Testing for Lyme Disease

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In this blog, we will look at testing for Lyme Disease. You will learn:

  • What the standard tests for Lyme Disease are
  • How accurate these standard tests are
  • How Functional Medicine can help to accurately test for Lyme Disease

Do your clients suffer from Lyme Disease and do you know how to accurately test for it? Have they been misdiagnosed?  If you are struggling with these issues, then this blog is for you. Please read on for the details! 

Do you get stuck clinically with chronic symptoms in your patients?  Would you like to have a larger impact on improving your clients’ issues?

The key to treating disease is an individual approach using nutrition, lifestyle and exercise. To improve your patients’ quality of life, you need to identify and address each patient’s root causes. Our functional medicine course will teach you how to do this. Look into our functional medicine school (mindbodyfunctionalmedicine.com) to have a greater impact on improving your client’s lives.

       ** Please note: If you want the short summary version of this article, then please click here **

What is Lyme Disease? 

We have written extensively about Lyme Disease (LD). See our recent blog “What is Lyme Disease?”.

Lyme Disease is a bacterial infection, transmitted via tick bites. In its acute, early phase, it can often be successfully treated. If it goes misdiagnosed or untreated, symptoms can worsen and seriously affect a person’s quality of life. Therefore, it is important to get an accurate diagnosis for Lyme Disease.  

There are many Lyme Disease symptoms. The classic symptom of Lyme is a bull’s-eye rash at the site of the tick bite, but not everyone gets this rash. Without the bull’s-eye rash, Lyme’s clinical presentation is often not specific. Doctors can mistake Lyme Disease for autoimmune or inflammatory disorders (Kenyon SM, 2021).

The diagnosis of Lyme Disease is based on symptoms and how the patient presents. The lab results can support or confirm the diagnosis, but they are not the only thing we look at. Lyme Disease is often a diagnosis of exclusion. This means we may diagnose Lyme by ruling out other diseases or conditions. We need to be sure to look at symptoms and the whole picture. In our Functional Medicine clinic, we always strive to ‘treat the patient not the lab’. This means we look at the patient and their symptoms and don’t just follow lab results, which can sometimes be wrong.

What is the Current Testing Available?

Using the current available tests for Lyme can be helpful in making a diagnosis. But we need to be aware that there are issues with the accuracy and usefulness of the current lab testing.

Serology testing has been the gold standard test for LD since the mid-1990′s (Kenyon SM, 2021). A serology test is an antibody test, based on a blood serum sample. An antibody is also called an immunoglobulin. It is a protein that the immune system produces in response to a foreign substance, called an antigen. Antibodies recognize and attach to antigens in order to remove them from the body.

The blood tests used today cannot identify the actual Lyme bacteria causing infection or its antigens. Instead, the tests identify the antibodies an infected person’s body produces in response to these antigens. If you have antibodies, then you have been exposed to Lyme and your body has produced the antibodies against the Lyme antigens. Lab tests to identify antibodies to the bacteria help to confirm or rule out a Lyme diagnosis.

Lyme lab test results can be variable depending on the length of infection and the test methodology used (Kenyon SM, 2021). The tests are most reliable a few weeks after an infection, once the body has had time to develop antibodies.

There are different types of serological tests. One test used for Lyme is an enzyme-linked immunosorbent assays (ELISAs). ELISAs use fluorescent light for signal detection (Branda, 2021). The signals are produced by enzyme reactions. These reactions happen while the test is identifying and counting a specific antigen or antibody in a solution. The ELISA detects whether or not the antigen and antibody for Lyme are in the blood. The ELISA has been shown in some studies to have a 66% chance of a false negative (Branda, 2021). Despite this evidence, it is considered the gold standard of care. We do not recommend using the ELISA as a way of diagnosing Lyme.

Another test for Lyme Disease is the Western blot, also called an immunoblot test. This is an immunoglobulin test that looks at the body’s ability to react to various proteins from Lyme bacteria. One of the problems with this test is that the interpretation is based upon old diagnostic criteria. This is why it is important to work with a Lyme literate doctor who has the training to properly evaluate the test results.

In addition to these two testing mechanisms, a third test is available. This third mechanism is PCR testing. PCR testing looks for DNA of the microorganism. We love testing sites such as Vibrant Wellness that combine the Western blot test with PCR tests. This helps reduce the chances of false negatives from testing.

The Two-Tier Test Approach

Current CDC guidelines recommend a two-test approach, using the ELISA and the Western blot tests. This standardized two-tiered testing protocol is meant to improve sensitivity in the first test and specificity in the second (Branda, 2021). While this is good in theory, it has MAJOR problems. The biggest problem with two tier testing is that the first tier is the ELISA. The ELISA has a 66% chance of a false negative. Further testing is only completed if the first tier is POSITIVE. Since the first tier has a high probability of a false negative, Lyme Disease is often missed with this sort of test.

Sensitivity is the ability of a test to correctly identify patients with a disease. A test that is 100% sensitive means all people sick with the specific disease are correctly identified as having the disease by the test i.e., there are no false negatives. A false negative test result is when the person has the disease, but the test result is negative.

Specificity is the ability of a test to correctly identify people without the disease. A test that is 100% specific means all healthy people are correctly identified as not having the specific disease the test looks for, i.e., there are no false positives. A false positive test result is when the person does not have the disease but the test result is positive.

We have already discussed the problem with the first tier not being effective. The ELISA is simply not sensitive enough to be able to properly identify Lyme Disease.

The second test to run is the Western blot test. If the ELISA test is positive or unequivocal, then the Western blot test is usually done to confirm the diagnosis. The Western blot checks for the antibodies IgG (immunoglobulin G) and IgM (immunoglobulin M) (Branda, 2021). Again, we strongly recommend that people skip the ELISA test and move straight to Western blot testing.

Immunoglobulin G is a type of antibody. It makes up about 75% of serum antibodies in humans and is the most common type of antibody found in blood circulation. Immunoglobulin M is another type of antibody in humans. IgM is the largest antibody and is the first antibody that appears in response to an initial exposure to an antigen.

A positive Western blot could result in either an IgM or IgG result. In the early stages of the Lyme infection, a positive IgM or IgG result confirms a recent infection with Borrelia burgdorferi. If the infection is older than 4 weeks, and the test shows a positive IgG result, this is evidence of a current or previous infection (Columbia Univ., 2022). However, because Lyme Disease can go dormant and then reactivate, IgMs will sometimes be active in those with chronic Lyme much older than 4 weeks.

How well do the Current Tests Work?

We recommend working with a Lyme-literate doctor, who has experience in diagnosing and treating Lyme Disease. Understanding Lyme test results requires experience and skill. Doctors who are not Lyme-literate may be using the wrong test or may not interpret the tests correctly (Schmid H, 2021). This means they may falsely tell you that you do not have Lyme Disease when you really do.

Consider the following statistics from lymedisease.org:

  • 56% of patients with Lyme Disease test negative using the two-tiered testing system recommended by the CDC (lymedisease.org, 2021).
  • 52% of patients with chronic Lyme Disease are negative by ELISA but positive by Western blot (lymedisease.org, 2021). Other studies have shown as high as 66% false negatives for the ELISA test.

Based on these numbers, there are clearly issues with the current Lyme tests.

What are the Issues with the Current Lyme Testing Approach?

Testing is not sensitive during the first 3 weeks of infection because the body takes time to produce antibodies (Columbia Univ., 2022). A negative test early on in infection is not meaningful as the antibody response takes 1 - 3 weeks to develop (Columbia Univ., 2022).

A positive test does not mean that an active infection is present. Having antibodies just means that a person has been infected with Lyme Disease recently or in the past. The immune system has a long memory, so antibodies may last for years after the infection is gone. The antibody test cannot definitively say whether or not an infection is present and active at the time of the test. We have to look at symptoms as well.

Lab accuracy is a potential issue (Molloy PJ, 2001). The test results in the Western blot depend on which lab does the test. An experienced lab typically has an accurate and high specificity with Western testing (Branda, 2021). Tests done at less experienced labs can be mistakenly interpreted by the lab and give a false result (Branda, 2021). The top three general medical laboratories in the nation fail to detect 35% of Lyme antibodies (Molloy PJ, 2001). We recommend using labs that specialize in Lyme and other tick-borne infections.

‘Cross-reactivity’ can be a problem with the current tests. Other microbes, such as a virus or another bacterium, may contain proteins that are similar to the Lyme proteins. The antibodies formed to target this other microbe then mistakenly will attach to the protein markers on the Lyme test and can lead to false positive results (Columbia Univ., 2022).

Antibody tests have poor sensitivity in both early Lyme disease and in the later stages of Lyme disease. This lack of sensitivity could result in a false negative result.

The Western blot test is difficult to interpret. It is important to have an experienced Lyme literate doctor who knows how to interpret the tests correctly, to get the right diagnosis. The test result is based on reading and interpreting a series of ‘bands’. Testing positive on some bands of the IgG Western blot may not be relevant. Some bands can attract cross-reactive antibodies that target other microbes. So, reactivity on a small number of bands does not necessarily mean there is a Lyme Disease infection (Columbia Univ., 2022)

There is no reliable test to check if Lyme has been cured or resolved, after Lyme treatment (Chou E, 2021). Antibodies will still be present even if the infection is not active, as they stay in the immune system for a long period after active infection. We can only judge this based on symptoms.

The ELISA and Western blot tests only detect one strain of one species of Borrelia, the Borrelia burgdorferi B31 strain (Branda, 2021). The tests do not pick up infections caused by the multiple other strains or species of Lyme Borrelia which exist. If a patient is infected with a species or strain that the test cannot identify, they will get a false negative test result and possibly a misdiagnosis (Branda, 2021). Almost all Lyme cases in North America are from the B. burgdorferi strain B31 (Branda, 2021). In Europe, most Lyme borreliosis cases are caused by B. afzelii or B. garinii and in Asia, B. garinii is the main strain (Branda, 2021).

In the US, the sensitivity of the Western immunoblot is higher in patients infected with B31 strains than in patients infected with other strains (Branda, 2021).

Doctors should use both the ELISA and the Western blot test. 10% of patients with a positive IgG Western blot test have a negative ELISA (Columbia Univ., 2022). The Western blot has a very high specificity (very few false positives). So, in a small number of cases, we cannot really rely on the ELISA test to indicate using a Western blot test. A true positive IgG Western blot result may be missed based on a false negative from the ELISA (Columbia Univ., 2022).

Functional Medicine Testing

Functional Medicine and Lyme-literate doctors use the Western blot test. The Western blot is the best first step in assessing for Lyme Disease. Interpreting this test takes skill. The test result is based on reading and interpreting a series of ‘bands’. Knowing which bands are relevant and reasonably specific for Lyme is key to a correct interpretation and diagnosis using the Western blot (Molloy PJ, 2001).

The Western blot test improves specificity (Branda JA, 2018). Which bands and how many are reactive on the Western blot can provide information about the length of infection, as the antibody response increases over time (Branda JA, 2018).  But this test’s high specificity is offset by poor sensitivity in the early stages of Lyme Disease. This is because the antibody response measured on the Western blot takes more time to develop (Branda JA, 2018).

It is also possible to take a Western Blot test with a PCR test. This helps reduce the chances of false negatives from testing.

We use the Western blot test to diagnose Lyme and have extensive experience in interpreting it correctly.

Research on New Testing Methods: The Future of Lyme Testing

New tests for Lyme Disease will hopefully be able to identify an active vs. a past infection.

Direct detection tests that could pick up the Lyme bacteria in either blood serum or urine would be better. But Lyme bacteria proteins may not be consistently present in blood or urine. So, these direct tests may not reliably detect Lyme, even using the most sensitive methods (Branda, 2021).

Other indirect tests may be developed, but they may not be able to provide a clear and definitive result (Branda, 2021). This is because indirect tests are reliant on a reaction in the host body in response to Lyme bacteria being present, and this takes time to develop. But new testing methods may improve upon the current technology of serology testing.

In Conclusion

Lyme is sometimes a diagnosis of exclusion where we rule out other diseases. Testing can be helpful if it is correctly interpreted. In our clinic, we conduct a detailed analysis and ‘treat the patient not the lab’. We will assess lab results, symptoms and the whole picture in order to come up with a correct diagnosis.

In our clinic, we have expertise in diagnosing and treating a range of complicated, difficult-to-diagnose conditions like acute and chronic Lyme Disease. We regularly diagnose, treat and resolve Lyme, chronic infections and other complex conditions in patients in our Functional Medicine clinic.

** Please stay tuned for our next Blog!  **

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