Third Installment: Clinical Diagnosis
Were you expecting a list of blood tests that would determine if Lyme disease is present or not? Surprise: “Lyme Borreliosis (LB) is diagnosed CLINICALLY, as no currently available test, no matter the source or type, is definitive in ruling in or ruling out infection with these pathogens, or whether these infections are responsible for the patient’s symptoms.” Some physicians rest the case of Lyme disease squarely on the Lyme titre, and some others, with the Western Blot. Based on Burrancano’s experience, and other physicians who specialize in Lyme disease the picture is much more complex than previously understood. Blood serology can be considered as informational, but cannot be used exclusively.
It is critical that concurrent conditions and even alternate diagnoses be considered; the entire clinical picture has to be taken seriously. The situation becomes very complicated in late, disseminated Lyme disease since any organ or system may be affected, and symptoms may or may not be caused by the Lyme vectors.
So, we can’t count on blood tests alone, we need to look at the whole clinical picture, and we need at the same time to question whether the presenting symptoms are related to “Lyme” or a separate disease state! This is not easy. The disease is known as devious and cunning, and it takes the medical equivalent of Sherlock Holmes to clarify diagnosis.
This is the term for a rash which sometimes accompanies a tick bite from an infected tick. Did you know that it is present in fewer than half of those bitten by an infected tick, and many that have a rash do not see it or misinterpret the rash. The rash begins four days to several weeks after the bite, and it may be warm to the touch. In less than 10% of the time there are multiple lesions. Some have an unusual or atypical appearance, just to add a little spice to the story. If the rash is ulcerated or if there is a vesicular center, this may represent a mix of infections at the same time.
Often, blood tests do not show positive for several weeks, so if the rash is present it is important to begin treatment immediately. The earliest treatment holds the highest success rate!
DIAGNOSING LATER DISEASE
Blood tests reveal if our body had been fighting the disease; these tests do not directly indicate whether the spirochete is currently present! (Test results are often inconsistent so it is important to use the most highly respected labs.)
• Start with the ELISA blood test. If that is positive, a confirmatory western blot.
This is not recommended since the ELISA is not sensitive enough to serve as an adequate screen; many patients are negative with the ELISA and positive on the Western Blot.
• IgM and IgG western blot.
Note: when late cases of Lyme disease are seronegative, 36% will transiently become seropositive at the completion of successful therapy. In those cases the CD-57 is useful.
LIST OF BLOOD TESTS
OK. Here is what you have been looking for, right?
1 - Western Blot
This blood test works by showing which “bands” are reactive. (For our purposes, we do not have to know the complex medical underpinnings of the test.) One very important band is 41KD because it shows up the earliest. Bands 18KD, 23-25 KD (Osp C), 34 KD (Osp B), 37 KD, 39 KD, 83 KD and the 93 KD bands are species-specific ones, but appear later, or may not appear at all.
2 - PCR
This test is now available. Though very specific, sensitivity is estimated at less than 30%. The reason for this is because Bb causes a deep tissue infection and is only temporarily found in the blood. For this reason a negative result does not rule out infection, but a positive one is significant. The patient needs to be free of antibiotics for at least six weeks for the test to be effective!
3 - Antigen capture
This test is becoming more widely available and can be done on urine, cerebral spinal fluid and synovial fluid. Sensitivity is low on this one too, less than 30% but specificity is high (greater than 90%).
4 - Spinal tap
These are not routinely recommended since a negative tap does not rule out Lyme disease. This test is done only on patients with pronounced neurological manifestations in whom the diagnosis is uncertain.
5 - Biopsy
Dr. Burascano strongly recommends a biopsy on all unexplained skin lesions along with a PCR and careful history taking. The pathologist needs to be alerted to look for spirochetes.
6 - CD-57
This test is a breakthrough in Lyme disease diagnosis and treatment. Chronic Lyme disease infections are known to suppress the immune system and can decrease the quantity of the CD-57 subset of what is known as “natural killer cells.” We can now use the CD-57 count to indicate how active the Lyme infection is and whether, after treatment ends, a relapse is likely to occur. This is a very important and helpful test to keep in mind to assist in diagnosis and treatment. Dr. Burrascano has found that LabCorp is the preferred lab as published studies were based on their assays. Active Lyme patients often measure about 60, whereas a normal count is above 200. If the CD-57 is not in the normal range when a course of antibiotics has ended, then a relapse will almost certainly occur.
OK. That’s it. Hopefully this translation of Dr. Burrascono’s information on the diagnosis of Lyme disease and the tests often ordered was helpful. The next installment will provide his checklist of symptoms often associated with Lyme or related co-infections.