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Guideline for Diagnosis of Lyme Disease

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Guideline for Diagnosis of Lyme Disease Powered By Docstoc
					                           Guideline for Diagnosis of Lyme Disease

Recommendation:

Lyme disease is diagnosed primarily based on clinical findings with serologic
confirmation in specific cases. Evidence-based recommendations by the American
College of Physicians (ACP) for areas of moderate endemicity, including Delaware, state
that Lyme disease should be diagnosed in persons with erythema migrans. It is
recommended that in a moderately endemic area, persons with erythema migrans should
be treated without serologic testing. It is recommended that in persons with classic
features of Lyme disease (see Table-1), clinicians should order a serum enzyme-linked
immunoabsorbent assay (ELISA), followed by a whole cell Western blot for indeterminate
ELISA results. The ACP does not recommend serologic testing for Lyme disease in
persons with non-classic symptoms or signs because false positive results are more likely
when the pre-test probability of the disease is low. Consequently, the ACP recommends
against antibiotic treatment for persons with positive serologic results without classic
features of Lyme disease (see Table-1). Evidence-based guidelines developed by the
American Academy of Neurology recommend that in persons with any symptoms or signs
suggestive of meningeal or neurologic involvement, cerebrospinal fluid tests may be
useful in directing treatment. Although there have been no controlled trials on the use of
electrocardiography in Lyme disease, it may be prudent to order a 12-lead
electrocardiogram in persons meeting criteria for Lyme disease. In persons who have
received the Lyme vaccine, ELISA and whole cell Western blot results may be difficult to
interpret. For chronic symptoms following standard antibiotic therapy for Lyme disease,
placebo controlled trials have demonstrated no benefit of prolonged antibiotic therapy.
Serologic screening in the general asymptomatic population or in high risk sub-
populations is not recommended.

Introduction:

         Lyme disease is the most common tick-borne disease in the US, with more than 16,000
cases reported each year.1 Lyme disease is a systemic illness resulting from infection with the
spirochete Borrelia burgdorferi.1 The terms Lyme disease and B. burgdorferi infection will be
used interchangeably in this literature review. Although Lyme disease is rarely fatal, untreated
Lyme disease can cause arthritis, heart block, polyneuropathy and encephalopathy weeks to
months after the initial infection.1 Diagnosis is based on identification of classic signs of Lyme
disease and likelihood of exposure.2
         The diagnosis of Lyme disease has been a source of controversy and expense for
patients and the medical system.3, 4 False positive results from B. burgdorferi serologic testing
are common in the general population, so experts recommend limiting serologic testing to
specific situations.2 False negative tests are common in the early stages of the disease.
Appropriate diagnosis is important in that Lyme disease can cause significant morbidity when left
unattended. On the other hand, false-positive tests may result in inappropriate treatment with
exposure of patients to potential adverse events related to antibiotic therapy.5 In addition, the
increased cost to the medical system of inappropriate testing may be substantial.
         It appears that clinicians use serologic testing without sufficient discrimination.3 A
retrospective study of physician practices on the Eastern Shore of Maryland demonstrated that in
the majority of cases of tick bites, physicians ordered unnecessary costly serologic testing and
prescribed prophylactic antibiotic therapy of unproven efficacy.3 An observational cohort study in
Connecticut showed that 60% of subjects who had been diagnosed with Lyme disease had no
evidence of past or present Lyme infection, and many of these subjects had undergone serologic
testing with prolonged courses of antibiotic treatment.4 However, due to the potential for Lyme
disease to mimic other conditions, there is also evidence that the diagnosis of Lyme disease may
also be frequently missed or delayed.6 A study among children indicated that clinicians often




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ascribed non-specific subjective symptoms to Lyme disease and failed to ascribe fleeting
objective signs to Lyme disease.7
         To address the issues surrounding appropriate diagnosis, in 1997 the American College
of Physicians (ACP) published an evidence-based guideline for the work-up of Lyme disease.2, 5
The ACP guidelines use clinical criteria to estimate of the predictive value of the laboratory
testing in the diagnosis of Lyme disease. The ACP guidelines will be used as the standard for
diagnosis in this guideline.2, 5
         The authors undertook this literature review to identify the existing evidence regarding
the appropriate clinical and laboratory diagnosis of Lyme disease. We also examined the
following topics as they relate to testing for Lyme disease: 1) the burden of suffering due to Lyme
disease, 2) the clinical manifestations of Lyme disease, and 3) screening in the general
population for Lyme disease. This review will identify but will not attempt to fill gaps in existing
research and recommendations. This guideline will discuss briefly prevention of Lyme disease,
including immunization, particularly in regard to its impact on diagnosis.

Method:

         We used a systematic approach to collect evidence from the published literature. We
searched evidence-based databases (the American College of Physicians Journal Club, the
National Guidelines Clearing House Database (www.guidelines.gov), the Agency for Healthcare
Research and Quality Database (www.ahcpr.gov), the Turning Research Into Practice website
(www.tripdatabase.com), the Cochrane Collaboration Database of Systematic Reviews
(www.cochrane.org) and the British National Health Service Centre for Reviews and
Dissemination (144.32.228.3/scripts/WEBC.EXE/NHSCRD/start)) and Medline using the term
“lyme” to identify articles meeting the following criteria: published since January 1996, abstract
available, human, English language.
         There were 961 abstracts and reviews that met these criteria. Studies were reviewed by
one author for relevance and method. For diagnosis, only studies with controls were included,
and for treatment, only studies with a randomized-controlled design were included.
Bibliographies from these articles were used to identify additional articles that authors thought
were important. Studies published outside the US were not used due to regional differences in
strains of Borrelia burgdorferi and clinical manifestations, unless the pathogenic strain was
identified in the study.8-10

Results:

Burden of Suffering

         When considering a diagnosis of Lyme disease, the clinician should be aware of the
epidemiology of the disease. The patient’s risk of acquiring Lyme disease in based on several
factors, including 1) the species of tick by which the patient has been bitten, 2) the duration of
attachment of the tick, 3) residence in an endemic area for Lyme disease, 4) the time of year,
and 5) potential exposures to tick infested areas. Knowledge of the feeding behaviors of the
vector of Lyme disease, Ixodes ticks, is important as well. These factors play an important part in
determining a given patient’s probability of having Lyme disease, and thus impact on the
appropriate clinical and laboratory diagnosis of the illness.

Incidence

         The Centers for Disease Control (CDC) initiated nationwide surveillance for Lyme
disease in 1982, and the Council of State and Territorial Epidemiologists designated it a
nationally reportable disease in 1991.11 Based on the CDC definition for reportable cases of
Lyme disease (See Table-1), the number of cases has increased from 7,943 cases in 1990 to a
high in 1998 of 16,801 cases.11 A total of 16,273 cases were reported to the CDC in their most
recent tabulation of data in 1999. Most cases occur in northeastern, mid-Atlantic, and north
central states. The reported incidence rates in Delaware are 22 times higher than the national


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average.11 The highest incidence of Lyme disease occurs in the following states by order:
Connecticut, Rhode Island, New York, Pennsylvania, Delaware, New Jersey, Maryland,
Massachusetts and Wisconsin.11 The Delaware Department of Public Health reported an
average of 145 total cases per year for the past three years, with 23 cases per 100,000 persons
in Kent County, 20 cases per 100,000 persons in New Castle County and 11 cases per 100,000
persons in Sussex County.12 There is some evidence from Maryland that Lyme disease meeting
CDC criteria is under-reported by 10 to 12-fold,13 and a review of Lyme reporting in Delaware in
1994 noted that cases had probably been under-reported.14 The actual number of cases and the
public health impact of the disease may be significantly higher than suggested by CDC
surveillance data. This literature search identified no surveillance studies for Lyme disease in the
general population in Delaware.

Etiology and Risk Factors

          In the United States, Lyme disease is caused by the tick-borne spirochete Borrelia
burgdorferi.11 In Delaware and the eastern United States, the deer tick, Ixodes scapularis, is the
vector for Lyme disease.15 Ixodes ticks are quite small compared to other ticks, usually about the
size of the head of a pin. Ixodes ticks live for two years.16 In the summer, Ixodes tick eggs hatch
into larvae which search for a blood meal, usually from mice which are thought to be the main
source of infection for the Ixodes ticks.16, 17 The larvae molt during the fall and winter, and
infected nymph ticks emerge in the spring and search for meals throughout the late spring,
summer and early fall.16 The nymph ticks appear to be the main source of human infection,
which also occurs primarily in the late spring, summer and early fall.16 Adult ticks feed in the late
fall, winter and early spring, mostly on deer but are capable of feeding on humans.16 Adult tick
activity is inhibited by snow cover or temperatures below 45 degrees F, but a warm spell may
reactivate adults leading to human infections in the winter.18 Rates of Lyme disease correlate
with the size of the Ixodes tick, deer and mouse populations.17, 19.
          Investigators have extensively studied the feeding habits of Ixodes ticks. In a study of
the typical attachment patterns of various tick species, Felz and Durden reported that the Ixodes
tick attached to widely distributed sites on the human body with no apparent site preferences.15
In animal studies, risk of infection increased greatly after 36 to 48 hours of tick attachment.20, 21
Infection has occurred, however, in up to 20% of animals with a tick attached for 24 hours.21 Even
higher rates of infection occur within a day when partially fed ticks re-attached.22 A study of tick
attachment in humans confirmed findings from animal studies that the risk of infection increases
with time, and was significantly higher after 72 hours of attachment as estimated by
measurement of tick engorgement.23 The actual risk of infection after a confirmed Ixodes tick bite
is very low, ranging from 1.4% as estimated from a meta-analysis24 3.7% measured by serology
alone without clinical correlation in a highly endemic area in Long Island.23
          In the most recent CDC report of the occurrence of Lyme disease in the US, cases
occurred in persons of all ages, with the highest rates in persons less than 15 years of age and
30-59 years of age.11 Fewer than 5% of cases occurred in persons older than 75 years of age.11
Rates were approximately equal among males and females (52.5% male, 47.5% female).11 For
more than half of cases, onset of illness occurred in June and July, during high activity of the
infective nymphal-stage tick, while onset occurred in fewer than 5.8% in December, January,
February.11 A study in Delaware among children demonstrated a correlation between Lyme
infection and the home environment; e.g. leaf litter in the yard and ground cover containing moist
humus, and no correlation with outdoor activities such as camping and fishing.25 Lyme disease
has also been shown to be more likely among persons living in rural residences,26, 27 persons
who engaged in spring or summer brush clearing, and persons living in homes near rock walls,
woods, deer or bird feeders.27




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Presentation, Morbidity and Mortality

          When considering a diagnosis of Lyme disease, the clinician should be familiar with the
typical clinical features of the illness. The clinical signs and symptoms associated with Lyme
disease are varied and may present in stages separated by weeks to months. However, the
clinical manifestations of Lyme disease are not infinite. Much of the inappropriate testing and
treatment of Lyme disease have been based on falsely attributing non-specific signs and
symptoms to infection with B. burgdorferi.
          The onset of infection with B. burgdorferi occurs one to thirty-six days after a tick bite.28
Most persons develop an early, localized form of Lyme disease characterized by a rash called
erythema migrans (EM) which may be accompanied by flu-like symptoms.2 EM is considered the
best clinical marker for Lyme disease, occurring in 60% to 80% of cases.2 A significant minority
of persons may have no symptoms with Lyme disease. In one study in Long Island, New York,
two of seven persons (29%) with documented seroconversion for B. burgdorferi were
asymptomatic.29 In a North American study, Strle reported that EM lasted for a median of four
days and often lacked central clearing.10 Based on observation of 237 cases of EM, Berger
concluded that EM has a variable clinical appearance, but usually presents as a centrifugally
expanding, erythematous annular patch.28
          In a case series of 79 persons with culture-proven EM, Nadelman et al observed the
spectrum of clinic presentations.30 The EM rash ranged in this study range in size from 6 to 73
cm and 18% of persons had multiple EM lesions.30 Of note, only 25% of persons noted a
preceding tick bite. Systemic symptoms were noted in 68% of persons, including fatigue (54%),
arthralgia (44%), myalgia (44%), headache (42%), fever/ and or chills (39%), stiff neck (35%) and
anorexia (26%).30 In addition to EM, 33% of subjects had an objective finding on physical exam,
including localized lymphadenopathy (23%), fever (16%), tender neck flexion (9%), and joint
tenderness (8%). The investigators noted nuchal rigidity, joint swelling and facial nerve palsy in
1% of patients.30 No subjects had new electrocardiographic evidence of atrioventricular block.30
Elevation of one or more liver enzymes, especially gamma-glutamyl transpeptidase and alanine
transaminase, have been reported in about 40% of persons with Lyme disease, especially in
persons with multiple EM rashes.30, 31 Upper respiratory symptoms are rare in Lyme disease and
may suggest a viral or other etiology.16 The possibility of meningitis must be considered in all
persons with Lyme disease, as Lyme meningitis has been reported to manifest subtly, with
headache and mild neck stiffness. True meningismus is reported only rarely.32
          When Lyme disease is untreated, infection and inflammation may spread, resulting in
advanced disease weeks to months after the initial exposure, involving the heart, nervous
system, and/or joints.33 Classic findings in Lyme disease are listed in Table-1.2 There is some
evidence that higher rates of advanced Lyme disease occur among African Americans, perhaps
because erythema migrans is missed.34 There are few studies of persons with untreated Lyme
disease. However, Steere et al. performed two such studies retrospectively. In a case review of
persons with untreated EM (n=26), Steere et al. reported the ratio of clinically apparent to
subclinical cases of B. burgdorferi infection (based on serology) was 1:1.35 Of persons who
developed symptoms and signs, most persons who developed EM progressed to arthritis, and
one person (4%) developed myocarditis.35 In their report on Lyme arthritis among persons who
did not receive antibiotics for EM, Steere et al reported that 51% of subjects developed one or
intermittent attacks of large joint arthritis, and a few developed polyarticular arthritis.36 The
arthritis subsided over months to years leaving 11% with chronic synovitis and 2% with
permanent joint disability.36 Late skin findings in Lyme disease include lymphocytoma and
acrodermatitis chronica atrophicans.16
          In a study of cardiac involvement in Lyme disease, Rubin et al evaluated 61 persons who
presented with EM (n=61) for electrocardiographic evidence of heart involvement.37 Heart block
was demonstrated in one person (1.6%), which resolved following treatment.37 There is no
evidence for long-term cardiac damage in persons treated for Lyme disease. In a case-control
study comparing the status of persons at five years post treatment for Lyme disease and persons
with no evidence of prior Lyme disease (n=336), Sangha et al demonstrated no increase in
cardiac symptoms or electrocardiographic abnormalities among persons who had been treated


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for Lyme.38 This literature review identified no report of increased mortality among persons with
untreated Lyme disease.
         Findings among children resemble those in adults. In a 20 month longitudinal study
among children aged 1 to 21 years (median 7 years), Gerber et al reported that 66% of subjects
presented with a single EM rash, 23% with multiple EM rashes, 6% with arthritis, 3% with facial
nerve palsy, 2% with aseptic meningitis and 0.5% with carditis.39 Cook et al., in an observational
study in Delaware, reported that Lyme disease was the most common cause of transient facial
nerve palsy among children in their population.40 High rates of Lyme meningitis (68%),
documented by abnormal cerebrospinal fluid protein or white blood cell count, have been
reported among children with facial nerve palsy.41 As in adults, Lyme meningitis may be subtle
and usually occurs without meningismus. In the study by Belman et al, only 32% of children with
elevated CSF white blood cell counts had headaches.41 When compared to children with viral
meningitis, children with Lyme meningitis presented with significantly less fever and similar rates
of headache, neck pain and malaise.42 In a case series in a pediatric emergency setting,
Bachman et al noted the diagnosis of Lyme arthritis was particularly difficult due to marked
elevations in erythrocyte sedimentation rates and synovial fluid white blood cell counts, resulting
in misdiagnosis of septic arthritis and arthrotomy in nearly half of cases (6/15).6 A small case
series (n=5) described findings concurrent with the acute infection or months later that were
consistent with a subtle encephalopathy. Clinical findings in these cases included behavioral
changes, forgetfulness, headache or fatigue and a complex seizure disorder in two cases.43
Electrocardiographic abnormalities were documented in 30% of patients in one study among
children presenting with Lyme disease and without overt symptoms of cardiac involvement.44
         The possibility of co-infection with other tick-borne illnesses in persons with Lyme
disease has prompted some researchers to recommend testing for other local tick-borne
pathogens, especially in persons with clinically moderate to severe symptoms.45, 46 Significant
rates of coinfection of ticks (10%)47 with B. burgdorferi and other tick-borne illnesses including
Babesia microti and the rickettsial-like pathogens causing human granulocytic erlichiosis (HGE)
have been reported. Rates of human co-infection with tick-borne illnesses have varied in reports,
partly depending on local prevalence of disease. Reported rates vary from 13%, in Wisconsin,
with Lyme disease and HGE,46 to 26% in Connecticut with Lyme disease, the ehrlichioses or
babesiosis,48 to only 0.7%, in a highly endemic area in Long Island, New York, with Lyme disease
and Rocky Mountain spotted fever, babesiosis or the ehrlichioses.29 Although most cases of
babesiosis are subclinical,49 Krause et al reported that persons co-infected with Lyme disease
and babesiosis experienced more severe and longer lasting illness with higher rates of fatigue,
headache, sweats, chills, nausea, conjunctivitis and splenomegaly.45 However, in a retrospective
case-control study, Wang et al determined that persons with serologic evidence of a past episode
of babesiosis in addition to a documented history of Lyme disease had no worse long-term
outcomes than persons with a history of Lyme disease and no evidence of exposure to Babesia
microti.49 At present, there is insufficient evidence to recommend screening for other tick-borne
illnesses in persons with Lyme disease.
         Some investigators describe a constellation of symptoms that has been called chronic
Lyme syndrome or post-Lyme syndrome.50 Investigators have described persistent symptoms
such as headache, myalgias, arthralgias, and fatigue in persons who received standard treatment
for Lyme disease. Some studies have demonstrated cognitive impairment, involving subtle
abnormalities of attention, verbal memory, verbal fluency, motor speed, sleep and mood, in
persons following treatment for Lyme disease.51, 52 As a result, clinicians and patients have come
to suspect untreated chronic Lyme disease in persons with non-specific symptoms but without
the classic features of Lyme disease as described in Table-1.50
          One of the main reasons for serologic testing for Lyme disease is the perceived
relationship between infection with B. burgdorferi and chronic non-specific symptoms. Many
persons without the classical features of Lyme disease have positive serologic results and are
treated with antibiotics.50 However, Lyme disease has not been proven to be a causative factor
among persons with persistent non-specific symptoms after treatment. There are no studies that
prospectively follow persons for symptoms such as fatigue, myalgias and memory loss before
and after contracting Lyme disease. Causation is implied by the results of a case series of
healthy persons in Europe, which reported higher rates of unexplained long-term fatigue among


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persons seropositive for B. burgdorferi .53 In another retrospective case-control study (n=353),
Shadick et al reported that six years after diagnosis, persons with a history of Lyme disease
reported significantly more joint pain, memory impairment and poorer functional status due to
pain. However, there were no demonstrable differences in musculoskeletal or neurological
examination or neurocognitive testing in this study.54 The 36% of patients with persistent
symptoms after treatment in this study had more severe acute presentations of Lyme disease
with features such as fever, headache, photosensitivity or neck stiffness.54 In another
retrospective case-control study (n=114) performed 10 to 20 years after diagnosis, Kalish et al.
noted higher rates of joint pain and sleep difficulties among persons with a history of Lyme facial
palsy who had not received antibiotic treatment for nervous system involvement compared to
persons who had received such treatment.55 Other authors have reported high rates of
fibromyalgia and chronic fatigue syndrome in persons with persistent symptoms after treatment
when compared to persons without chronic symptoms following treatment for Lyme disease.51
         Other studies provide indirect evidence that Lyme disease may not be a causative factor
of long-term non-specific symptoms either in persons without a history of classic features of Lyme
disease or following treatment. In a case-control study (n=79) in New Jersey, Schutzer and
Natelson demonstrated no significant difference in rates of positive Lyme serology between
controls and persons meeting criteria for chronic fatigue syndrome or fibromyalgia without
antecedent classical features of Lyme disease.56 In another large study, Seltzer et al. determined
that many persons who reported chronic pain, fatigue, and difficulties with daily activities one to
eleven years after diagnosis of Lyme disease, had not met CDC surveillance criteria for Lyme
disease initially. The frequencies of chronic symptoms in these patients matched the frequencies
in age-matched controls from the general population.57 A predisposition to developing chronic
symptoms following Lyme disease has been suggested by two studies. Solomon et al. reported
that chronic symptoms after treatment for Lyme disease were correlated with a prior history of
traumatic psychological experiences.58 Barr et al. reported no objective evidence of memory
impairment in persons with subjective perception of memory loss. The subjective perception of
memory loss in this study correlated with depression.59 Even if persistent Lyme disease is a
cause of long-term non-specific symptoms following standard treatment for Lyme disease, the
benefit of further antibiotic treatment in these persons is controversial. (See Benefit of Early
Detection and Treatment section of this guideline).


Diagnosis

          The requirements for a diagnosis of Lyme disease vary depending on the stage of
disease. In their 1997 evidence-based guideline, the American College of Physicians (ACP)
used the 1990 Centers for Disease Control (CDC) surveillance criteria, summarized in Table-1,
as a basis for a clinical definition of Lyme disease.2, 60 The ACP guideline based
recommendations on the accuracy of the serum enzyme-linked immunoabsorbent assay (ELISA)
serologic test (or the indirect immunofluorescence assay which is considered an equivalent test,
see below) combined with the likelihood of Lyme disease occurring in different clinical scenarios
accounting for local incidence rates of Lyme disease.2 In all three of Delaware’s counties, Lyme
disease occurs at a moderate rate of endemicity (see section on Incidence) defined by the CDC
as an annual rate of 10 to 29 cases per 100,000 people. The ACP guideline does not specifically
discuss the variability of Lyme disease throughout the year and whether testing should be altered
depending on the season. The low rate of acute infection during winter months argues against
serologic testing for early stage Lyme disease in the winter, while the delay of weeks to months
for later stage disease argues for maintaining the same threshold for ordering Lyme serology
year round.

Table-1: CDC 1990 Clinical Case Definition for Lyme Disease
Clinical Case Definition 1) Erythema migrans or
                         2) At least one advanced manifestation as defined below, and laboratory
                         confirmation of infection.
Advanced Manifestations           1) Musculoskeletal system


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                        Recurrent brief attacks lasting weeks or months of objective joint
                        swelling in one or a few joints, sometimes followed by chronic arthritis in
                        one or a few joints. Manifestations not considered criteria for diagnosis
                        include chronic progressive arthritis not preceded by brief attacks and
                        chronic symmetrical polyarthritis. Arthralgia, myalgia or fibromyalgia
                        syndromes alone are not criteria for musculoskeletal involvement.
                        2) Nervous system
                        Any of the following, alone or in combination: lymphocytic meningitis,
                        cranial neuritis, particularly facial palsy (may be bilateral);
                        radiculoneuropathy, or rarely encephalomyelitis (must be confirmed by
                        showing antibody production against B. burgdorferi in the CSF,
                        demonstrated by a higher titer of antibody in CSF than in serum).
                        Headache, fatigue, paresthesia, and mild stiff neck alone are not criteria
                        for neurologic involvement.
                        3) Cardiovascular system
                        Acute-onset, high-grade (2 or 3) atrioventricular conduction defects that
                        resolve in days to weeks and are sometimes associated with
                        myocarditis. Palpitations, bradycardia, bundle-branch block, or
                        myocarditis are not criteria for cardiovascular involvement.
Adapted from Wharton.

          Due to the limitations of laboratory testing for Lyme disease, authors have emphasized
that the diagnosis should be based on the clinical scenario; e.g. a history of tick-bite and
objective physical findings. Serologic testing should be used to support the clinical diagnosis and
not as the sole basis for treatment decisions.33, 61 Serologic testing for antibodies against B.
burgdorferi, including the serum ELISA, the indirect immunofluorescence assay and Western
blotting, are the standards in laboratory testing for Lyme disease 2 and can be useful in several
situations. It is important clinicians to understand the time course of the host antibody response
to B. burgdorferi infection and the performance characteristics of these laboratory tests to use
them appropriately.
          Serodiagnosis early in the course of Lyme disease is insensitive, as the host antibody
response to B. burgdorferi infections develops slowly. In a prospective study of 46 antibiotic-
treated persons with culture-proven EM, Aguero-Rosenfeld et al. reported that at diagnosis, only
33% of subjects had a positive ELISA result and 43% had a positive Western blot result; i.e. false
negative test results occurred in over half of subjects.62 Similarly, Nadelman et al. reported
positive ELISA results at diagnosis in only 34% of persons with culture proven EM.30 In the study
by Aguero-Rosenfeld et al, at days 8 to 14, 91% of subjects had a positive ELISA and/or Western
blot result.63
          In an area of moderate endemicity, a clinical diagnosis of early Lyme disease without
serologic testing is adequate to decide on initiating treatment in patients with a rash resembling
EM. The likelihood of Lyme disease in this clinical setting was estimated by the ACP expert panel
to be about 80%, while the sensitivity of the serum ELISA test in early Lyme disease has been
determined to be only 59%.2 Thus, a negative ELISA test in this setting is more likely to represent
a false negative result.2 Although EM-like rashes after a lone star tick (Amblyomma americanum)
bite have been reported,64 these are relatively uncommon and no new recommendations were
identified in this literature search that modified the recommendation to treat these rashes as
Lyme disease. In persons with EM, clinicians should inquire about symptoms suggesting Lyme
meningitis such as headache, subjective neck stiffness and photophobia. The American
Academy of Neurology, in an evidence-based 1996 guideline, stated that CSF testing may be
necessary to confirm nervous system involvement in Lyme disease including suspected Lyme
meningitis.65 This literature search identified no guidelines or prospective controlled studies
addressing the benefit of routine electrocardiographic testing for asymptomatic heart block in
persons with Lyme disease. Clinicians may consider CSF or electrocardiogrphic testing as the
treatment recommendations for nervous system and cardiac involvement with Lyme disease
entail intravenous therapy rather than the oral therapy used for uncomplicated cases of early
Lyme disease.


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           Serologic testing should not be used to determine the need for antibiotic therapy in
persons presenting with symptoms such as arthralgias, myalgias, headache, fatigue or
palpitations alone, without the classic signs of advanced Lyme disease (Table-1). The ACP
expert panel estimated that persons with such symptoms have a likelihood of Lyme disease of
less than 20%.2 In advanced Lyme disease, ELISA testing has a relatively low specificity of
81%. Therefore, in persons at lower than 20% risk of Lyme disease a positive ELISA is more
likely to represent a false positive result.2 Although the ELISA cannot be recommended for
routine use in any person without classic signs of Lyme disease, the 95% sensitivity of the ELISA
in advanced Lyme disease is high enough that a negative test may be used to rule out Lyme
disease.2
           Serologic testing may be useful in confirming a diagnosis of Lyme disease in patients
with classic signs and symptoms (Table-1) in areas of moderate endemicity. The ACP panel
estimated the likelihood of Lyme disease to fall between 20% and 80%2 in such patients.
Clinicians should ensure that there are objective clinical findings; e.g. Lyme arthritis presenting
with a swollen, not merely a painful, joint.2 In advanced Lyme disease, serologies are nearly
uniformly positive.2 The relatively high sensitivity of 95% for ELISA testing allows the clinician to
consider a positive ELISA in this setting as diagnostic for Lyme disease. In the case of an
indeterminate ELISA result, clinicians should obtain further testing using a Western blot (see
below).2 The high sensitivity of ELISA testing also implies that a negative test essentially rules
out Lyme disease. Clinicians should seek another cause of symptoms or signs in such patients
and repeat serologic testing for Lyme disease is not warranted.2 Studies have not shown clinical
utility in testing for seroconversion using paired acute-phase and convalescent-phase serum
samples and this approach cannot be recommended.2
           As in patients with early Lyme disease, CSF and electrocardiographic testing may be
useful in some patients with symptoms of chronic Lyme disease.2 The utility of CSF analysis in
adults or children with facial nerve paralysis without symptoms or signs of meningeal involvement
remains controversial.66 This review did not identify any prospective controlled studies that
addressed the benefit of routine electrocardiographic testing for asymptomatic heart block in
persons with Lyme disease.
           In persons with suspected rare manifestations of Lyme disease such as myositis or
neurophthalmologic conditions, there have been too few studies to develop an evidence-based
approach.2 The ACP recommends an ELISA test followed by a Western blot for indeterminate
results in these cases.2
           The Western blot is a serologic test like the ELISA but is capable of identifying particular
antibodies against B. burgdorferi. Thus, the Western blot is more specific than the ELISA. ELISA
and immunofluorescence testing may cross react with other borrelia species,67 treponemal
species68 or other pathogenic bacteria in peridontitis68 or subacute bacterial endocarditis.69
Western blot testing may help identify antibodies against B. burgdorferi even in such cases.
            The Western blot may not necessarily add additional information to the results of an
ELISA.2 One study suggested that the two-test protocol (ELISA follows by Western blot testing)
did not increase the specificity of the ELISA alone.70 In addition, adding the Western blot reduces
the sensitivity of serologic testing.71 One controlled study reported a sensitivity of only 50% and a
specificity of 100% using the two-test protocol.71 However, the Western blot is recommended in
addition to the ELISA in cases where an ELISA result is indeterminate.2, 61 Clinicians may
consider a positive Western blot in persons with classical symptoms and an indeterminate ELISA
as confirmation of Lyme disease.2 Like the ELISA test, the Western blot has a low positive
predictive value in persons at low risk, so testing in the context of non-specific or absent
symptoms is more likely to render a false positive result.72, 73
           The Lyme vaccine complicates serologic testing. Traditional whole cell ELISA testing
produces false positive results in persons following Lyme vaccination.74 Some researchers have
reported false positive testing using Western blot testing as well.75, 76 However, Aguero-
Rosenfeld et al. reported good discrimination between immune responses due to infection,
vaccination, and infection in vaccinated persons.62 Preliminary studies have demonstrated that
use of recombinant antigens from B. burgdorferi eliminating the outer surface protein A (OSP-A)
instead of the traditional whole cell ELISA, allow clinicians to distinguish the vaccination immune
response from active infection on ELISA testing.74, 76 These results need confirmation in


                                                                                                     8
controlled trials before recombinant ELISA testing can be widely recommended in vaccinated
persons. At present, clinicians should use caution in interpreting Western blot results in persons
who have received the Lyme vaccine.
         The serum indirect immunofluorescence assay may be used instead of the serum ELISA
in diagnosis of Lyme disease.2 Although some authors have noted that readings of
immunofluorescence assay results are more subjective than ELISA readings, on review of the
literature, the immunofluorescence assay appears to provide a sensitivity and specificity equal to
the ELISA.2
         Other laboratory methods used in diagnosis of Lyme disease include ELISA testing of
cerebrospinal fluid (CSF), culture of B. burgdoferi, T-cell proliferative assays, polymerase chain
reaction (PCR), and tick testing. None of these tests have demonstrated utility in the diagnosis of
Lyme disease.2 Culture isolation and histologic visualization of B. burgdorferi, have been studied
only in case series, therefore there is insufficient information to determine the accuracy of these
techniques.2 Culture may be useful for confirmation of the diagnosis of a non-typical EM rash,
but a negative result should not be used to rule out Lyme disease.2 B. burgdorferi has been
isolated from the advancing edge of EM lesions, with positive culture rates of 60%77 to 80%78
when a 2mm punch biopsies is used. The isolation rate was only 29% using saline lavage
needle aspiration.77 Culture of CSF, synovial fluid or tissue is less helpful as B. burgdorferi is not
easily recovered from clinical specimens other than EM lesions.2 Direct visualization of B.
burgdorferi in myocardial, retinal and brain samples has not been studied in controlled trials.2 In
studies designed to maximize recovery of B. burgdorferi from blood of persons with early Lyme
disease, Wormser et al. reported positive cultures in 25-50% of cases.66, 79
         In children, studies suggest that clinicians may use a similar diagnostic strategy as that in
adults. Fawcett et al., in a retrospective study of children diagnosed and treated for Lyme
disease in Delaware, reported that the presence of an EM rash or positive two-step serologic
testing correlated with good response to treatment.80 Seronegative children without EM and only
non-specific symptoms did not respond to multiple courses of antibiotic therapy.80

Screening

         Lyme disease does not meet US Preventive Services Task Force criteria for screening in
the asymptomatic general population. These criteria are: 1) screening must detect disease
earlier than without screening, 2) screening must be accurate, and 3) screening and treatment
must improve likelihood of a favorable outcome over the outcome when patients present with
signs and symptoms of disease.81 AS discussed previously, serologic testing is inaccurate in
early Lyme disease given the prolonged time course of antibody production. In an area of
moderate endemicity for Lyme disease such as Delaware, serologic testing for Lyme disease is
not useful in screening asymptomatic persons or in persons without classic features of Lyme
disease because the low risk of true disease in such cases means that a positive test more likely
represents a false positive result.5 No studies have demonstrated benefit from serologic
screening in sub-populations at higher risk for disease. A prospective screening study using
serologic testing among psychiatric patients in an area endemic for Lyme disease demonstrated
no increased rate of Lyme infection, leading the authors to conclude that screening in this
population was not useful.82 In addition, a short delay in diagnosis of Lyme disease may not have
serious consequences as evidence suggests that outcomes for persons treated for symptomatic
Lyme infection are good.1, 66
Discussion:

          Given the availability of effective treatment for Lyme disease, clinicians have been liberal
in their use of serologic tests as an aid in diagnosing Lyme disease. The common, but
inaccurate, perception that Lyme disease “can present like anything” also promotes the use of
serologic testing in unclear cases. However, serologic testing may be inaccurate, especially in
cases in which patients do not have typical signs and symptoms of Lyme disease. In persons
lacking classic features of Lyme, overdiagnosis disease based on false positive serologic testing
may result in inappropriate use of antibiotics with unnecessary exposure of patients to the
potential adverse effects and added expense of drug therapy. Clinicians should recognize the


                                                                                                     9
classic manifestations of Lyme disease, and then apply serologic testing carefully only as a
confirmation of the clinical diagnosis. Finally, there is no evidence to support further antibiotic
therapy in persons following antibiotic treatment for Lyme disease without persistent or recurrent
classic features of the illness. Guidelines have been developed by the American College of
Physicians for the diagnosis of this disease, and for the appropriate use and interpretation of
serologic testing. It is hoped that this literature review provided adequate background and a lucid
presentation of these guidelines to aid clinicians in diagnosing Lyme disease.




                                                                                                 10
   Clinical Evaluation of Lyme disease




                                                        Endemic Lyme
                                                        disease Area-
                                                          Delaware




        Erythema migrans or altleast one advanced manifestation as defined below:
             1) Musculoskeletal system - Recurrent brief attacks lasting weeks or months of objective joint
             swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints.
             Manifestations not considered criteria for diagnosis include chronic progressive arthritis not
             preceded by brief attacks and chronic symmetrical polyarthritis. Arthralgia, myalgia, or
             fibromyalgia syndromes alone are not criteria for musculoskeletal involvement.
             2)Nervous system - Any of the following, alone or in combination: lymphocytic meningitis,
             cranial neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy, or rarely
             encephalomyelitis (must be confirmed by showing antibody production against B. burgdorferi
             in the CSF, demonstrated by a higher titer of antibody in CSF than in serum). Headache,
             fatigue, parethesia, and mild stiff neck alone are not criteria for neurologic involvement.
             3)Cardiovascular system - Acute-onset, high-grade (2 or 3) atrioventricular conduction
             defects that resolve in days to weeks and are sometimes associated with myocarditis.
             Palpitations, bradycardia, bundle-branch block, or myocarditis are not criteria for
             cardiovascular involvement.




Erythema migrans (single or multiple lesions) with or                          Cardiac, neurologic, musculoskeletal
     without other manifestations noted above.                                     manifestations noted above.

                  Lyme disease
                                                                                              ELISA
                   diagnosed



                                                                    Negative              Indeterminant                    Positive

                                                            Lyme disease                                                   Lyme disease
                                                                                          Western Blot
                                                              ruled out                                                     diagnosed


                                                                                   Negative               Positive

                                                                           Lyme disease                   Lyme disease
                                                                             ruled out                     diagnosed



                                                                                                                      11
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                                                                                              14
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