Laboratory Diagnosis of Lyme Borreliosis

Abstract

Lyme borreliosis is caused by a growing list of related, yet distinct, spirochetes with complex biology and sophisticated immune evasion mechanisms. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases. The pathogenesis of Lyme borreliosis is incompletely understood, and laboratory diagnosis, the focus of this review, requires considerable understanding to interpret the results correctly. Direct detection of the infectious agent is usually not possible or practical, necessitating a continued reliance on serologic testing. Still, some important advances have been made in the area of diagnostics, and there are many promising ideas for future assay development. This review summarizes the state of the art in laboratory diagnostics for Lyme borreliosis, provides guidance in test selection and interpretation, and highlights future directions.

Keywords: Borrelia; Borrelia burgdorferi; Borreliella; Lyme disease; borreliosis; diagnosis; diagnostics; molecular methods; serology.

FIG 1

Kinetics of the antibody response in patients treated with antimicrobial therapy for localized erythema migrans (A) or erythema migrans with evidence of dissemination (B), as detected by polyvalent ELISAs. As shown, the antibody response typically reaches a higher titer and declines less rapidly when the duration of EM prior to administration of effective antimicrobial therapy is ≥7 days, compared with <7 days. (Based on data from references and .)

FIG 2

Ladder immunoblots demonstrating typical IgM and IgG antibody responses in individual patients with common manifestations of Lyme borreliosis. The correlating antibody titer, as measured using a semiquantitative whole-cell sonicate ELISA method, is shown at the bottom of each test strip. For the patient with erythema migrans, serum studies are shown using a sample collected during the acute phase of illness (at the time of initial presentation, prior to antimicrobial administration; strips 5 and 22) and using a sample collected in convalescence (28 days after initial presentation, following a standard course of antimicrobial therapy; strips 16 and 23). For the patient with neuroborreliosis, serum studies are shown using a sample collected during active infection (at the time of initial presentation, prior to antimicrobial administration; strips 10 and 27). For the patient with Lyme arthritis, serum studies are shown using a sample collected during active infection (at the time of initial presentation, prior to antimicrobial administration; strips 9 and 26) and using a sample collected 30 years after antimicrobial therapy (remote past infection; strips 14 and 38). Abbreviations: Conv, convalescent; Rem, remote; FC, functional control; CC, conjugate control; Cutoff, cutoff control; kDa, kilodalton; Neg, negative.

FIG 3

Conventional two-tiered serologic testing protocol for the diagnosis of Lyme borreliosis. (Adapted from reference .)

FIG 4

VlsE primary and tertiary structure. (A) The unique conserved N- and C-terminal regions are colored gray, direct repeats are red, and invariant regions of the cassette are blue, whereas variable cassette regions are orange. IR-VI (arrow) forms an alpha helix buried within the tertiary structure, with little surface exposure. (B) Schematic representation of the primary structure (color code as used in panel A). (C) Dimeric model of VlsE based on the crystal structure, illustrating how the formation of potential dimers could effectively shield invariant regions at the monomer-monomer interface. (Republished from reference with permission of the American Society for Biochemistry and Molecular Biology. Note: The figure, as originally published, has been modified here with the addition of an arrow in panel A.)

FIG 5

Recommended laboratory testing strategies for North American patients presenting with common manifestations of Lyme borreliosis.

FIG 6

Modified two-tiered serologic testing protocols for the diagnosis of Lyme borreliosis, using two polyvalent (total antibody) assays. Two orthogonal EIAs are used, either sequentially (A) or concurrently (B).

FIG 7

Modified two-tiered serologic testing for the diagnosis of Lyme borreliosis, using one polyvalent (total antibody) EIA, one IgM-specific EIA, and one IgG-specific EIA. The polyvalent assay can be used in the first tier, followed by orthogonal IgM- and IgG-specific assays in the second tier (panel A) or, alternatively, the IgM- and IgG-specific assays can be used in the first tier, followed by an orthogonal polyvalent assay (panel B). If desired, all three tests could be performed in parallel (concurrently) rather than sequentially (not shown).