MODULE 2: DIAGNOSING LYME DISEASE

Lesson 1: Stages of Lyme disease

• Early localized
• Early disseminated
• Chronic

Lesson 2: Differential Diagnosis – The Great Imitator

• Is Lyme Auto-immune?

Lesson 3: Signs and Symptoms of Lyme and Co-infections

Lesson 4: Testing for Lyme disease

• Direct tests
• Indirect tests

Lesson 5: Testing for Co-infections

Lesson 6: Knowing which tests to run and optimizing results

Lesson 7: Other tests to consider

LESSON 1: STAGES OF LYME DISEASE

• Before we talk about the symptoms of Lyme disease, let’s go over the three main stages of the disease.
• There are different phases of infection in Lyme disease.

Lyme disease is classified according to:

• longevity of infection.
• where it has spread in the body.
• how systemic it has become.
• types of signs and symptoms it is causing.
• Phases may not occur according to linear timeline – for example, some people experience symptoms of advanced neurological Lyme soon after a tick bite.
• The earlier the infection can be identified, the greater the success in treatment.

Early localized Lyme

• The classic sign of early local infection = circular, outwardly expanding rash called erythema migrans (or EM rash).
  • Classic EM rash is target shape – a red outer ring with a central clearing.
    • Nicknamed “bulls eye rash” because of it’s target-like appearance.
  • EM rashes can be patchy, diffuse, cover large areas of the body.
  • EM rash may occur at the site of the tick bite 3-30 days after the bite.
  • EM rash is absent in over 50% of Lyme disease cases.
  • Many patients have no recollection of such a rash, or if they think back to a rash they might have had, they may have not recognized it as an EM rash.
  • EM rashes are often misdiagnosed as ringworm, cellulitis, or spider bites.
• Early localized Lyme may present with flu-like illness, fevers, malaise, muscle soreness and headache.
• Can progress to later stages, even without the rash.
• Lyme disease should be considered with flu-like illness combined with possible exposure through activities such as camping, hiking or gardening.
  

Early disseminated Lyme

Bacteria spread through the bloodstream and affect other parts of the body:

• Muscle, joint and tendon pain, often migrating to different parts of the body.
• Dizziness and headaches, heart palpitations, severe fatigue and mood changes are common.
• Neurological symptoms – Bell’s palsy, meningitis, burning/ shooting pains.
• Skin sensations - crawling, tingling and burning.
• Cognitive changes - brain fog, memory loss and difficulty with focus and concentration.
• Psychological symptoms - severe anxiety, irritability, panic attacks, obsessive- compulsive traits.

Chronic Lyme disease

For a diagnosis of chronic Lyme disease, these three criteria must be present:

1. Illness present for at least one year (this is approximately when immune breakdown attains clinically significant levels).
2. Persistent major neurologic involvement (such as encephalitis/encephalopathy, meningitis, etc.) or active arthritic manifestations (active synovitis).
3. Active infection with B. burgdorferi (Bb), regardless of prior antibiotic therapy (if any).
   • Ref: Joseph Burrascano, MD, a physician at the forefront of Lyme disease treatment and research in the United States, and author of Advanced Topics in Lyme Disease: Diagnostic Hints and Treatment Guidelines for Lyme and Other Tick-borne Illness. There is a copy of these guidelines in your Resources folder.

Definitions given by ILADS:

• Persistent Lyme disease - symptoms continuing despite 30 days of treatment;
• Recurrent Lyme disease - the patient relapsing in the absence of another tick bite or EM rash;
• Refractory Lyme disease - a patient responding poorly to antibiotic therapy.

From this point on, our conversation is mostly going to be around chronic Lyme disease – although we will definitely cover treatment of acute Lyme in our treatment module.

LESSON 2: DIFFERENTIAL DIAGNOSIS, IS LYME AUTOIMMUNE?

Lyme disease is known as the “Great Imitator.”

• Its list of symptoms is long and varied.
• Can present differently in different individuals.
• Lyme disease can look atypical.
• Patients may have 3 symptoms or 33 symptoms.

Following is a sampling of illnesses that Lyme disease can mimic:

• Amyotrophic Lateral Sclerosis (ALS)
• Attention Deficit Disorder
• Autism
• Chronic Fatigue Syndrome
• Crohn’s Disease
• Encephalitis
• Fibromyalgia
• Interstitial Cystitis
• Irritable Bowel Syndrome
• Juvenile Arthritis
• Lupus
• Meningitis
• Motor Neuron Disease/ ALS
• Multiple Sclerosis
• Obsessive-Compulsive Disorder
• Parkinson’s Disease
• Psychiatric Disorders (depression, bipolar, OCD etc.)
• Raynaud’s Syndrome
• Rheumatoid Arthritis
• Scleroderma
• Sjogren’s Syndrome
• Thyroid disorders

Many of these diagnoses describe symptoms but do not give underlying cause.

• Especially true of “syndromes” – fibromyalgia, chronic fatigue syndrome.

Clues to Lyme disease being causative:

1. An individual has a constellation of symptoms involving multiple body systems. This is where allopathic medicine can fail because each specialist only looks at one individual system.
2. Traditional diagnostic tests do not lead to anything conclusive or any clear diagnosis (“The tests came back normal. There’s nothing wrong with you.”)
3. An official diagnosis can be made (such as one of the above) but standard medical treatment does not have the expected benefit or result.
4. A therapeutic trial of anti-Lyme treatment (such as a course of antibiotics) leads to Herxheimer reactions and/or symptom improvement.

Is Lyme an auto-immune disease?

• Lyme disease is not considered an autoimmune disease, however, can trigger auto-immunity within the body.
• Some people present with rheumatoid arthritis, Sjogren’s syndrome, lupus, Hashimoto’s thyroiditis etc.
  • These diagnoses may be correct and valid, but Lyme may have been the precipitating factor – triggering sufficient immune dysregulation that an auto- immune process occurred.
  • Sometimes also shows up as positive rheumatoid arthritis (RA) factor, or positive anti-nuclear antibodies (ANA), but no other markers that would confirm a specific diagnosis like lupus or Sjogren’s.
• Auto-immune susceptibility also underlies importance of gluten-free diet as anti-gliadin and anti-transglutaminase markers can be examples of the auto-immune trigger.
• Treating Lyme can improve or eliminate auto-immunity - I have seen ANA and RA turn from positive to negative with Lyme treatment.
• Theory: Ty Vincent – developer of Low-dose Immunotherapy for Lyme disease (offshoot of LDA).
  • Dr Vincent believes that Lyme disease is an auto-immune disease – that millions of people are infected with Lyme; and that the difference between those who get sick and those who don’t is an immune hyper-activation i.e. Lyme triggering an auto-immune process which leads to illness.

LESSON 3: SIGNS AND SYMPTOMS OF LYME AND CO-INFECTIONS

Comprehensive Symptom List For Lyme Disease

• This list does not distinguish co-infections, we will separate those out afterwards.
• Can be any combination of these symptoms.
• See also Burrascano’s Lyme symptom checklist, which is in your Resources area.
• Here is a fairly comprehensive list of the possible symptoms of Lyme disease (reproduced with permission from Canadian Lyme Foundation www.canlyme.org):

Skin

• Rash at the site of the bite.
• Rash on other parts of the body.
• Raised rash, disappearing and recurring.
• Striae (stretch marks) that may be red or purple.
• Scratches on the skin (like cat scratches).
• Lumps (nodules) under the skin.

Head, Face, Neck

• Unexplained hair loss.
• Headaches, mild or severe.
• Seizures.
• Pressure in head, white matter lesions in brain (MRI).
• Twitching of facial or other muscles.
• Facial paralysis (Bell’s palsy).
• Tingling of the nose, tongue, or cheek.
• Facial flushing.
• Stiff or painful neck.
• Jaw pain or stiffness.
• Dental problems (unexplained), tooth pain.
• Sore throat, clearing throat a lot, phlegm, hoarseness, runny nose.
• Difficulty swallowing, feeling as if something is stuck in the throat.

Eyes/Vision

• Double or blurry vision.
• Increased floaters; flashing lights.
• Pain in the eyes, or swelling around the eyes.
• Hypersensitivity to light.
• Phantom images in the periphery of vision.

Ears/Hearing

• Decreased hearing in one or both ears, plugged ears.
• Buzzing in the ears.
• Pain in the ears, over sensitivity to sounds.
• Ringing in one or both ears.

Digestive and Excretory Systems

• Diarrhea.
• Constipation.
• Irritable bladder (trouble starting, stopping).
• Interstitial cystitis.
• Upset stomach (nausea or pain).
• GERD (gastro esophageal reflux disease).

Musculoskeletal System

• Bone pain, joint pain or swelling, carpal tunnel syndrome.
• Stiffness of joints, back, neck, tennis elbow.
• Muscle pain or cramps.
• Fibromyalgia.
• Tendonitis.

Respiratory and Circulatory Systems

• Shortness of breath.
• Air hunger - cannot get full/satisfying breath.
• Chronic cough.
• Chest pain or rib soreness.
• Night sweats or unexplained chills.
• Heart palpitations or extra beats.
• Endocarditis.
• Heart blockage.

Neurological System

• Tremors or unexplained shaking.
• Burning or stabbing sensations in the body.
• Weakness, peripheral neuropathy or partial paralysis.
• Pressure in the head.
• Numbness in the body, tingling, pinpricks.
• Poor balance, dizziness, difficulty walking.
• Increased motion sickness.
• Light headedness, wooziness.

Psychological/ Psychiatric

• Mood swings, irritability, bipolar disorder.
• Unusual depression.
• Disorientation (getting or feeling lost).
• Feeling as if you are losing your mind.
• Over-emotional reactions, crying easily.
• Too much sleep, or insomnia.
• Difficulty falling or staying asleep.
• Narcolepsy, sleep apnea.
• Panic attacks, anxiety.
• Obsessive-compulsive traits.

Cognitive

• Memory loss (short or long term).
• Confusion, difficulty in thinking.
• Difficulty with concentration or reading.
• Speech difficulty (slurred or slow).
• Word finding difficulty.
• Stammering speech.
• Forgetting how to perform simple tasks.

Reproduction and Sexuality

• Loss of sex drive.
• Sexual dysfunction.
• Unexplained menstrual pain, irregularity.
• Unexplained breast pain, discharge.
• Testicular or pelvic pain.
• Vulvodynia.

General Well-being

• Phantom smells.
• Unexplained weight gain or loss.
• Extreme fatigue.
• Swollen glands/lymph nodes.
• Unexplained fevers (high or low grade).
• Continual infections (sinus, kidney, eye, etc.).
• Symptoms seem to change, come and go.
• Pain migrates (moves) to different body parts.
• Early on, experienced a "flu-like" illness, from which you have not recovered completely.
• Low body temperature.
• Allergies/ chemical sensitivities.
• Increased effect from alcohol and possibly more intense hangovers.
• Not unusual to have 30 or 40 boxes checked.
• One of big challenges – how they look does not represent how they feel.
  • Family and friends tell them they look great and don’t believe anything is wrong.
  • Doctors also can underestimate the seriousness of their illness as outward presentation does not always match their inward experience.

Symptoms of Co-infections

• There can be so much overlap between symptoms of Lyme and various co-infections, but important to look for nuances to get an accurate diagnosis.
• Each co-infection has a few key clues.
  • I look especially for Bartonella and Babesia, as Ehrlichia and Rickettsia tend to have more overlap with Lyme symptoms, and also more overlap in their treatment.

Borrelia:

• Gradual onset of symptoms.
• Multi-system – e.g. joint pain along with cardiac involvement; cognitive deficits with fatigue and muscle/ joint pain.
• Migratory pain from joint to joint.
• Fatigue and lethargy, worse in the afternoon.
• Numbness/ tingling/ pins and needles in extremities.
• Monthly cycles in both men and women, syncing with menstrual cycle for women.
• Stiff, crackly joints.
• Headaches originating in the neck.
• Slow response to treatment with initial flare (Herxheimer reaction), improvement over weeks with monthly symptom flare.
• EM rash in 25% to 50%.

Relapsing Fever:

• Symptoms tend to come for 2-9 days, then fade, and cycle in that way.
• Headache.
• Neck pain.
• Muscle/ joint pain.
• Easy bruising.
• Nosebleeds.
• Petechiae (small red-purple dot on the skin).
• Nausea.
• Loss of appetite.
• Lack of coordination.

Bartonella:

• Gradual onset of initial illness.
• Central nervous system symptoms out of proportion to musculoskeletal.
• CNS irritability including muscle twitches, tremors, insomnia, seizures, agitation, anxiety, severe mood swings, outbursts and antisocial behavior; OCD traits.
• More severe psycho-emotional symptoms – severe anxiety, OCD, panic attacks.
• Headaches – feel like ice picks in the head.
• Gastritis or abdominal pain, bowel problems (IBS).
• Tender sub-cutaneous nodules along the extremities, especially the outer thigh, shins, and triceps.
• Occasional lymphadenopathy (swollen, enlarged lymph nodes).
• Striae or stretch marks that are new, out of place, can be white or red/ purple in color.
• Scratches that appear on the skin out of nowhere, can disappear just as quickly.
• Pain in the sides and back of the ribs.
• Pain in soles of the feet, painful to walk in the morning.
• Tachycardia (rapid heart beat).
• Photophobia (light sensitivity).
• Rapid response to treatment but a rapid return of symptoms if treatment is stopped too early.
• Patients will say “from my neck down, I can live with my symptoms, from my neck up I’m a mess”.

Babesia -

• Night sweats and sometimes day sweats as well.
• Shortness of breath, air hunger, sighing.
• Dry, chronic cough.
• Fullness in the throat, difficulty swallowing.
• Severe headaches - dull, all over head, feels like head is in a vice/head pressure.
• Dizziness, light-headedness.
• Capillary angiomas especially on breasts.
• Vasculitis (red skin with white splotches).
• Hormone imbalance.
• Easy bruising.
• Burning symptoms.
• Head/ tooth/ sinus/ jaw symptoms.
• Stiff, crackly neck.
• Nausea.
• Ear ringing.
• Blurry vision.
• Vivid/ violent dreams, nightmares.
• Flushing.
• Flare-ups every 4-6 days.
• Failure to respond to Lyme treatment.
• Feeling of spaciness, wooziness, and impending doom.

Ehrlichia/ Anaplasma:

• Rapid onset of initial illness.
• Headaches-sharp, knife-like, and often behind the eyes.
• Muscle pain, not joint pain, can be mild or severe.
• Neurological symptoms – seizure disorders, shooting pains.
• Tendon pain.
• Pain in the right upper quadrant of the abdomen.
• Low WBC count, elevated liver enzymes.
• Rapid response to treatment.

Rickettsia:

• Fever/ chills.
• Headaches.
• Confusion.
• Aching muscles.
• Gastrointestinal symptoms – nausea, loss of appetite.
• Swelling of lymph nodes.
• Malaise.

LESSON 4: TESTING FOR LYME DISEASE

Points to remember:

• Inadequate testing for Lyme disease is one of the main reasons for misdiagnosis and under-diagnosis of Lyme disease.
• The ELISA test is not sufficient as a screen or diagnostic test for Lyme disease.
• The CDCs two-tiered system of ELISA test reflexed to Western Blot only if ELISA was positive was never intended to be used for diagnostic purposes.
• Lyme disease is a clinical diagnosis, backed up by lab tests. Must consider history, signs and symptoms, and response to treatment.
• A laboratory test can officially report as negative but can still have indicators of Lyme that are clinically significant.

Fundamentals of Testing

Lab testing for Lyme disease falls into two categories –

1. Direct tests
   • PCR
   • FISH
   • Culture
   • Biopsy
   • Antigen-capture tests
2. Indirect tests
   • ELISA
   • IFA
   • Western blots
   • Antibody tests
   • T-spot tests
   • CD-57

Ideally we run at least one direct and one indirect test to maximize the chances of obtaining an
accurate response.

• Or at least two indirect tests.

Direct tests: tests that look for the pathogen or parts of the pathogen in various body tissues
and fluids.

• Examples – PCR, FISH, culture, biopsy, antigen-capture tests.
• These tests tend to be less sensitive, but more specific – in other words, it can be difficult to find the pathogens in a particular blood or tissue sample, but if they are detected the chance of false positive is low.

Indirect tests: measure immune response to the pathogens.

• Examples – ELISA, Western blots, IFA, antibody tests, T-spot tests.
• Major challenge with indirect tests is that Lyme disease suppresses immune response.
• Indirect tests measure an immune response to a pathogen that suppresses immune response.
• Inherently challenging situation – underlies the importance of running multiple types of tests, using labs with the most advanced methodology, recognizing clinically relevant indicators within the tests, and considering the test results within the context of the history and clinical presentation.
• May cross-reference with white blood cell count and total antibody count – IgG, IgA, IgM to indicate status of immune system overall.

Direct Tests

PCR

• PCR - Polymerase Chain Reaction.
• 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.
• More likely to be positive in early infection.

Pros:

• Not dependent on immune function or immune reactions.
• High level of specificity.
• Available for multiple pathogens - Borrelia and co-infections.

Cons:

• Pathogens often burrow into tissues and may not be floating around in the bloodstream where they can be easily detected.
• Results optimized by running PCR on different types of body fluids – whole blood, serum, urine.
• 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.

Culture

• Culture test available in U.S. (Advanced Labs).
• Patient’s blood taken, introduced to a medium that promotes growth of bacteria.
• Bacteria that grow are identified by their cell characteristics and growth characteristics.
• Confirmed by immuno-staining; can be further confirmed by PCR testing.

Pros:

• Highly sensitive and specific.
• May be more reliable than Western blot and more sensitive than PCR.
• Advanced Labs claim high sensitivity and specificity.

Cons:

• Not available world-wide.
• At this time, culture tests for co-infections are not available.

Biopsy

Tissue samples can be taken from almost anywhere on the body and evaluated for different infections.

• Not a first line test, but may be performed in certain circumstances.

Pros:

• Can be helpful, especially when done at the site of an EM rash.
• Can also help identify small fiber nerve degeneration (linked to neuropathy and progression of Lyme disease).

Cons:

• More invasive procedure.

Lyme Direct Antigen Test

• Looks for Borrelia bacteria, or parts of Borrelia bacteria, in the urine.
• 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.
• Usually done with “provocation” i.e. Antibiotics a few days prior to collection.
• 3-day urine collection done (1 sample each day for 3 days).

Pros:

• Provocation with antimicrobials provoke bacterial death, making remnants more likely to show up in the urine.
• Can be used if Western blot results ambiguous.

Cons:

• Provocation typically done with intense course of medications, which can cause major Herxheimer reactions in some patients.

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.

Sample provocation schedule used by LLMD:-

Day 1 onwards

• Doxy 200 bid or minocycline
• Tinidazole 500 tid
• Zithro 500 or 600 qd

Day 4 – try to time this with day 1 of menses

• Rocephin 2gm IM
• Bicillin 1.2 mill IM

Day 5

• Urine #1
• Rocephin 2mg IM

Day 6

• Rocephin 2gm IM

Day 7

• Urine #2

Day 8

• Urine #3

Indirect Tests

ELISA test

Don’t bother.
Let’s move on.
Just kidding!

• However, ELISA test is the problem child of the Lyme testing community.
• The most commonly run Lyme test by non-Lyme literate practitioners, but one of the least useful.
• I only run ELISA test if patient absolutely does not have the means to pay out-of-pocket for any other test, and needs insurance coverage, just in case it might show up a Lyme- specific band and/or positive result.
• Insurance often will not cover other tests unless ELISA is positive.
• More often - patients come in with ELISA tests from other practitioners. A few are even positive!

Why is the ELISA test inadequate?

• Does not have required sensitivity to provide an adequate screen.
  • College of American Pathologists stated that a screening test must have at least 95% sensitivity to provide an adequate screen – ELISA does not have that level of sensitivity.
  • Studies show that 56% of Lyme patients test negative using the two-tiered approach recommended by the CDC (Stricker & Johnson, 2007). In fact, 52% of patients with chronic disease are negative by ELISA but positive by Western blot (Donta, 2002).
  • Therefore, approximately half of Lyme cases would have been missed with ELISA testing alone.
• 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.

Pros:

• Insurance coverage.

Cons:

• Inadequate sensitivity level.

IFA Test

Immuno Fluorescence Assay (IFA), or IFA test – pooled antibody test of IgG, IgM and IgA. The IFA is typically run in conjunction with Western Blots. It should not be used instead of a Western Blot.

• Makes up part of the Basic Lyme Panel through IGeneX.

Negative: <40
Equivocal: 40
Positive: > or = 80

Pros:

• Because it measures both IgM and IgG, it’s not as variably based on time after infection (assuming IgM antibodies present earlier in infection and IgG later in infection).
• Useful when run in conjunction with other tests, to make up part of the picture.
• Public health agencies recognize IFA test in its reporting, which can help accurate epidemiology.

Cons:

• Not a great stand-alone test, not diagnostic in and of itself.
• Concerns over cross-reactivity with antibodies to other spirochetes (this concern lessens in a Lyme-specialty labs that have high-quality testing procedures and highly experienced lab technicians).

Western Blot Test

• One of the foremost tests used in the evaluation of Lyme disease.
• More sensitive than ELISA or IFA, especially if performed by a laboratory that looks for all the bands that are related to Borrelia.
• 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.
• IgM and IgG antibodies are evaluated separately.
• CDC recognizes fewer bands than private labs => less information.
• Private labs such as IGeneX recognize a wider range of bands and therefore produces more and better information.

Labcorp/ Quest and other labs test by CDC criteria:

• 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
• In IgG testing, five of following 10 bands must be positive:
  • 18 kDa
  • 23 kDa
  • 28 kDa
  • 30 kDa
  • 39 kDa
  • 41 kDa
  • 45 kDa
  • 58 kDa
  • 66 kDa
  • 93 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 23, 31, 34, 39 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 pathogens, so a positive 41 can be indicative of other types of infections.

To register an IGeneX positive result, 2 of the above bands need to be positive in both the IgM and IgG Western blots.

Exceptions –

• 31 and 41 – reports as indeterminate.
• 31 and 83-98 – reports as negative.
• In both cases, follow up with band 31 confirmation test to confirm result.
• $100 add-on test – can be run on same blood sample as original panel.
• Test #488 for IgM and #489 for IgG.

IGeneX will report CDC criteria too – so a patient can be CDC negative and IGeneX positive.

• Advantages of IGeneX testing and reporting –
• Expanded criteria gives more thorough information => more clinically relevant.
• Many LLMD’s view even 1 Lyme-specific band as clinically relevant.
• Reports degrees of reactivity – from IND (indeterminate) to ++++. Can indicate degree of immune response.

Points to be aware of with Western blot:

• Even an indeterminate band may have clinical significance if it’s a Lyme-specific band.
• Even though by textbook definitions, IgM is supposed to be the first antibody on the scene of infection, with IgG coming in a few weeks later, and IgM levels declining; in chronic Lyme we often see IgM positive results in patients with long-term recurrent and persistent infections.
• While IGeneX reports the degree of reactivity on each band, the higher the reactivity does not necessarily mean the more severe the infection. In fact the opposite may be true, where the greater the band activity can often indicate a healthier immune response. Patients who have been infected for many years may no longer be mounting a significant immune response, and so their results may be “less positive”.
• The Western blot is probably the most clinically useful of the indirect tests, however still only shows exposure to Lyme disease; diagnosis is still done based on clinical picture – history, signs/symptoms and I would add response to treatment – as well as lab results.

A Note About Relapsing Fever tests:

• IGeneX now offers testing for Tick-Borne Relapsing Fever.
• RF is a different kind of Borreliosis.
• TBRF found in USA, Central Europe, Russia, Japan.
• Presents very similar to Lyme disease, relapsing aspect may not be noticeable, so good to test for it to be complete, especially in patients from those areas.

Relapsing fever divided into three categories:

1. Louse-borne RF
   1. Strain – B. recurrentis
2. Soft tick-borne RF
   1. Strains – several, include B. hermsii, B. duttoni, B. hisponica and others
3. Hard tick-borne RF
   1. Strain – B. miyamotoi

IGeneX tests – miyomotoi strain.

Relapsing Fever tests:

• PCR
• Western blots

T-spot/Elispot tests

• Elispot tests use cellular immune system to test rather than humoral immune system.
• Borrelia activates T cells as well as antibodies; T-spot tests measure how many T-cells have been activated.
• Theory is that T-cell activation occurs immediately after infection, and stops approximately six to eight weeks after completion of effective therapy or when the infection is resolved.
• Thus measuring T-cell reactivity to Borrelia may not be as subject to variability of antibody responses.
• May also be a good way to track effective treatment.

Pros:

• Not dependent on antibody responses (or lack thereof).
• More time-sensitive – will drop when infection is resolved.

Cons:

• Questions around sensitivity – I have seen T-cell tests negative in IgM positive patients who are highly symptomatic. CD-57 Test
• Immune marker that can reflect the degree of immunosuppression due to Borrelia, and hence the severity of the Lyme infection.
• CD (cluster designation) markers are found on T cells and NK cells – they give cells their appearance and function.
• Over 200 identified markers, numbered according to 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 immune cell expresses CD-57 marker, it is written as CD-57+.
• Lab testing can measure number of cells that carry a certain designation on T cell or NK cell.
• Borrelia has been associated with CD-57 (specifically Borrelia, not co-infections).
• The sicker/more immune suppressed the patient, the lower the CD-57 count appears to be.

Pros:

• Can be an indicator of the role of Lyme in symptomatology versus other illnesses that can cause similar symptoms eg CFS, RA, MS.
• Can sometimes help track treatment response and recovery.
• Gives clues about co-infections i.e. If the patient is very sick but has a high CD-57, it might indicate that co-infections are playing a greater role in their illness than Borrelia.

Cons:

• Not always a reliable indicator; levels can fluctuate day to day.
• Do not always change in response to treatment, even when patient improves.
• I have had several patients in remission retest their CD-57 and it’s just as low as before
  treatment => demoralizing! L
• Labs only run CD-57+ test on NK cells, not on T cells, so may be missing part of the
  picture.
• Not all labs run it correctly. In the U.S., IGeneX and Labcorp are the labs with the best
  methodology.

LESSON 5: TESTING FOR CO-INFECTIONS

Accurate Co-infection testing is extremely necessary.

• Undetected and untreated co-infections are one of the key reasons for treatment failure in Lyme disease.
• Co-infection information makes a huge difference in treatment planning, so it must be considered early on.

Main tests:

• Antibody tests
• FISH test
• PCR test

Antibody 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

IGeneX criteria for all the co-infections listed above are the following:

• I consider even mild elevations clinically significant.
• Remember with immune suppression, tests results are going to lean more towards false negative than false positive.
• Eg – IgM 20 – I would still treat for that co-infection, especially if the symptom picture matches that of the co-infection.
• As with Borrelia Western blots, we often see IgM elevations even in patients with long-term illness.

FISH tests

FISH = Fluorescent In-Situ Hybridization

• Direct test – does not rely on immune system/ antibody production.
• Smear test – ribosomal RNA will be marked on a thin smear of blood and examined under the microscope. Pathogens will fluoresce.
  • Good specificity, moderate sensitivity.
  • Currently available for Babesia and Bartonella through IGeneX.

Babesia strains examined:

• Babesia duncani
• Babesia microti

Whole blood examined, since Babesia lives in red blood cells.

Bartonella strains examined:

• B. vinsonii
• B. berkhoffii
• B. henselae
• B. quintana

PCR Tests

• Same methodology as PCR tests for Borrelia.
• Good specificity but not as great sensitivity.

Co-infections offered via PCR with IGeneX:

• Babesia – microti and duncani
• Bartonella henselae
• Ehrlichia – HME and HGA
• Rickettsia rickettsii and typhi

I tend to order FISH and antibody tests primarily, more than PCR.

LESSON 6: KNOWING WHAT TESTS TO ORDER AND OPTIMIZING RESULTS

• This lesson has been updated as of April 2023 to reflect changes in the laboratories themselves, as well as the tests available and what I have been choosing and why.
• All the previously taught information still applies – in particular that the ELISA test run through large commercial labs such as Labcorp and Quest are still inadequate and often do a disservice to patients because they potentially provide so many false negatives which could potentially prevent a patient seeking any further Lyme testing or treatment.
• Also, some labs are no longer in business, (Advanced Labs) and some I tried to use and am not using currently because of concerns as to sensitivity and specificity (DNA Connexions).
• Armin Labs in Germany I believe offers good quality testing, but is less practical for us in the United States.
• Galaxy Labs I used to use for Bartonella testing, but now that IGeneX has improved its Bartonella testing I do not see the need.
• Also, they only tested IgG antibodies for Bartonella quintana and henselae, not IgM, which I felt was overly limited. Rarely did a person come back negative on those two IgG markers.
• I will discuss a lab that has got involved in Lyme testing and is becoming quite popular, and the pros and cons I see of that particular lab (Vibrant Wellness).
• In my opinion, IGeneX is still the gold standard and is my go-to so I prefer to use their testing where possible.
• The two labs I am seeing now are Vibrant Wellness, and IGeneX, so I will go into more
  detail on each of those.

1. Vibrant Wellness

• Vibrant has grown rapidly into many different, more integrative, lab testing areas, including tick-borne infections, environmental toxins, mycotoxins, heavy metal testing, hormone testing, a variety of different gut health tests, etc.
• I personally felt they were trying to offer everything that previously I might have picked and chosen my favorites from different labs, and funnel all of those things into their lab.
• I have concerns about their interpretation of results, which I will share more on later.

Includes –

• Borrelia burgdorferi
• Borrelia mayonii
• Borrelia afzelii
• Borrelia garinii
• Borrelia bavariensis
• Borrelia spielmanii
• Borrelia hermsii
• Borrelia turicatae
• Borrelia miyamotoi
• Borrelia andersonii
• Borrelia maritima
• Borrelia californiensis
• Borrelia bissettiae
• Borrelia lusitaniae
• Borrelia valaisiana
• Borrelia yangtzensis
• Borrelia turcica

Lyme plus TBRF (PCR)

• Borrelia burgdorferi
• Borrelia mayonii
• Borrelia afzelii
• Borrelia garinii
• Borrelia bavariensis
• Borrelia spielmanii
• Borrelia hermsii
• Borrelia turicatae
• Borrelia lonestari

Coinfections 1 (IgG & IgM)

• Babesia microti
• Babesia duncani
• Bartonella henselae
• Bartonella elizabethae
• Bartonella vinsonii
• Bartonella quintana
• Anaplasma phagocytophilum
• Ehrlichia chaffeensis

Coinfections 1 (PCR)

• Babesia microti
• Babesia duncani
• Bartonella henselae
• Bartonella elizabethae
• Bartonella vinsonii
• Bartonella quintana
• HGA Anaplasma phagocytophilum
• HME Ehrlichia chaffeensis

Tick-borne Panel 2.0 – contains all of the above PLUS:

Coinfections 2 (IgG & IgM)

• Rickettsia typhi
• Powassan Virus
• Tickborne Encephalitis Virus
• West Nile Virus
• Chlamydophila pneumoniae
• Coxsackie Virus
• Mycoplasma pneumoniae

Coinfections 2 (PCR)

• Rickettsia rickettsii
• Rickettsia typhi
• Powassan virus
• Tickborne Encephalitis Virus
• West Nile Virus
• Chlamydophila pneumoniae
• Coxsackie virus
• Mycoplasma pneumoniae

Tickborne 2.0 + Opportunistic infections:

All of the above plus:-

Opportunistic Infections (IgG & IgM)

• Cytomegalovirus
• Epstein Barr Virus
• Parvovirus
• Toxoplasma gondii
• HSV-1
• HSV-2
• HHV-6
• HHV-7
• Streptococcal A

Opportunistic Infections (PCR)

• Parvovirus B19
• Toxoplasma gondii

Costs –

TBD 1.0 = $480

TBD 2.0 =$798

TBD 2.0 + Opportunistic infections = $1199

• As you can see the Vibrant panels are relatively less expensive than other panels and contain a vast number of pathogens and antigens.
• Their testing can be done via blood draw or dried blood spot (DBS), however PCR tests cannot be run when sample taken via DBS.
• However, the concern I have with the Vibrant panel is their interpretation.

Tickborne:
<10 = negative
10-20 = borderline
> 20 = positive

However, in their Western blot interpretation, they will count “moderates” towards the total result.

Whereas IGeneX only counts positive values to their final result.

This is their criteria:

IgM positive if:

• VLS E 1 or C6 Peptide or WCS (whole cell sonicate) is borderline or positive
• And 2 bands: 23-35 kda, 31 kda, 34 kda, 39 kda, 83-93 kda

IgG positive if: VLSE1 or C6 Peptide and positive in 2 bands: 18, 23-25, 28, 30 31, 34, 39, 41, 45, 58, 66, 83-93
Example: you can see that there are no “positive” markers, all are moderate/indeterminate, and yet the person receives a positive diagnosis of Lyme via Vibrant criteria.

• A LOT has to come back to the patient and their clinical presentation.
• Many people choose Vibrant because of the cost, but in my opinion the testing is not as clear in their result reporting as IGeneX, which leads to even more confusion in an already confusing space.
• Also, their reports are often 50 pages long which can be really overwhelming for both patient and practitioner!

Caveat: We do use Vibrant for SOT therapy.

• In SOT therapy, the patient must have a positive lab result within six months of doing the SOT.
• SOT therapy is also specific to a particular strain of the pathogen, so given that Vibrant tests so many different strains, and that the lab that creates the SOT accepts an indeterminate number as a positive result, that can be advantageous.
• My bigger concern is interpretation and whether they are finding everyone positive for Lyme and co-infections, even if one moderate antibody was found.
• If a person had one IgG antibody at level 12, for example, does that mean they have that infection?

EG:

Summary of Vibrant

Pros:

• Tests for many strains
• Good option for SOT testing
• Lower cost
• Can do Dried Blood Spot (except PCR) 

Cons:

• Results ambiguous
• Considers “moderate” elevations towards positive results.
• Rarely see IgM positive on Borrelia

IGeneX

• Still gold standard and the best lab option in my opinion.
• Is more expensive than Vibrant but more reliable, clear results.

IGeneX has improved their testing over the years.

• Borrelia burgdorferi – used to offer Western blot, now advanced that to an Immunoblot – more sensitive.
• Immunoblots offer speciation.
• If a band 31 is indeterminate on an immunoblot you can run a confirmation test to make sure it was Borrelia triggering that reading (test #488 and 489) – called an 31kDa epitope IgG and IgM respectively.
• Now also offering Immunoblot testing for Tick-borne Relapsing Fever, Babesia and Bartonella instead of just the IgM and IgG antibody tests that were described in the previous lesson.
• This is HUGE as it brings so much more accuracy to our results and makes co-infections easier to diagnose accurately.
• IFA has been replaced by Lyme screen immunoassay IgG and IgM (no longer pooled antibodies IgA, IgM, IgG).
• Has come out with culture-enhanced PCR tests for all major pathogens. Results take one month to turn around.
• Keeps blood samples on file for two months in case any further tests need to be run (including the band 31 confirmation tests). FISH/PCR tests cannot be run on existing samples.
• IGeneX offers a urine PCR test similar to that of DNA Connexions (test #TBD7).

Recommendations for selecting the best panel:-

• Firstly, always test for co-infections.
• Choose a panel - once starting to patchwork individual tests you lose the panel discounts so might not be cost effective.
• PCR still does not find a lot of positive especially in people who have been infected for a long time, so for me the extra findings (or lack thereof) do not justify the increase in expense.
• Love that we now have immunoblot for Borrelia burgdorferi, TBRF, Babesia and Bartonella so I use panels that incorporate those.
• I like to get FISH tests for Babesia and Bartonella if possible.

Favorite panel –

Currently called TBD 5 IBL-S – tick-borne disease panel 5.

• IBL = immunoblot.
• S = speciation.

Current cost (subject to change) – $1970.50

This panel contains –

Lyme screen immunoassay IgM and IgG (formerly IFA test)

Immunoblot for: 

• Borrelia burgdorferi
• Tick-borne relapsing fever (Borrelia miyamotoi, hermsii, turicatae)
• Babesia (microti, duncani, spp)
• Bartonella (elizabethae, vinsonii, henselae, quintana)

IgM and IgG IFA

• HME
• HGA

IgG IFA 

• Rickettsia rickettsii/typhi

FISH

• Babesia
• Bartonella

Second choice – TBD4 IBL-S

Current cost (subject to change) - $1662.50

This panel contains –

Lyme screen immunoassay IgM and IgG (formerly IFA test)

Immunoblot for:

• Borrelia burgdorferi
• Tick-borne relapsing fever (Borrelia miyamotoi, hermsii, turicatae)
• Babesia (microti, duncani, spp)
• Bartonella (elizabethae, vinsonii, henselae, quintana)

IgM and IgG IFA

• HME
• HGA

IgG IFA

• Rickettsia rickettsii/typhi

* Everything in the TBD5 except the FISH tests for Babesia and Bartonella.

If people can’t afford those panels, here are the options:-

• Remember that IGeneX does bill Medicare; testing must be ordered by an MD.
• Run the ELISA and Western blots through Labcorp, Quest etc and see what they show, but remember a negative result does not mean Lyme is not there (lots of false negatives)
• Run the basic Lyme panel without the TBRF or co-infections. That would be Lyme Immunoblot panel 1 through IGeneX.
• Run the TBD 1.0 through Vibrant as a screen, but be prepared to wade through the results and do a lot of interpretation based on clinical presentation.

Optimizing Results aka Overcoming The Challenges of Lyme Testing

• Do not give up if ELISA is negative.
• Run as many different types of tests as possible.
• The Immunoblot test is the more advanced version of the Western Blot test.
• Run both direct and indirect tests – usually PCR or FISH, then IFA/ Immunoblot.
• Use a lab that is known for Lyme testing such as the ones listed in this module.
• Unless you really know your co-infections, run a co-infection panel in addition to a Lyme panel.
• Consider if a certain test needs a “provocation” protocol. Most notably the urine antigen test.
• Consider whether your patient could tolerate a short-term, aggressive regimen or if that would set them back.
• Consider treating with doxycycline or a Lyme-specific herb for 21 days prior to blood collection for Western blots as a provocation agent. In general, I do not use provocation for the majority of my patients prior to testing.
• Being on antibiotics may reduce PCR accuracy, but it should not impact Immunoblots.
• Look at immune markers such as CD-57, and general antibody levels/ immune function.
• Remember that Lyme disease is a clinical diagnosis, so if you don’t find it on labs but the history and clinical presentation fit, then still treat the patient. If you feel nervous about starting antibiotic therapy in the absence of a positive test result, then start with natural antimicrobials and see how they progress.

LESSON 7: OTHER TESTS TO CONSIDER

Lyme disease impacts every body system and can cause much collateral damage.

• Important to assess and correct where it may be impacting, in order to maximize recovery.

Caution: do not do too much all at once and get overwhelmed!

• Bear in mind Lyme patients’ cognitive limitations with test instructions, especially for take-home kits.

Here are tests to consider:

General blood work:

• Red blood cell count, hemoglobin, hematocrit – especially in Babesia patients as can be hemolytic and cause anemia.
• White blood cell count – typically low in Lyme patients.
• Liver and kidney function – baseline then monthly with antibiotic therapy; screen for everyone.
• Iron and ferritin – especially in Babesia patients as hemolytic; and patients with fatigue.
• B12 and folate – especially in chronically fatigued patients.
• Vitamin D.

Methylation:

• Basic – blood tests for A1298C and C677T. Labcorp, Quest, others.
• Other private labs such as 23 and me offer more extensive SNP testing.
• Can be hard to interpret – can refer out for interpretation and assistance.

Hormones:

• Adrenal testing – salivary cortisol test to measure morning, noon, afternoon and night cortisol; plus DHEA. BioHealth Diagnostics, Neuroscience.
• Thyroid testing – TSH, free T3, free T4, reverse T3, anti-thyroglobulin, anti-TPO. Most labs ok.
• Hormones – estradiol, progesterone (both day 18-19), testosterone free and total. Any lab ok for bloodwork; sometimes can add in with salivary adrenal testing.

Digestion/Nutrition:

• IgG food sensitivity test – finger stick or blood draw. Great Plains Lab or US Biotek.
• Gluten intolerance panel – Enterolab stool tests.
• Microbial Organic Acid Test – urine test. Great Plains Lab. My preferred for assessing Candida through arabinose metabolites.

Immune system:

• Autoimmune markers – ANA, RA Factor.
• Quantitative antibody levels – IgG, IgA, IgM, IgE. Low antibody levels overall can contribute to seronegativity on Lyme labs.
• C4a and C3a – neurotoxin markers.
• Inflammatory markers – sed rate, CRP
• CD-57.

Other Infections:

• Chlamydia pneumonia, mycoplasma pneumonia – IgG and IgM.
• Viruses – Epstein-barr virus, Cytomegalovirus, Human Herpes virus 6, Human Simplex I and II.
• Candida antibodies – IgG, IgM, IgA. I prefer microbial organic acid test (urine), but antibodies often covered by insurance.

Toxic Stressors:

• Heavy metal testing – prefer provoked urine test unless patient too sensitive. I do not find hair tests nearly as accurate but may be a good choice in more sensitive people. Doctors Data.
• Mold markers/ mycotoxin levels. Two ways to do this:
  1. Mycotoxin levels directly – urine test, Real Time Labs.
  2. Indicators of mold toxicity – Labcorp, Quest.
     • Shoemaker’s guidelines:
     • Vasoactive intestinal peptide (VIP) – low in mold patients
     • Melanocyte-stimulating hormone (MSH) – low in mold patients
     • TGF-beta-1 – high in mold patients.
     • C4a – high in mold patients.
     • HLA genotyping – shows genetic susceptibility.