In the early stages of Lyme disease, erythema migrans is the strongest indicator of infection. If this occurs and is associated with a tick bite and possibly the development of a lymphocytoma, antibiotic treatment should be initiated immediately, without waiting for test results to corroborate the diagnosis. This is because borrelia-specific antibodies do not appear until 2-6 weeks after the onset of infection (1,2). The first issue is that erythema migrans occurs in only 50% of cases, whereas in the same percentage of cases, patients with borrelia do not recall being bitten by a tick (3). In this instance, serological tests, culture, and PCR may serve as alternate methods for diagnosing the disease.
The primary diagnostic tools for Lyme borreliosis are serological ests and PCR. Serological tests begin with an Elisa test, which must be validated by an immunoblot test if the result is positive. However, for a variety of reasons, the standard serological antibody tests - Elisa followed by immunoblot - frequently produce false negative results. To begin with, the specificity and sensitivity of these tests are poor, and the results could differ. Positive means both are positive at the same time (4), according to most guidelines (5,6,7,8), a contentious judgment given that neither the Elisa test nor the immunoblot are standardised for the identification of Lyme-specific antibodies. As long as the two tests aim to determine different antibodies, the challenge becomes normal. Thus, at least 15% of cases have a false negative immunoblot, which officially rejects the diagnosis of borreliosis even though the disease is present (9, 10).
However, a negative serological result does not rule out Lyme borreliosis for various reasons. Antibiotic treatment may prevent antibody formation, and seroconversion may not occur (11). Antibodies will also be undetectable if cortisone is used as an immunosuppressant, if the immune system is exhausted, or when there is a hereditary predisposition (12).
Consequently, the sensitivity of serological tests for Lyme Boreliosis can vary significantly:
50% for localized erythema migrans
77% for Lyme borreliosis
97% for chronic atrophic acrodermatitis
96% for Lyme arthritis
73% for non-specific Lyme disease (13)
Polymerase Chain Reaction (PCR) testing may be relevant not only for skin biopsies collected in the early stages of infection, but also for cerebrospinal fluid punctures in the event of neuroboreliosis and synovial fluid punctures in the case of joint inflammation (14). A negative result, however, does not rule out the diagnosis of borreliosis.
The sensitivity of the PCR test for Borrelia depends on the stage of the disease and anatomical location.
65%–90% for skin biopsies during erythema migrans and for chronic atrophic acrodermatitis (15, 16, 17)
50%–85% for joint samples (18)
10%–30% for cerebrospinal fluid (19)
It is also useful to assess antibodies in cerebrospinal fluid using the Elisa approach, as well as a novel method, the determination of the chemokine CXCL13, which is considerably enhanced in neuroboreliosis even in the early stages of the disease (20).
Perhaps the best test to indicate an active Lyme borreliosis infection is the lymphocyte transformation test, which is recommended by the German Borreliosis Association (21). "LTT for Borrelia is clearly positive even in the early stage of Borrelia infection (even if erythema migrans is present) and is generally negative or at least clearly regressive 4 to 6 weeks after successful completion of antibiotic treatment."
Indications for a Borrelia LTT include:
- evidence of an active Borrelia infection
- HIV-positive patients with ambiguous symptoms
- a seronegative or borderline serological result in patients with a strong clinical suspicion of Lyme borreliosis
- monitoring the therapy approximately 4-6 weeks after the completion of an antibiotic course
- monitoring the patient's progress if there is clinical suspicion of a Lyme borreliosis relapse
- a new infection." (22)
There is a chance that the first symptoms of the disease will not manifest until weeks, months, or even years after infection (23,24), and laboratory tests may be of no use. In this case, a differential diagnosis based on clinical clues is the sole solution, and treatment can only be assessed clinically. In these circumstances, a thorough understanding of the chronic phase manifestations of the disease is required.
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