CHAPTER 9: Testing
For Lyme Disease

The following is an excerpt taken from the book, The Beginner's Guide to Lyme Disease , written by Dr. Nicola McFadzean.

Testing for Lyme disease is yet another aspect that fuels the controversy and exacerbates the issue of misdiagnosis and under-diagnosis of Lyme. This is because many Lyme tests are not sensitive enough to catch all cases. This is truer of some types of tests than others, as we will see.

The thing to stress before we launch into a discussion on lab testing for Lyme disease is that Lyme disease is primarily a clinical diagnosis which can be made based on a person’s history, symptom picture and physical examination. Laboratory findings should be used to back up, or confirm, clinical presentation. Many cases of Lyme disease are not diagnosed because of negative lab results, even in the face of a textbook presentation of signs and symptoms, or a strong enough case history to warrant the diagnosis. In many cases a therapeutic trial of an agent that would kill the Lyme bacteria, such as an antibiotic or an herbal antimicrobial, can give valuable clues into the presence of infection. Theoretically, if the person did not have Lyme disease, a course of antibiotics would not dramatically affect their symptom picture. An antibiotic trial that validates the Lyme diagnosis might give a response of either an improvement, or a worsening of symptoms consistent with a Herxheimer reaction (this will be explained in more detail in later sections). Either way, some shift in symptoms would be expected.

In Section One in our discussion of the inherent political challenges in Lyme disease, we learned that the CDC surveillance criteria were initially designed for epidemiological purposes, such as, to track prevalence of Lyme disease cases. They were never meant to be used for diagnostic purposes.

As a reminder the CDC surveillance criteria entail a two-tiered approach to testing, and dictate that a positive sensitive ELISA or IFA must be followed by a positive Western Blot with a defined number of approved antibody bands to be considered positive.

We will see, however, that this two-tiered approach is a flawed system and leaves many people inaccurately diagnosed, and without the medical support and treatment they need.

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So that you know what all these tests are, let us get some definitions and descriptions out of the way.

In broad terms, tests for Lyme disease can be categorized as direct and indirect.

• Direct tests look for the bugs or parts of the bugs in various body tissues and fluids. Direct tests include PCR, FISH, cultures and biopsies, and antigen-capture tests.
• Indirect tests measure a person’s immune reaction to the bugs. Indirect tests include ELISA, IFA and Western Blots for Borrelia, and IgG and IgM antibody tests for co-infections.

Lab testing efficacy is determined by sensitivity and specificity. Sensitivity is how likely the test is to find the infection if it is present. A highly sensitive test has a high probability of finding, or measuring, a particular criterion. Specificity, on the other hand, is how accurate a test is in measuring a particular organism, species, or substance. If a test is specific it will clearly define a marker, without too much variability, confusion, false positives or false negatives. In other words, a highly sensitive test will find a needle in a haystack. A highly specific test will tell you for sure that it is a needle.

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PCR stands for Polymerase Chain Reaction. It is a test whereby the DNA, or genetic material of the bacteria, is detected in the blood, serum or other bodily fluids such as the cerebrospinal fluid (CSF) or urine. The downside of the PCR test is that the bacteria often like to hide in the tissues, not simply float around in the blood, so they are difficult to detect. The upside is that the PCR test is not dependent on immune reactions or immune function. A person with a dampened immune response is just as likely to show a positive PCR as a person with a strong immune response. This may not be true of indirect tests, which rely heavily on immune response.

A PCR test that detects a spirochete in the blood is quite specific. While there is some possibility of a false positive, a spirochete visualized is a spirochete visualized; it is specific. The test is not that sensitive, however, as spirochetes may not be easily found in the blood due to their burrowing and hiding in the tissues. If the spirochetes are not hanging out in the blood stream, looking for them there may be a futile endeavor. For this reason PCR tests may be more useful in the early stages of infection when spirochetes are more likely to be in the blood.

PCR testing is also limited by the number of Borrelia strains it can identify. Since there are several strains of Borrelia worldwide known to cause disease in humans, a PCR must assess a range of those strains to be most sensitive.

The culture test for Borrelia has not been widely used clinically to date, although a culture test is now available in the United States.

In a culture test, a small amount of the patient’s blood is removed from their body and introduced into a specific medium that promotes growth of a certain type of bacteria. The bacteria that grow are identified by their cell characteristics and growth characteristics, further confirmed by immuno-staining. To go one step further, PCR testing can be run and various strains identified from the sample. In simple terms, the blood sample is put into a specific medium, allowing some time for the Borrelia to grow, then double-checked that it is Borrelia by examination of its traits and its DNA.

The Borrelia culture is a step forward in that it is deemed more reliable than the Western Blot test, and more sensitive than a PCR. Advanced Laboratory Services, Inc. in Pennsylvania, USA, now offer a spirochete/ Borrelia culture test, which at the time of writing it is only available within the United States.

Advanced Laboratory Services, Inc.

501 Elmwood Ave

Sharon Hill PA 19079

855-238-4949 (ph)

855-238-4946 (fax)

A biopsy is another direct test as it measures the actual microbes, not an immune response to a microbe.

Biopsies are tissue samples that are taken from almost anywhere on the body and evaluated for different infections. Although biopsies are not commonly done in the Lyme community, they can be helpful especially when there is a localized zone of infection, such as at the site of a recurring EM rash. Biopsies are also sometimes done to assess small fiber nerve degeneration, which is linked with neuropathy and progression of Lyme disease.

A biopsy is a more invasive procedure than a blood draw, and is not among the first-line lab tests performed to evaluate or diagnose Lyme disease.

An antigen capture test looks for Borrelia bacteria, or parts of Borrelia bacteria, in the urine. Again, it is a direct test as it is not relying on an immune response but rather looking for the microbe itself. The antigens are parts of the Borrelia bacteria – when isolated from the urine, they are combined with rabbit antibodies specifically targeted to B. burgdorferi antigens. These antigen-antibody complexes are treated with a color developing solution, which turns blue-purple and shows the presence of the Borrelia.

The urine antigen test is often done with a "provocation". By giving antibiotics a few days prior to the collection, thus provoking the bacteria, we can accelerate their destruction making their remnants more likely to show up when measured in the urine.

The ELISA test, the problem child of Lyme testing and diagnostics, is the mostly widely run test in the general medical community, and also one of the least useful. Unfortunately, it is the test that is used as a first port of call for many doctors, and a negative result on the ELISA, also used as a screening test for Lyme disease, is used, often incorrectly to rule it out. The ELISA test is offered by many labs worldwide and is often covered by insurance (in fact, insurance often requires that it be the first test run, and will not cover other tests without the ELISA).

There are some fundamental problems with relying on the ELISA test to diagnose Lyme disease. First, the ELISA test does not have adequate sensitivity to fit the two-tiered approach recommended by the CDC. The group responsible for Lyme disease proficiency testing for the College of American Pathologists stated that a screening test must have at least 95% sensitivity to provide an adequate screen, and that the ELISA test simply does not have that level of sensitivity. ¹

In fact, studies have shown that in patients with culture-positive Lyme disease, only 65-70% show an antibody response. Therefore, a full 30-35% of confirmed Lyme cases would have been missed with ELISA testing alone.

To understand how indirect tests such as the ELISA work, we must understand some basic facts about the immune system.

Antibodies are immune cells, and there are two different kinds of antibodies that are evaluated in Lyme testing (and really, testing for any infection). One is the IgM antibody and the other is the IgG antibody. Typically an IgM antibody is going to present much earlier in infection, approximately two to four weeks after exposure. The IgM antibody may stay elevated, indicating an ongoing active exposure. It may also convert to an IgG response. The IgG antibody has a slightly different role. It is not a "first responder" like the IgM antibody. It comes in later, after several weeks of infection, and may stay elevated for long periods of time – months or even years after the initial infection.

Think of the IgM antibodies as the marines (M for marine). They are the first on the scene when there is a threat or invasion; they attack first and ask questions later. The IgG are the ground forces (G for ground). They let the marines check out the situation first then come into play later, maybe several weeks or even months later. Both arms of this immune system military are necessary and have their strategic roles. The timing of each becomes relevant according to which diagnostic tests are ordered in which time frame post-infection.

Even though they are first on the scene, even the IgM antibodies take a few weeks to appear, typically within 2-4 of the initial infection. One can see then, that a patient presenting with an EM rash a few days after infection needs to be immediately evaluated and diagnosed clinically. By the time antibodies appear, the infection may already have been present for a few weeks and valuable treatment time been lost. I would go so far as to say that a flu-like illness with a known exposure to ticks, such as through camping or hiking, should be viewed this way.

IgG antibodies can be confusing as they can also show exposure to an infection without an active infection. An example of this might be after a vaccine, where a variant of a microbe is introduced to the immune system to force it to have an immune response. That way, IgG memory cells are formed, and if that individual encounters the infection again, the IgG memory cells recognize it right away, direct the immune system into action (quick, send in the Marines!) and mount a quicker, more efficient response to the microbe. IgG antibodies may reflect an individual being exposed to Borrelia without becoming sick with it.

One of the problems with this testing is when it measures immune response. Since Lyme disease is known for dampening (weakening) the immune response, this becomes very problematic. The bugs in this case reduce a person’s capability to mount an immune response – the indirect tests such as ELISA are measuring an immune reaction – and so negatives arise even in the presence of disease. Further, in more chronic infections, IgG antibodies may be absent 50% of the time, posing further complications for diagnosis in chronic illness. ^2,3,4 Subsequently we also evaluate IgM antibody response in persistent or recurrent disease.

The other limitation of antibody testing is that if an individual is treated with antibiotics early, to the extent that the infection is mostly eradicated, it can reduce or completely quell their antibody response. Therefore, they could test negative but still have some infectious process in their body. At a later stage, if symptoms return, most of the antibody markers may not be present.

ELISA testing is also hampered by the actual testing methodology. Testing must be developed to detect more unique and specific antigens for Borrelia. Most commercially available kits use a whole cell sample of the Borrelia microbe. More sensitive testing would recognize and use smaller, more specific pieces of the bug that are known to be reactive, not the whole thing lumped into one.

We can see a double-pronged problem with the ELISA testing. First, the test itself is not sensitive enough. Second, the Borrelia microbe curtails immune response so that the signals necessary to trigger a positive result are lower. Together, it is a profoundly unreliable system.

Let’s use the analogy of sound. If a microphone recorded sound, it would need the sound to be at a certain decibel (volume) level to be able to record it, but the microphone would also need to be of good quality with a decent level of sensitivity. If either the volume was too low or the microphone was of low quality (not designed to record lower and higher notes, just the central ranges), then the sound would not register or be accurately recorded. If both were present – poor sound output and low microphone quality - the chances of a great recording would be doubly jeopardized.

This is how it is with ELISA testing for Lyme disease, and why it is so crucial to combine laboratory findings with the clinical picture to make an accurate diagnosis. Indirect lab tests alone, especially ELISA tests, leave a lot to be desired in terms of sensitivity, and many very ill patients will go undiagnosed. Despite CDC guidelines and their two-tiered approach, a negative ELISA test cannot rule out Lyme disease and should never be used as a stand-alone test.

Another indirect test is the Immuno Fluorescence Assay, or IFA test. It detects antibodies against B. burgdorferi, but it pools the various antibodies (IgG, IgM and IgA). Therefore, it is looking for an immune response but is not as variable based on time after infection in comparison with the ELISA. The IFA is typically run in conjunction with Western Blots. It should not be used instead of a Western Blot.

The IFA test is useful when run with other tests, to make up part of the picture. It is not necessarily a stand-alone test and is not necessarily diagnostic in and of itself. While concerns have arisen over time as to the specificity of the IFA for Lyme-specific antibodies and for its potential for cross-reactivity with antibodies to other spirochetes, studies have shown that with high quality testing procedures and highly experienced lab technicians, the IFA test has good specificity and sensitivity. Therefore the IFA should be run through a lab that specializes in Lyme testing to increase its validity.

The Western Blot test is one of the foremost tests used in the evaluation of Lyme disease. It is also an indirect test, as are the ELISA and IFA; however it is a more sensitive test if performed by a laboratory that looks for all the bands that are related to Borrelia. IgM and IgG antibodies are evaluated separately, with the IgM being detected as early as one week post-exposure.

Unfortunately, as has been the case with anything so far relating to CDC criteria, the CDC has also played a role in creating limitations in Western Blot testing and reporting.

A Western blot reports certain numbers, or "bands", which can be positive, negative, or indeterminate. The bands represent certain antigens, which are the parts of the bacteria that the immune system reacts to.

There is a discrepancy as to which bands are clinically significant, and how many of the bands need to be positive to get a positive result. FDA-approved, commercially available kits (such as the Mardx Marblot) are restricted from reporting all of the bands. These rules were set up in accordance with the CDC surveillance criteria. Private laboratories that are not beholden to these rules and criteria are free to produce tests that actually help people get an accurate assessment.

In IgM testing, by CDC criteria, two of the following bands must be positive to record a positive result:

23-25 kDa

39 kDa

41 kDa

IGeneX, on the other hand, a U.S. based specialty Lyme lab, recognizes the following bands as clinically significant and relevant to Lyme disease:

23-25 kDa

31 kDa

34 kDa

39 kDa

41 kDa

83-93 kDa

Their research has shown that the 31, 34 and 83-93 bands are significant and quite specific to Borrelia infection. The 41 band, on the other hand, shows a lot of cross-reactivity with other flagella-bearing organisms, so a positive 41 can be indicative of other types of infections.

Clearly, the expanded IGeneX criteria give a more rounded and inclusive view of Lyme immune recognition, and allow for a more clinically helpful assessment. Many Lyme-literate medical doctors and experts in Lyme disease believe that just one positive or even equivocal of the above bands is clinically significant.

The other benefit of IGeneX testing is that the bands are reported according to a range – from IND (indeterminate, or weak positive), +, ++, +++ all the way through to ++++. The stronger the immune response to a band, the more +’s are reported. Therefore, even if a patient’s test results are negative, but they have, for example, two IND bands (an IND does not "count" as a positive band), it gives clues that the person may be affected by Borrelia. It may seem logical that the more +’s a patient has, the more aggressive and severe their infection, but in fact the opposite might be true. Because Lyme disease disables the immune system, sometimes the sickest individuals have a lower immune response and a ‘less positive’ looking test result; it does not mean they are any less sick.

The IgG Western Blot has even more stringent criteria than the IgM Western blot. At least five bands must be positive (out of a possible 10) to be regarded as positive according to the CDC. The test looks for 10 bands: 18, 23-25, 28, 30, 39, 41, 45, 58, 66 and 83-93 kDa. Results showing four positive bands, or five equivocal (borderline) bands, report as negative and are completely disregarded. Bands 31 kDa and 34 kDa - both of which are significant antigens that appear later in the immune response and are highly Lyme specific - so specific, in fact, that these bands represent the antigens used in developing the Lyme vaccine - are also excluded. How ironic that these antigens were relevant enough for developing the Lyme disease vaccine, but not relevant enough to be included in the laboratory reporting for Lyme. (By the way, the Lyme vaccine is no longer available due to numerous lawsuits by people who believed that the vaccine made them sick and actually infected them with Lyme disease; the manufacturer cites "low sales" as the reason for the withdrawal in 2002).

To demonstrate this, one study showed that although 89% of patients with EM rash developed IgG antibodies as detected by Western Blot some time during their disease, only 22% were positive by the standards of the CDC. ⁵

Another limitation to the Western Blot is the CDC’s belief that an IgM Western Blot should only be used within the first month of infection, even though other studies have shown that the IgM Western Blot can be positive even in recurrent or persistent disease. Some patients who have been ill for many years will still show a positive IgM Western Blot and a negative IgG Western Blot. Other patients with culture-positive Lyme disease will remain seronegative on any kind of Western Blot testing (approximately 20-30% in fact). Such is the challenge of Lyme disease testing.

Although the most clinically useful of all indirect tests, a positive Western Blot still only suggests exposure to Lyme disease, it does not diagnose Lyme disease. Diagnosis is still done based on the clinical picture – a person’s history and exposure coupled with their current symptoms.

TESTING FOR CO-INFECTIONS

Along with testing for Borrelia, it is imperative to test for co-infections. Information gained from co-infection testing can make a significant difference to the treatment path chosen. Different microbes require different medications and different herbs to counter them. Probably the best example of this is Babesia. Babesia is a parasite, while Borrelia is a bacterium. The medications that work well for Borrelia will not work well for Babesia. The consensus among hundreds of Lyme-treating doctors is that undetected and untreated co-infections are one of the key reasons for treatment failure in Lyme disease.

There are a few different ways to test for co-infections. The main types are antibody tests, FISH tests and PCR tests.

The co-infections that IGeneX offers antibody testing for are:

Babesia duncani

Babesia microti

Bartonella species

Ehrlichia chafeensis (HME)

Anaplasma phagocytophila (HGA)

Rickettsia rickettsii/ typhi

Antibody testing, similar to what we discussed in the indirect tests for Borrelia, measures the immune system’s reaction to these various microbes. The tests done are IgG and IgM. Remember, IgM is a marker of either a new infection or current/ active infection. IgG indicates either prior exposure or a more chronic/ longer-term infection.

In interpreting these tests, I regard an elevation in either antibody clinically significant when combined with a symptomatic patient. IGeneX criteria for all the co-infections listed above are the following:

IgM <20 negative

IgM 20-160 may or may not indicate active infection

IgM >160 indicates an active infection

IgG <40 negative

IgG 40-160 may or may not indicate active infection

IgG >160 indicates an active infection

As an example, if a patient has an IgM level of 20 for a particular infection, I would consider treating that co-infection, especially if the symptom picture matches that of the co-infection . Remember, for co-infections as well as Borrelia, the diagnosis is based primarily on clinical presentation.

The Fluorescent In-Situ Hybridization (FISH) test is a direct test - it does not rely on immune response and is a way to visualize the microbes directly - that uses a sample examined as a thin smear in order to identify and mark the ribosomal RNA. Under a microscope, the bugs, whose presence indicates an active, current infection, literally glow in the dark.

The Babesia FISH test detects both Babesia duncani and Babesia microti. It is performed on whole blood, since the parasites exist within the red blood cells themselves.

The Bartonella FISH test detects B. vinsonii, B. berkhoffii, B. henselae and B. quintana, so it can detect several different strains. The FISH test actually shows the microbes fluorescing under a microscope. Bartonella, rod-shaped bacteria, have been stained with a substance specific to mark them so a positive result will reflect the sighting of characteristic bacteria of this shape.

FISH tests have a high level of specificity so there are very few false positives. Remember though, a negative FISH does not necessarily mean that the infection is not present. It simply means that it was not detected in that particular sample.

Like the FISH, PCR tests for co-infections are direct tests. DNA, or parts of the DNA of the bacteria, are evaluated in the blood sample. In my experience, FISH tests are more sensitive than PCR tests for co-infections and are more frequently utilized.

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By now you may be asking why we test at all, if the tests are not 100% reliable and if Lyme disease is a clinical diagnosis anyway. The answer is that the more information we can gather, the better. Testing can give confirmation on a suspected illness, shed light on which co-infections are present and help in assessing the severity of an infection. For example, if a patient tests indeterminate on the Lyme Western Blot but has a positive FISH test for Babesia and Babesia duncani antibodies at 80 or 160, then they may have a dominant Babesia infection, and treatment should start there.

Similarly, if a patient shows a positive PCR for Borrelia, a positive IgM Western Blot, and all negative co-infection testing, and unless they have symptoms that are pathognomonic of a specific co-infection, their initial treatment should be tailored around the Borrelia. However, another person can have positive antibodies to Borrelia, Babesia, Bartonella and Rickettsia, and in that case, we know we have a complex situation that is going to require several different medications to address them all.

Lab tests are very useful and should be regarded as important pieces of the puzzle. Alone, they do not rule in or out infection, but when combined with history, symptoms, tick exposures and so on can give very useful information to help shape the big picture.

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OTHER TESTS THAT MIGHT BE USEFUL

Not only are there tests for the infections themselves, but there are a couple of other markers and tests that can help assess an individual’s health. This is not a complete list of tests as there are literally dozens of tests that may be useful in various scenarios.

The CD-57 is not so much a test to detect Lyme disease as it is an immune marker that tends to be low in the presence of Lyme disease. CD or cluster designation markers are identifying markers on certain immune cells called T cells and NK cells. They give cells their variance in appearance and function. So far, there are approximately 200 known CD’s, numbered according to their order of discovery. Any T cell or NK cell will carry many different CD markers.

If a cell expresses a certain marker, it is designated with the number of that marker and a "+" sign. So if an immune cell expresses the CD-57 marker, it is written as CD-57+. Through laboratory testing, we can measure the number of cells that carry a certain designation, either on the T cell or NK cell.

Clinically, measuring certain CD markers can help evaluate certain illnesses. Lyme disease has been associated with a low CD-57 count – specifically Borrelia infection (as opposed to co-infections). The sicker the patient, the lower the CD-57 count appears to be.

Measuring the CD-57 count can be helpful for a number of reasons. First, other illnesses such as chronic fatigue syndrome, rheumatoid arthritis or multiple sclerosis might mimic Lyme, but those illnesses will not cause a drop in the CD-57, so this marker can help in determining Lyme disease as distinct from other chronic illnesses with similar symptom pictures. Also, the CD-57 can be used to track treatment progress, as it should return towards normal levels as the infection improves. It also can give clues into co-infections. CD-57 levels are impacted by Borrelia but not significantly by co-infections, so if a patient is still symptomatic despite Lyme treatment and has a rising CD-57 count, it can be a clue that co-infections, not the Borrelia itself, are driving the remaining symptoms.

Of course, nothing is as straightforward as it seems, especially in Lyme disease. Many chronically ill Lyme patients present with a low CD-57 count, and despite long-term treatment and a resolving symptom picture, their counts stay frustratingly low. There are sometimes discrepancies between one lab and another, and numbers can fluctuate up and down between readings in ways that do not seem to correlate with the degree of illness or recovery.

It is important to remember that the lab is running the CD-57 on the NK cells, not the T cells. T cells will express CD-57 markers, but they are not clinically relevant to Lyme in the same way that the CD-57+ NK cells are. Running the CD-57 test on the T cells may be one reason for apparent discrepancies in results.

The CD-57 test is a worthwhile test to run as a gauge of immune response to Borrelia. While it sometimes shows inconsistencies, it may provide another piece of the puzzle and more information to shed light on that person’s case. In the United States, the CD-57+ NK test is available through Labcorp as well as IGeneX.

We have already seen that the production of biofilm by colonies of bacteria can create bacterial defenses that are difficult to overcome. The bacterial colonies produce biofilm then hide in it, evading antibiotic and immune attack. The colonies become quite sophisticated – they attach to other structures that allow the flow of nutrients in and toxins out of their milieu, making them very resilient.

Fry Labs (Arizona, U.S.) initially began smear testing to provide assessment of Bartonella and other protozoans in the blood of chronically ill patients. As their work progressed, they saw colonies with biofilm in many of the blood samples. They have further developed their stain techniques and can provide insight into the degree of biofilm involvement, literally giving a visual picture of it. In patients who are being treated with antibiotic therapy and making slow or minimal progress, assessing biofilm may be of great value.

Run by Infectolab in Augsburg, Germany, the Elispot-LTT test uses a different part of the immune system to the antibody testing. Antibodies are part of the humoral immune response; we also have a cellular immune response that involves T cells and NK cells. (The CD-57 cell marker described above is part of the cellular immune system).

A Borrelia infection will activate T-cells as well as antibodies. Activation of T-cells occurs immediately after infection, and stops approximately six to eight weeks after completion of effective therapy or when the infection is resolved. Therefore, measuring T-cell reactivity to Borrelia might be another useful diagnostic tool, as it is not as subject to the variability of antibody responses in different patients and at different times of infection.

According to Infectolab, the Elispot-LTT will detect even a single reactive T-cell, is accurate in both acute and chronic infection, and is a helpful indicator of whether infection is truly resolved at the end of therapy. The Elispot-LTT test is available for a range of infectious agents including Borrelia, Chlamydia pneumonia, Chlamydia trachomatis, Ehrlichia, Anaplasma, Yersinia and the Epstein-Barr virus.

Infectolab

49-821-4550-740 (ph)

49-821-4550-741 (fax)?

As you can see, there are several challenges to getting accurate and reliable testing for Lyme disease.

The first is that the ELISA test is the first test administered if Lyme is suspected. We have already seen that the ELISA test is not a sufficiently sensitive test to be clinically useful. Unfortunately, many doctors run the ELISA test, and if the results are negative, make a definitive statement that the person does not have Lyme disease. Any discussion of Lyme disease after that meets with cold response or total dismissal.

In those very few cases where the ELISA test comes back positive, a follow up confirmation test would be the Western Blot. If run through larger commercial labs, the Western Blot test is not going to recognize some of the bands that are necessary to give the complete picture, such as the 31 and 34 kDa bands.

Often, if an ELISA is negative, doctors will not run Western blots at all. They have been taught about the two-tier testing – ELISA first, then Western Blot only if ELISA is positive. That two-tiered system was designed for research and epidemiological purposes; it was never meant to be used for clinical diagnostic purposes and is simply not appropriate or adequate in the clinical setting.

Any of the indirect tests have the inherent challenge that they measure immune response. We know that Lyme can dampen immune response, so the very markers needed to diagnose infection are dampened by the infection itself, leading to a lower chance of diagnosis. It is ironic that the more profound and chronic the infection in the body, the lesser the response may be on indirect testing.

Adequate testing for co-infections is often not performed. This leads to an incomplete picture of a person’s chronic infections and may lead to inadequacies in treatment protocols.

There are ways to get more reliable and comprehensive testing done. Here are some ways to maximize laboratory information:

• Make sure testing is done through a lab that has expertise in Lyme and co-infection testing, and is not restricted to CDC criteria. IGeneX Laboratory in Palo Alto, California is a specialist Lyme lab that offers the most reliable and comprehensive testing at this time. It is possible to send blood samples from most countries to IGeneX via Fedex or other international courier.

To run IGeneX testing, contact the lab directly and request a blood kit. A doctor’s signature is required on the requisition form to authorize the testing.

1-650-424-1191 (ph)

1-650-424-1196 (fax)

• Run as many different types of tests as possible, both direct and indirect. This means doing IFA, PCR and Western blots for Borrelia. IGeneX testing (PCR and Western Blot) also covers a variety of strains of Borrelia, including the B. afzilii, B. garinii, and B. andersonii, meaning it is relevant for strains found in other countries as well as North American strains.

Based on the data that IGeneX has collected to date, a comprehensive Lyme panel will detect about 80% of all Lyme patients (this represents the sensitivity of the test). The overall specificity of this panel is greater than 95% with all three types of tests run (IFA, Western Blot and PCR).

Fry Laboratories

1-480-292-8560 (ph)

1-480-656-4932 (fax)

• To get as complete a picture as possible, run additional immune markers such as the CD-57 NK cell count. Make sure the lab uses the NK cells, not the T cells, in their testing methodology. C4a and C3a complement are two other markers that may indicate inflammation and neurotoxicity in the system. These are also immune markers that can be run through local, commercial labs.
• Determine whether antimicrobial therapy is indicated prior to testing. There are mixed views as to whether testing should be "provoked", that is, an antimicrobial given for a few weeks before the blood is collected with the aim of killing off some microbes and stirring up the immune system to produce a louder "noise" for the test to measure. Certainly, many patients are too ill to be able to tolerate such an approach, as the Herxheimer reaction may be too great (more on Herxheimer reactions in the following section). Many patients require a gentler introduction to antimicrobial therapy, whereas a provocation can require higher doses right off the bat. Also, many patients would have a difficult time convincing their local doctor to give them such doses of antibiotics without an official diagnosis to base it on.

Having said that, there are some cases where I have used antibiotics and/ or antimicrobial herbs to try to generate a greater immune response. And there are some cases where a negative IgM Western Blot has turned into a positive Western Blot after a few weeks of antimicrobial therapy. In general, I do not use provocation for the majority of my patients prior to testing.

The most important thing to stress is that Lyme disease is still a clinical diagnosis. We use lab testing to support that diagnosis, to give information on co-infections, and to give quantitative information that we can use over the course of treatment to track progress. The best way to get accurate and reliable information is to do testing through a specialty Lyme lab such as IGeneX and to run a variety of test types (both direct and indirect) to increase the likelihood of revealing evidence of the infection. Co-infection testing is imperative to round out the picture.