna S. Shah, Iris Du Cruz, Danuta Wronska, Steven Harris, Nick S. Harris

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panda
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Re: Guidelines for Diagnosis and Treatment German Borreliosi

Post by panda » Thu 11 Oct 2012 4:50

Thank you Chuck!

http://www.highbeam.com/doc/1G1-162234812.html
Shah et al., Comparison of specificity and sensitivity of IGeneX Lyme Western Blots using IGeneX criteria and CDC criteria for a positive Western Blot.(confirmed Lyme disease ),
Townsend Letter: The Examiner of Alternative Medicine, April 1, 2007:
We evaluated the antibody response of an in-house developed Western Blot (WB) assay prepared using two strains of Borrelia burgdorferi for 37 sera from patients with confirmed Lyme disease drawn between 21 days and 13 years after initial diagnosis, 45 sera from patients with tick-borne diseases other than Lyme disease, and 60 sera from patients who were negative for tick-borne diseases. For IgG, the following bands were graded--18, 23-25, 28, 30, 31, 34, 39, 41, 45, 58, 66, and 83-93 kDa bands. For IgM, bands 23-25, 31, 34, 39, 41, and 83-93 kDa were graded. Western Blots were scored as positive or negative as per CDC and IGeneX criteria. The IGeneX criteria for IgG and/or IgM WB positivity for Lyme disease is based on the recognition of two of the following bands: 23-25, 31, 34, 39, 41, and 83-93 kDa.

Also in Australia the IGeneX Western Blot is used, comparing with CDC criteria:
http://www.asid.net.au/images/PDFs/Post ... ic%201.pdf fig. 1-3

Best wishes,
Panda

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