Lyme Disease, Borrelia burgdorferi
Aiding in the diagnosis of Lyme Disease (LD).
Indications for Testing
Early localized Lyme disease does not require diagnostic testing before antibiotic therapy is started. A presumptive diagnosis can be made on the basis of the clinical presentation and a credible history of exposure to infected blacklegged vector ticks.
Diagnostic testing is appropriate for people with a history of tick exposure and symptoms of disseminated LD. Borrelia burgdorferi is the causative agent of LD. Test sensitivity improves as the agent affects tissue systems other than the skin. However, testing should be limited to those with objective signs of infection. Please refer to the table below.
|Stage of Infection||Recommended Clinical Management and Testing Strategy||Specimens of Choice for Diagnostic Testing|
|Erythema migrans, acute phase-Seasonal occurrence and exposure in an endemic area*||Clinical diagnosis and empirical treatment||None|
|Erythema migrans, acute phase- Out of season or no known exposure in an endemic area||2-tiered serology** – Repeat EIA in six weeks if negative; treatment at physician’s discretion.***||Serum, Plasma, Biopsy|
|Characteristic neurological, cardiac or joint involvement||2-tiered serology**||Serum,Synovial fluid or CSF|
|Persistent symptoms following recommended treatment||None||None|
*Endemic areas are localities where blacklegged ticks are established and B. burgdorferi cycles of transmission are maintained.
**Where appropriate, EIA is followed by confirmatory WB using diagnostic kits licensed in Canada.
***NAAT or bacterial culture are not generally performed.
Group Test Information
|Test Code||Reporting Name||Available Separately||Always Performed|
|BBURABGM||B. BURGDORFERI Ab IgG + IgM||No||Upon request|
|BBURDCFP||B. BURGDORFERI DNA;CSF;PCR||No||Upon request|
Recommended Testing Approach
The immune response to B. burgdorferi infection begins with the appearance of IgM antibodies, usually within two weeks of a vector tick bite. These antibodies may persist for months or even years despite effective antimicrobial therapy. Following IgM response IgG antibodies develop in most patients, typically after one month of infection.
A two-tiered serology testing is recommended for LD diagnosis. This consists of an enzyme immunoassay (EIA) screening followed by confirmation with Western blot (WB) testing for the detection of IgM and or IgG antibodies. When the above tests are performed in sequence the overall sensitivity and specificity are maximized.
Serology provides a snapshot of the immune status of the patient at the time of the specimen collection. For instance, if LD is suspected on the basis of symptoms but early serological testing is negative, follow-up testing on a convalescent sample is recommended.
EIAs are used as screening tests to detect IgM andor IgG antibodies that are directed against B. burgdorferi. EIAs rely on the use of whole-cell preparations of B. burgdorferi andor recombinant antigens. While most EIAs are highly sensitive they may lack specificity, in that false positives results can occur due to other medical conditions.
WB is used as the confirmatory test as it has greater specificity than EIA. WB detects IgM and or IgG antibodies that are directed against electrophoretically separated antigen extracts and recombinant antigens native to B. burgdorferi, and can differentiate IgM from IgG antibodies. A positive WB result is required to confirm exposure to B. burgdorferi. Demonstration of seroconversion from IgM to IgG antibodies by WB provides definitive evidence of a recent infection.
Two Tier Testing Algorithm
Special Instructions For Ordering Tests
The following must be provided:
1. Detailed travel history and date of onset of symptoms – This should be included on the requisition as it helps to apply the most appropriate testing algorithm.
2. History of antibiotic treatment – This can compromise the immune response to infection and may affect the interpretation of test results.
3. Presence of other infections or pre-existing conditions – Infection with other related pathogens (e.g. syphilis) and autoimmune disorders as these may lead to false-positive results.
4. Prior history of laboratory-confirmed LD– This is important as there is no pattern of serological response that can differentiate re-infection from an initial infection with B. burgdorferi.
Test Method Name
Enzyme Immunoassay (EIA)
Western Blot (WB)
B. BURGDORFERI Ab IgG + IgM
Lyme IgG/IgM EIA
Lyme IgG Western Blot
Lyme IgM Western Blot
B. BURGDORFERI DNA
For testing IgM/IgG Antibodies by EIA:
Fresh human serum collected in serum separator tube. Minimum volume required– 0.5 mL. Hemolytic or lipemic sera may yield anomalous results.
Serum specimens may be stored refrigerated up to 5 days. For longer delays store samples frozen until shipped for testing; ship frozen sample on dry or wet ice.
Note: For Western Blot-IgM the specimen should be collected during the acute phase (<6 weeks) of onset of symptoms.
For testing IgG Antibodies by EIA:
A minimum volume required- 0.5 mL. Collect CSF into sterile tube without preservatives. In order to perform this test, the total albumin and total IgG concentrations of both the serum and CSF must be provided.
If submitting CSF, a sample of serum must also be submitted (see instructions for SERUM Collection above). Collect both CSF and serum samples at the same time.
Both CSF and serum specimens may be stored refrigerated up to 5 days. For longer delays store samples frozen until shipped for testing; ship frozen samples on dry or wet ice.
For testing by PCR:
CSF or Synovial fluid – minimum volume required 1.0 mL.
CSF and synovial fluid should be collected into sterile container without preservatives.
Store CSF and synovial fluid frozen until shipped for testing. Ship samples frozen on dry ice.
For testing by PCR:
Fresh biopsy required – 1 to 5 mg
Paraffin-embedded tissue or sections – 10 to 35 µm thick.
Fresh or paraffin-embedded tissue should be placed in moistened gauze and placed into sterile container and shipped.
Reject Due To
|Specimens other than||SERUM, CSF, Synovial fluid, biopsy|
|Anticoagulants other than||NA|
Aiding in the diagnosis of LD.
Interpretation of LD WB results in conjunction with positive or equivocal EIA results
|Both IgM and IgG WB negative||Result NOT consistent with B. burgdorferi infection. However, if symptoms persist, submit follow-up samples 6 weeks later.|
|Only IgM WB positive||Potentially a false-positive result if this is NOT an acute case (i.e. < 6 weeks post onset of symptoms).|
|Only IgG WB positive||Result consistent with B. burgdorferi infection of > 6 weeks duration.|
|Both IgM and IgG WB positive||Result consistent with recent or previous B. burgdorferi infection.|
ARUP Consult. Borrelia burgdorferi – Lyme Disease. The Physician’s Guide to Laboratory Test Selection and Interpretation. ARUP Laboratories, National Reference Laboratory, Salt Lake City, UT.
Hatchette, T.F., Davis, I., & Johnston, B.L. 2014. Lyme disease: clinical diagnosis and treatment. CCDR. 40:194-208
Lyndsay, L.R., Bernat, K., & Diabernardo, A. 2014. Laboratory diagnostics for Lyme Disease. CCDR. 40:209-217.
Mayo Medical Laboratories. Unit Code 83856: Lyme Disease Serology, Spinal Fluid. Test Catalogue. Mayo Medical Laboratories, Mayo Clinic, Rochester, MN.
National Microbiology Laboratory. Guide to Services. www.nml-lnm.gc.ca.
Steere, A. C. 2010. Borrelia burgdorferi (Lyme Disease, Lyme Borreliosis), p. 3071-3081. In Mandell, D., Bennett, J. E., and Dolin, R. Principles and practice of infectious diseases, 7th ed., vol. 2. Churchill Livingstone, Elsevier, Philadelphia, PA.
Wilske, B., Johnson, B. J. B., and Schriefer, M. E. 2007. P, p. 971-986. In Murray, P. R., Baron, E. J., Jorgensen, J. H., Landry, M. L., and Pfaller, M. A. Manual of Clinical Microbiology, 9th ed., vol. 2. ASM Press, American Society for Microbiology, Washington, DC.
See recommended testing approach and test interpretation
Day(s) and Time(s) Test Performed
Monday to Friday, as per standard NML protocols
Maximum Laboratory Time
Serology: Up to 20 calendar days
PCR: Up to 15 calendar days
Specimen Retention Time
As per standard NML protocols
Performing Laboratory Location
National Microbiology Laboratory, Winnipeg, MB