{"product_id":"understanding-lyme-disease-testing-a-patients-complete-guide-to-diagnosis","title":"Understanding Lyme Disease Testing: A Patient's Complete Guide to Diagnosis","description":"\u003cp\u003eLyme borreliosis (Lyme disease) is the most common illness spread by ticks in the United States and a growing public health challenge worldwide. This review examines how the causative bacterium, \u003cem\u003eBorrelia burgdorferi\u003c\/em\u003e, is detected and diagnosed in the laboratory, from growing the organism in culture to microscopic and molecular methods. It explains why different \u003cem\u003eBorrelia\u003c\/em\u003e species cause different patterns of illness in North America, Europe, and Asia, and why the choice of diagnostic test matters so much. The authors emphasize that culturing the bacterium remains the strongest proof of active infection, although it is slow and technically demanding.\u003c\/p\u003e\n\n\u003ch1\u003eDiagnosis of Lyme Borreliosis\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eWhy Lyme Disease Research Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#bacterium\"\u003eThe Bacterium Behind Lyme Disease\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#genome\"\u003eInside the Genome: Unusual Features\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#species\"\u003eThe Many Species of Lyme Bacteria\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#surface\"\u003eHow the Bacterium Changes Its Coat\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#spectrum\"\u003eThe Full Spectrum of Lyme Disease\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#lab\"\u003eLaboratory Diagnosis: The Big Picture\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#culture-media\"\u003eGrowing the Bacteria: Culture Techniques\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#culture-specimens\"\u003eWhich Patient Samples Can Be Cultured\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of This Research\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eLyme disease is caused by Borrelia burgdorferi, a spirochete transmitted by Ixodes ticks, with about 95% of U.S. cases in 12 states.\u003c\/li\u003e\n\u003cli\u003eCulture of the bacterium is the strongest proof of active infection but takes up to 12 weeks and requires specialized media and skilled microscopists.\u003c\/li\u003e\n\u003cli\u003eErythema migrans, the expanding rash of at least 5 cm, appears in at least 80% of patients with objective evidence and can be diagnosed clinically.\u003c\/li\u003e\n\u003cli\u003eUp to 10% of patients with Lyme arthritis may have joint inflammation lasting months or years despite antibiotics, more common with certain HLA DRB variants.\u003c\/li\u003e\n\u003cli\u003eDifferent Borrelia species cause disease in North America, Europe, and Asia, leading to regional differences in late manifestations like arthritis or ACA.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eWhy Lyme Disease Research Matters\u003c\/h2\u003e\n\n\u003cp\u003eLyme borreliosis (LB) — the medical name for Lyme disease — is transmitted by ticks of the \u003cem\u003eIxodes ricinus\u003c\/em\u003e complex. These are the same hard-bodied ticks, sometimes called deer ticks, that feed on people in wooded areas. The illness was first described as a distinct condition in the United States in the late 1970s.\u003c\/p\u003e\n\n\u003cp\u003eSince 1982, when public health tracking began, more than \u003cstrong\u003e200,000 cases\u003c\/strong\u003e have been reported to the U.S. Centers for Disease Control and Prevention (CDC). Between 1998 and 2001, roughly \u003cstrong\u003e17,000 cases\u003c\/strong\u003e were reported each year. In 2002, that number rose to \u003cstrong\u003e23,763 cases\u003c\/strong\u003e, giving a national incidence of \u003cstrong\u003e8.2 cases per 100,000 people\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eCases are highly concentrated geographically. About \u003cstrong\u003e95% of all cases\u003c\/strong\u003e occur in just 12 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin. That cluster sits in the northeastern, mid-Atlantic, and north central regions of the country.\u003c\/p\u003e\n\n\u003cp\u003eLyme disease is not only a North American problem. It is widely distributed across European countries, and it also occurs in far eastern Russia and parts of Asia. Because the disease is so common and so geographically widespread, the demand for reliable laboratory testing is enormous. In the United States alone, an estimated \u003cstrong\u003emore than 2.7 million serum samples\u003c\/strong\u003e are tested every year for antibodies against \u003cem\u003eB. burgdorferi\u003c\/em\u003e.\u003c\/p\u003e\n\n\u003cp\u003eTo meet that demand, laboratories have introduced many different tests. Some detect the bacterium directly. Others look for the immune system's antibodies using whole-cell lysates (broken-up bacterial material), recombinant antigens (lab-made proteins), or peptide antigens (short protein fragments). These tests are enzyme immunoassays (EIA, a test that uses a color change to detect a reaction). This review assesses how those tests were developed and how well they perform.\u003c\/p\u003e\n\n\u003ch2 id=\"bacterium\"\u003eThe Bacterium Behind Lyme Disease\u003c\/h2\u003e\n\n\u003cp\u003eThe causative agent, \u003cem\u003eBorrelia burgdorferi\u003c\/em\u003e, is a spirochete — a helically shaped (corkscrew-like) bacterium with multiple endoflagella (internal whip-like tails that let it swim). The cells are configured with \u003cstrong\u003e3 to 10 loose coils\u003c\/strong\u003e and measure \u003cstrong\u003e10 to 30 micrometers (µm) in length and 0.2 to 0.5 µm in width\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eThe organism was first recovered in 1982 from the vector tick \u003cem\u003eIxodes dammini\u003c\/em\u003e, now renamed \u003cem\u003eIxodes scapularis\u003c\/em\u003e. It was subsequently grown from skin biopsy specimens, cerebrospinal fluid (CSF, the fluid surrounding the brain and spinal cord), and blood samples. These samples came from patients in both the United States and Europe.\u003c\/p\u003e\n\n\u003cp\u003eCultured \u003cem\u003eB. burgdorferi\u003c\/em\u003e organisms are motile and swim when placed on freshly prepared slides. Live organisms can be seen using dark-field or phase-contrast microscopy — techniques that make thin, transparent objects visible without staining. They can also be recognized under a standard light microscope after staining with silver stains, or with fluorescent microscopic methods.\u003c\/p\u003e\n\n\u003cp\u003eThe structure of the bacterium has several layers. Its ultrastructure (fine internal anatomy) includes:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eAn outer slime surface layer (called the S-layer)\u003c\/li\u003e\n  \u003cli\u003eA trilaminar outer membrane surrounding the periplasmic space (the gap between the inner and outer membranes)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e7 to 11 periplasmic flagella\u003c\/strong\u003e inside that space\u003c\/li\u003e\n  \u003cli\u003eAn innermost compartment called the protoplasmic cylinder\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"genome\"\u003eInside the Genome: Unusual Features\u003c\/h2\u003e\n\n\u003cp\u003e\u003cem\u003eB. burgdorferi\u003c\/em\u003e was the first spirochete to have its complete genome (its entire set of genetic instructions) sequenced. The genome of the reference strain, \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto B31, totals \u003cstrong\u003e1,521,419 base pairs (bp)\u003c\/strong\u003e — the individual \"letters\" of genetic code.\u003c\/p\u003e\n\n\u003cp\u003eThat total splits into a linear chromosome of \u003cstrong\u003e910,725 bp\u003c\/strong\u003e, with a G+C content (a measure of the chemical makeup of DNA) of \u003cstrong\u003e28.6%\u003c\/strong\u003e, plus \u003cstrong\u003e21 plasmids\u003c\/strong\u003e — 9 circular and 12 linear — with a combined size of \u003cstrong\u003e610,694 bp\u003c\/strong\u003e. Plasmids are small, separate loops or strands of DNA that sit outside the main chromosome.\u003c\/p\u003e\n\n\u003cp\u003eComparing this genome to that of a related European species, \u003cem\u003eBorrelia garinii\u003c\/em\u003e strain PBi, researchers found most of the chromosome is conserved: \u003cstrong\u003e92.7% identity\u003c\/strong\u003e in both DNA and amino acid sequence. The chromosome plus two linear plasmids (lp54 and cp26), which carry approximately \u003cstrong\u003e860 genes\u003c\/strong\u003e, appear to form the basic genetic inventory of all Lyme \u003cem\u003eBorrelia\u003c\/em\u003e species. Not every strain of \u003cem\u003eB. burgdorferi\u003c\/em\u003e has the full set of plasmids, so total genome size varies between isolates.\u003c\/p\u003e\n\n\u003cp\u003eGenome analysis revealed several features that are uncommon among bacteria:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eA linear chromosome and multiple linear and circular plasmids\u003c\/li\u003e\n  \u003cli\u003eA unique organization of ribosomal RNA genes: a single 16S rRNA gene (\u003cem\u003errs\u003c\/em\u003e) with tandemly repeated 23S (\u003cem\u003errl\u003c\/em\u003e) and 5S (\u003cem\u003errf\u003c\/em\u003e) rRNA genes\u003c\/li\u003e\n  \u003cli\u003eMore than \u003cstrong\u003e150 lipoprotein-encoding genes\u003c\/strong\u003e, accounting for \u003cstrong\u003e4.9% of chromosomal genes\u003c\/strong\u003e and \u003cstrong\u003e14.5% of plasmid genes\u003c\/strong\u003e — significantly higher than any other bacterial genome sequenced at that time\u003c\/li\u003e\n  \u003cli\u003eA substantial fraction of plasmid DNA that appears to be in a state of evolutionary decay\u003c\/li\u003e\n  \u003cli\u003eEvidence of numerous, potentially recent DNA rearrangements among plasmid genes\u003c\/li\u003e\n  \u003cli\u003eA lack of recognizable genes for making amino acids, fatty acids, enzyme cofactors, and nucleotides\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe bacterium also lacks genes for tricarboxylic acid cycle enzymes (part of the cell's energy-producing machinery) and for compounds involved in electron transport. Taken together, these missing genes indicate that \u003cem\u003eB. burgdorferi\u003c\/em\u003e is parasitic by nature — it depends on its host for many basic building blocks rather than manufacturing them itself.\u003c\/p\u003e\n\n\u003ch2 id=\"species\"\u003eThe Many Species of Lyme Bacteria\u003c\/h2\u003e\n\n\u003cp\u003eEleven \u003cem\u003eBorrelia\u003c\/em\u003e species within the \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato complex (the broader group of related Lyme bacteria) have been described worldwide. They are not distributed evenly.\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNorth America:\u003c\/strong\u003e three species — \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto, \u003cem\u003eBorrelia andersonii\u003c\/em\u003e, and \u003cem\u003eBorrelia bissettii\u003c\/em\u003e\n\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eEurope:\u003c\/strong\u003e five species — \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto, \u003cem\u003eB. garinii\u003c\/em\u003e, \u003cem\u003eBorrelia afzelii\u003c\/em\u003e, \u003cem\u003eBorrelia valaisiana\u003c\/em\u003e, and \u003cem\u003eBorrelia lusitaniae\u003c\/em\u003e\n\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsia (China, Japan, Korea):\u003c\/strong\u003e seven species — \u003cem\u003eB. garinii\u003c\/em\u003e, \u003cem\u003eB. afzelii\u003c\/em\u003e, \u003cem\u003eB. valaisiana\u003c\/em\u003e, \u003cem\u003eBorrelia japonica\u003c\/em\u003e, \u003cem\u003eBorrelia tanukii\u003c\/em\u003e, \u003cem\u003eBorrelia turdi\u003c\/em\u003e, and \u003cem\u003eBorrelia sinica\u003c\/em\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eNot all of these species make people sick. In Europe, at least three are known to be pathogenic (disease-causing) in humans: \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto, \u003cem\u003eB. garinii\u003c\/em\u003e, and \u003cem\u003eB. afzelii\u003c\/em\u003e. In the United States, \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto is the only species known to cause human infection.\u003c\/p\u003e\n\n\u003cp\u003eWithin \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu stricto, researchers have identified several subtypes. Studies have linked specific subtypes to hematogenous dissemination (spread of the bacteria through the bloodstream) and tissue invasion in patients, as well as in experimentally infected animals.\u003c\/p\u003e\n\n\u003cp\u003eIn Asia, only \u003cem\u003eB. garinii\u003c\/em\u003e and \u003cem\u003eB. afzelii\u003c\/em\u003e have been definitively confirmed as human pathogens. Studies in patients and laboratory animals suggest that \u003cem\u003eB. bissettii\u003c\/em\u003e, \u003cem\u003eB. valaisiana\u003c\/em\u003e, and \u003cem\u003eB. lusitaniae\u003c\/em\u003e may also be capable of causing disease, but their ability to infect humans is not well established.\u003c\/p\u003e\n\n\u003cp\u003eGenetic comparisons show these species are closely related, with highly conserved chromosome gene orders and similar plasmid profiles. More recent studies, however, have documented meaningful genetic heterogeneity (variation) among isolates both in the United States and in Europe. A large number of \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato gene sequences are now available in GenBank, the public database maintained by the National Center for Biotechnology Information, including \u003cem\u003efla\u003c\/em\u003e, \u003cem\u003evlsE\u003c\/em\u003e, \u003cem\u003ebmpA\u003c\/em\u003e, and \u003cem\u003edbpA\u003c\/em\u003e, plus genes for 16S rRNA and outer surface proteins A and C.\u003c\/p\u003e\n\n\u003ch2 id=\"surface\"\u003eHow the Bacterium Changes Its Coat\u003c\/h2\u003e\n\n\u003cp\u003e\u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato expresses different surface proteins depending on where it is living — a survival strategy for adapting to different environments inside ticks and mammals. This matters enormously for diagnosis.\u003c\/p\u003e\n\n\u003cp\u003eWhen the spirochete resides in the midguts of unfed ticks, it displays OspA but not OspC. During a tick's blood meal, some spirochetes stop making OspA and begin making OspC instead. Other genes are expressed only in a mammalian host, or are significantly ramped up there. These include VlsE, DbpA, BBK32, Erp, and Mlp proteins.\u003c\/p\u003e\n\n\u003cp\u003eResearchers have used whole-genome microarrays (tools that measure the activity of thousands of genes at once) to study gene expression under conditions mimicking unfed ticks, fed ticks, and mammalian hosts. In one key experiment, \u003cem\u003eB. burgdorferi\u003c\/em\u003e B31 was grown at \u003cstrong\u003e23°C and 35°C\u003c\/strong\u003e, simulating the temperatures found in tick vectors and mammalian hosts, respectively. A total of \u003cstrong\u003e215 open reading frames\u003c\/strong\u003e (gene sequences) were differentially expressed at the two temperatures. Strikingly, \u003cstrong\u003e136 of these — 63% — were carried on plasmids\u003c\/strong\u003e. That finding highlights how important plasmid-carried genes are for adjusting to different environments.\u003c\/p\u003e\n\n\u003cp\u003eGenetic diversity and differential gene expression have direct consequences for laboratory testing. The choice of PCR primers (short DNA sequences used to detect bacterial genetic material) can target different segments of the genome. The selection of particular antigens for antibody tests can also change how sensitive and specific a diagnostic assay is.\u003c\/p\u003e\n\n\u003ch2 id=\"spectrum\"\u003eThe Full Spectrum of Lyme Disease\u003c\/h2\u003e\n\n\u003cp\u003eInfection with \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato can produce skin, neurological, cardiac, and musculoskeletal disorders. The basic clinical picture is similar worldwide, but there are well-documented differences between Europe and North America. Those differences are attributed to the different bacterial species causing disease on each continent, and even within Europe, patterns vary by region depending on which species dominates.\u003c\/p\u003e\n\n\u003cp\u003eEarly infection usually begins with localized erythema migrans (EM) — the expanding red rash often called the \"bull's-eye\" rash. Within days or weeks, it may be followed by clinical evidence of disseminated infection affecting the skin, nervous system, heart, or joints. Months later, late infection can appear.\u003c\/p\u003e\n\n\u003cp\u003eEM is the characteristic sign of early infection and the clinical hallmark of Lyme disease. In recent series, it is recognized in \u003cstrong\u003eat least 80% of patients\u003c\/strong\u003e who have objective clinical evidence of infection meeting the CDC's surveillance definition. The rash starts at the site of the tick bite as a red macule or papule (a flat or slightly raised spot), rapidly enlarges, and sometimes develops central clearing.\u003c\/p\u003e\n\n\u003cp\u003eThe clinical diagnosis of early Lyme disease with EM relies on recognizing the characteristic appearance of a skin lesion \u003cstrong\u003eat least 5 cm in diameter\u003c\/strong\u003e. At this stage, patients may have no symptoms at all. More commonly in the United States, patients may experience flu-like symptoms such as headache, myalgia (muscle aches), arthralgias (joint pain), or fever.\u003c\/p\u003e\n\n\u003cp\u003eSome investigators treat the combination of constitutional symptoms plus EM as evidence of dissemination, but the authors note this is not evidence based. They prefer to call this presentation \"symptomatic EM\" instead.\u003c\/p\u003e\n\n\u003cp\u003eHematogenous dissemination (spread through the bloodstream) can reach the nervous system, joints, heart, or other skin areas. Occasionally, hematogenous dissemination reaches other organs, and it can produce a wide range of early Lyme disease manifestations. Patients with objective evidence of dissemination usually experience one or more of the following syndromes:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eMultiple EM lesions\u003c\/li\u003e\n  \u003cli\u003eAtrioventricular conduction defects (disrupted electrical signaling in the heart)\u003c\/li\u003e\n  \u003cli\u003eMyopericarditis (inflammation of the heart muscle and surrounding sac)\u003c\/li\u003e\n  \u003cli\u003eArthritis\u003c\/li\u003e\n  \u003cli\u003eFacial palsy (weakness of the facial nerve)\u003c\/li\u003e\n  \u003cli\u003eMeningitis (inflammation of the membranes around the brain and spinal cord)\u003c\/li\u003e\n  \u003cli\u003eMeningoradiculoneuritis, also known as Bannwarth's syndrome (nerve root inflammation)\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eLate Lyme disease may develop in some untreated patients months to a few years after tick-transmitted infection. Its major manifestations are arthritis, late neuroborreliosis (peripheral neuropathy or encephalomyelitis — nerve damage or brain and spinal cord inflammation), and acrodermatitis chronica atrophicans (ACA, a slowly progressive skin condition).\u003c\/p\u003e\n\n\u003cp\u003eLyme arthritis begins as intermittent attacks of mono- or pauciarticular arthritis (affecting one or a few joints), especially large joints. In \u003cstrong\u003eup to 10% of patients\u003c\/strong\u003e, arthritis may persist for months or a few years despite treatment with antimicrobials (antibiotics and related drugs). Treatment-resistant arthritis is seen more frequently in patients with certain HLA DRB alleles (inherited immune-system gene variants). Researchers have suggested that autoimmunity — the immune system attacking the body's own tissues — plays a role in this form.\u003c\/p\u003e\n\n\u003cp\u003eWhere a patient lives shapes what late disease looks like. Lyme arthritis is the most common late manifestation in North America, while ACA appears to be the most common late manifestation in Europe. Again, these differences are likely due to the different bacterial species causing infection on each continent.\u003c\/p\u003e\n\n\u003ch2 id=\"lab\"\u003eLaboratory Diagnosis: The Big Picture\u003c\/h2\u003e\n\n\u003cp\u003eA variety of laboratory techniques have been developed for directly detecting \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato. These assays provide evidence of intact spirochetes, or of spirochete components such as DNA or protein, in tick vectors, reservoir hosts (animals that carry the bacteria in nature), or patients.\u003c\/p\u003e\n\n\u003cp\u003eFour different approaches have been used in the clinical laboratory:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003eMicroscope-based assays\u003c\/li\u003e\n  \u003cli\u003eDetection of \u003cem\u003eB. burgdorferi\u003c\/em\u003e-specific proteins\u003c\/li\u003e\n  \u003cli\u003eDetection of \u003cem\u003eB. burgdorferi\u003c\/em\u003e-specific nucleic acids (DNA)\u003c\/li\u003e\n  \u003cli\u003eCulture (growing the organism)\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eOf these, \u003cstrong\u003eculture of \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato undoubtedly offers the best confirmation of active infection\u003c\/strong\u003e, and it has been increasingly used as a diagnostic tool by researchers on both sides of the Atlantic. Growing the organism also lets scientists study the structural, molecular, antigenic, and disease-causing properties of the different species.\u003c\/p\u003e\n\n\u003cp\u003eDirect microscopic detection of the bacterium has limited clinical usefulness for confirming Lyme disease, because organisms are so sparse in clinical samples. Antigen detection assays other than PCR suffer from the same problem. Antigen capture tests have been used to detect bacterial antigens in the CSF of patients with neuroborreliosis. These tests have also been used in urine samples from patients with suspected Lyme disease, but their reliability is poor or, at best, questionable.\u003c\/p\u003e\n\n\u003ch2 id=\"culture-media\"\u003eGrowing the Bacteria: Culture Techniques\u003c\/h2\u003e\n\n\u003cp\u003eThe liquid media (nutrient solutions) used to grow \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato today were derived from the original Kelly medium through a series of modifications over time. Current versions include:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eBarbour-Stoenner-Kelly II medium (BSK II)\u003c\/strong\u003e — uses CMRL-1066 without glutamine, plus Yeastolate, neopeptone as the peptone preparation, and HEPES as a buffer\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eBSK-H\u003c\/strong\u003e — omits gelatin and uses different proportions of certain ingredients\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKelly medium Preac-Mursic (MKP)\u003c\/strong\u003e — removes Yeastolate and uses different proportions of certain ingredients; also called the Pettenkofer modification\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStoerner modification\u003c\/strong\u003e — adds Yeastolate and CMRL-1066, without glutamine and without sodium bicarbonate\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThese modern media support growth better than older versions. They allow recovery from low inocula (small starting numbers of bacteria), produce shorter generation times, and reach maximal spirochete concentrations of about \u003cstrong\u003e10\u003csup\u003e8\u003c\/sup\u003e to 10\u003csup\u003e9\u003c\/sup\u003e organisms per milliliter\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eKey ingredients of BSK II include CMRL-1066, a standard medium used for growing mammalian cells. Other ingredients include bovine serum albumin fraction V, a rich protein source that also stabilizes pH, and N-acetylglucosamine, a building block for the bacterial cell wall. BSK II also includes rabbit serum, citrate, pyruvate, and many other components. The growth-promoting ability of these media depends on careful selection of key ingredients, which can vary widely in composition.\u003c\/p\u003e\n\n\u003cp\u003eIncubation conditions matter too. Temperatures of \u003cstrong\u003e39°C (about 102°F) or higher may reduce or prevent growth\u003c\/strong\u003e. Cultures are incubated for \u003cstrong\u003eup to 12 weeks\u003c\/strong\u003e — far longer than is needed for most other human bacterial pathogens. That long wait reflects the spirochete's prolonged generation time of \u003cstrong\u003e7 to 20 hours or longer\u003c\/strong\u003e during log-phase growth.\u003c\/p\u003e\n\n\u003cp\u003eLaboratories detect growth by periodically examining a sample of the culture fluid for spirochetes. Laboratories use either dark-field microscopy or fluorescence microscopy after staining with acridine orange dye or a specific fluorescent-labeled antibody. Any spirochete-like structures seen must be confirmed as \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato, either by showing reactivity with specific monoclonal antibodies (identical, lab-made immune proteins) or by detecting specific DNA sequences using PCR.\u003c\/p\u003e\n\n\u003cp\u003eExperience matters here. A lack of familiarity with microscopic detection of \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato can lead to false-positive readings, because other structures such as cellular debris may look thread-like and be mistaken for the bacteria.\u003c\/p\u003e\n\n\u003cp\u003eThe organism can also be grown on solid media, with agarose added to solidify the liquid medium, and incubated under microaerophilic (low-oxygen) or anaerobic (oxygen-free) conditions. One advantage of solid media is that individual colonies can be identified, allowing researchers to isolate particular clonal strains.\u003c\/p\u003e\n\n\u003cp\u003eLaboratory-propagated strains of \u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato can also be cocultivated (grown together) with tick cell lines and with certain mammalian cell lines. These cocultivation techniques may prove useful for primary isolation of the bacterium directly from clinical specimens.\u003c\/p\u003e\n\n\u003ch2 id=\"culture-specimens\"\u003eWhich Patient Samples Can Be Cultured\u003c\/h2\u003e\n\n\u003cp\u003e\u003cem\u003eB. burgdorferi\u003c\/em\u003e sensu lato can be recovered from a variety of tissues and body fluids from patients with Lyme disease. These include:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eBiopsy and lavage (washing) specimens from EM skin lesions\u003c\/li\u003e\n  \u003cli\u003eBiopsy specimens from ACA skin lesions\u003c\/li\u003e\n  \u003cli\u003eBiopsy specimens from borrelial lymphocytoma skin lesions (a rare, benign skin nodule associated with Lyme disease)\u003c\/li\u003e\n  \u003cli\u003eCerebrospinal fluid\u003c\/li\u003e\n  \u003cli\u003eBlood\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThis breadth of possible sample types is important, because it means the recovery of the organism depends heavily on which tissue is sampled and at what stage of illness. The original scientific review continues from this point into detailed discussions of molecular detection methods. These methods include PCR and real-time quantitative PCR. The review also covers immunologic diagnosis. It also covers antibody detection methods such as immunofluorescence assays. The review also discusses enzyme immunoassays, Western immunoblotting, two-tier testing, and newer tests using recombinant and peptide antigens. It further covers borreliacidal antibody assays, detection of antibodies bound to circulating immune complexes, antibody testing in cerebrospinal fluid, and cellular immune response tests.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of This Research\u003c\/h2\u003e\n\n\u003cp\u003eThis review describes the state of diagnostic testing as of 2005, so the technologies discussed — and the performance figures quoted — reflect what was available at that time. Newer methods have entered the laboratory since then.\u003c\/p\u003e\n\n\u003cp\u003eSeveral limitations run through the whole field. Direct microscopic detection is limited by how few organisms are present in patient samples. Antigen detection tests outside of PCR have poor or questionable reliability. Culture, though the strongest confirmation of active infection, requires up to 12 weeks, needs specialized media and skilled microscopists, and can produce false-positive readings when staff lack experience. Even the bacterial genome varies between strains. Gene expression shifts depending on whether the organism is in a tick or a mammal — factors that can change how well a given diagnostic test performs.\u003c\/p\u003e\n\n\u003cp\u003eThe review also notes areas where knowledge remains unsettled. The ability of \u003cem\u003eB. bissettii\u003c\/em\u003e, \u003cem\u003eB. valaisiana\u003c\/em\u003e, and \u003cem\u003eB. lusitaniae\u003c\/em\u003e to cause human disease is not well established. And the idea that constitutional symptoms alongside EM prove the infection has disseminated is described by the authors as not evidence based.\u003c\/p\u003e\n\n\u003ch2 id=\"recommendations\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eYou may live in the northeastern, mid-Atlantic, or north central United States. You may have traveled to these regions. You may also live in or have traveled to Europe or parts of Asia where Lyme disease occurs. Understanding the diagnostic picture can help. Understanding the diagnostic picture can help you have a better conversation with your doctor.\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKnow the rash.\u003c\/strong\u003e Erythema migrans appears in at least 80% of patients with objective evidence of Lyme disease. A skin lesion of at least 5 cm that enlarges over days is the classic sign and can be diagnosed clinically, without a laboratory test.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eExpect a clinical diagnosis first.\u003c\/strong\u003e When the characteristic rash is present, doctors can often diagnose early Lyme disease by its appearance alone.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUnderstand that culture takes time.\u003c\/strong\u003e Growing the bacterium is the strongest proof of active infection, but cultures are held for up to 12 weeks because the organism divides slowly — roughly every 7 to 20 hours.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk which sample is being tested.\u003c\/strong\u003e The bacterium is found in different body sites at different stages — skin biopsies of EM, ACA, or lymphocytoma lesions, cerebrospinal fluid, and blood. The right sample depends on your symptoms.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk about the test's limitations.\u003c\/strong\u003e Microscopy and non-PCR antigen tests can miss the organism or produce unreliable results, and reading cultures requires experience to avoid false positives.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eReport persistent joint symptoms.\u003c\/strong\u003e Up to 10% of patients with Lyme arthritis may have joint inflammation that lasts months or years despite antibiotic treatment. This is more common in people with certain inherited HLA DRB gene variants.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe bottom line: Lyme disease is common, geographically concentrated, and caused by a genetically complex organism that changes its surface proteins as it moves between ticks and humans. That complexity is exactly why no single laboratory test is perfect, and why diagnosis still depends on combining your symptoms, your exposure history, and carefully chosen laboratory results.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is the most reliable way to confirm an active Lyme infection?\u003c\/h3\u003e\n\u003cp\u003eGrowing the bacterium in culture is the strongest proof of active infection. However, it is slow and technically demanding, requiring up to 12 weeks because the organism divides roughly every 7 to 20 hours. It also needs specialized media and skilled microscopists to avoid false-positive readings.\u003c\/p\u003e\n\u003ch3\u003eHow long does a Lyme culture take, and why?\u003c\/h3\u003e\n\u003cp\u003eCultures are held for up to 12 weeks. This long wait is because the bacterium has a prolonged generation time of 7 to 20 hours or longer during log-phase growth. Laboratories check periodically for growth using dark-field or fluorescence microscopy, and any spirochete-like structures must be confirmed with specific antibodies or DNA testing.\u003c\/p\u003e\n\u003ch3\u003eWhich body samples can be tested for Lyme bacteria?\u003c\/h3\u003e\n\u003cp\u003eThe bacterium can be recovered from several tissues and fluids: skin biopsies from erythema migrans, acrodermatitis chronica atrophicans, or borrelial lymphocytoma lesions; cerebrospinal fluid; and blood. The right sample depends on your symptoms and stage of illness, because the organism is found in different body sites at different times.\u003c\/p\u003e\n\u003ch3\u003eCan I be diagnosed with Lyme disease without a lab test?\u003c\/h3\u003e\n\u003cp\u003eYes. When the characteristic erythema migrans rash is present, doctors can often diagnose early Lyme disease by its appearance alone. The rash appears in at least 80% of patients with objective evidence of infection, and a skin lesion of at least 5 cm that enlarges over days is the classic sign.\u003c\/p\u003e\n\u003ch3\u003eWhat does it mean if my Lyme arthritis doesn't improve with antibiotics?\u003c\/h3\u003e\n\u003cp\u003eUp to 10% of patients with Lyme arthritis may have joint inflammation that lasts months or years despite antibiotic treatment. This treatment-resistant form is seen more frequently in people with certain inherited HLA DRB gene variants, and researchers have suggested that autoimmunity plays a role in this type of arthritis.\u003c\/p\u003e\n\u003ch3\u003eWhy do Lyme disease symptoms differ between North America and Europe?\u003c\/h3\u003e\n\u003cp\u003eDifferent Borrelia species cause infection on each continent. In North America, B. burgdorferi sensu stricto is the only species known to cause human infection, and Lyme arthritis is the most common late manifestation. In Europe, three species are pathogenic, and acrodermatitis chronica atrophicans is the most common late manifestation.\u003c\/p\u003e\n\u003ch3\u003eAre antigen tests or microscopy reliable for diagnosing Lyme disease?\u003c\/h3\u003e\n\u003cp\u003eDirect microscopic detection has limited clinical usefulness because organisms are sparse in clinical samples. Antigen detection assays other than PCR suffer the same problem. Antigen capture tests used on cerebrospinal fluid or urine have poor or questionable reliability. Culture remains the strongest confirmation of active infection, though it is slow and technically demanding.\u003c\/p\u003e\n\u003ch3\u003eI have a negative Lyme serology but ongoing joint and heart symptoms — when should I seek a second opinion on my Lyme disease diagnosis?\u003c\/h3\u003e\n\u003cp\u003eA negative antibody test does not rule out Lyme disease, because test performance shifts with the bacterial species, the antigens chosen, and the stage of illness. Culture of the bacterium is the strongest confirmation of active infection, but it takes up to 12 weeks and needs specialized media and skilled microscopists. If your symptoms persist despite a negative result, or if joint inflammation lasts months after antibiotics, an independent review can help clarify the picture. An independent review of your exposure history, symptoms, and laboratory results can help clarify the picture. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e Diagnosis of Lyme Borreliosis\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication details:\u003c\/strong\u003e \u003cem\u003eClinical Microbiology Reviews\u003c\/em\u003e, July 2005, Volume 18, Number 3, pages 484–509. Copyright © 2005, American Society for Microbiology. DOI: 10.1128\/CMR.18.3.484–509.2005.\u003c\/p\u003e\n\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47427809935516,"sku":null,"price":0.0,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0599\/5449\/5644\/files\/ddn-medical-article-understanding-lyme-disease-testing-a-patients-complete-guide-to-diagnosis-hero.png?v=1790203976","url":"https:\/\/diagnosticdetectives.com\/it\/products\/understanding-lyme-disease-testing-a-patients-complete-guide-to-diagnosis","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}