Lab
Lyme Titer
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Lyme Titer
, Lyme Disease Antibody, Lyme Borreliosis Antibody, Lyme ELISA, Lyme Western Blot
Indications
Endemic area with classic lyme symptoms and signs
Endemic area with non-specific symptoms >2 weeks
No test needed if highly endemic area and classic signs
Treat empirically if high pretest probablity
Erythema Migrans
in endemic area is diagnostic
Titers are insensitive for
Lyme Disease
in <2 weeks
Precautions
Information based on IDSA and CDC guidelines
IDSA: Infectious Disease Society of America
IDSA is considered standard of care recommendations
Tertiary centers (e.g. Mayo) follow these guidelines
Other guidelines (e.g. ILADS) are not reviewed here
ILADS: International Lyme and Associated Diseases
ILADS guidelines are considered controversial
Mechanism
Borrelia Burgdorferi
Antibody
Lyme IgM
Present within 1-3 weeks after disease onset
Peaks between 3 and 6 weeks
Presence represents
Early
Lyme Disease
Persists in prolonged
Lyme Disease
Reappears in Late
Lyme Disease
exacerbation
Lyme Specific IgG
Requires more than 3 weeks to develop
Peaks months after disease onset
Efficacy
Test Sensitivity
(two tiered testing)
Timing in relation to
Erythema Migrans
rash
Acute
Erythema Migrans
rash: 30-40% seropositive
Two to four weeks after
Erythema Migrans
: 60-70% seropositive
Six weeks after
Erythema Migrans
: 90% seropositive
Timing in relation to Lyme phase
Stage 1: Early localized
Acute phase: 17% seropositive
Convalescent: 53% seropositive
Stage 2: Early disseminated
Multiple
Erythema Migrans
lesions: 43% seropositive
Cardiac or neurologic findings: 100% seropositive
Stage 3: Late
Arthritis
or neurologic findings: 100% seropositive
References
Steere (2008) Clin Infect Dis 47(2): 188-95 [PubMed]
Disadvantages
Serology
(
ELISA
) has
False Positive
s,
False Negative
s
Diagnosis should be clinical
Test Lyme Titer to confirm diagnosis
Test Specificity
varies per timing of disease
Early-Stage: 93%
Late-Stage: 81%
Causes
Lyme serology
False Positive
s
Infectious Mononucleosis
(esp. Lyme IgM)
Rheumatologic Condition
s (esp. Lyme IgM)
Prior Lyme
Vaccine
(
LYMErix
)
Test
Western Blot
and ignore OspA band
Cross reactivity with
Treponema
infection
Syphilis
Yaws
Relapsing Fever
Causes
Lyme serology
False Negative
s
Testing within first 2 weeks of symptoms
Antibiotics early in course of lyme infection
Inadequate antibiotic course can blunt seroconversion
Protocol
Tier 1: Obtain Lyme
Serology
(polyvalent
ELISA
)
Initial test in all cases
Move to tier 2 tests if positive or equivocal
Tier 2:
Immunoglobulin G
Western Blot
Test
Tests for IgM and IgG Immunoblots
Confirms positive or equivocal Lyme Titer
With Lyme
Serology
,
Test Specificity
: 99-100%
IgG must be positive for symptoms >4 weeks
Pitfalls
Avoid using labs that do not follow CDC guidelines
Avoid starting at Tier 2 (
Western Blot
)
High
False Positive Rate
Faint positive bands in uninfected person is common
Borrelia Burgdorferi
PCR or culture not recommended
Exception: Atypical dermatitis
Avoid urine
Antigen
test (unreliable with high
False Positive Rate
)
Reference
Steere in Mandell (2000) Infectious Disease, p. 2504-14
(1995) MMWR Morb Mortal Wkly Rep 44:590 [PubMed]
Klempner (2001) Am J Med 110:217-9 [PubMed]
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