CLINICAL MICROBIOLOGY REVIEWS, July 2005, p. 484–509 Vol. 18, No. 3 0893-8512/05/$08.00ϩ0 doi:10.1128/CMR.18.3.484–509.2005 Copyright © 2005, American Society for Microbiology. All Rights Reserved. Diagnosis of Lyme Borreliosis Maria E. Aguero-Rosenfeld,1,4* Guiqing Wang,2 Ira Schwartz,2 and Gary P. Wormser3,4 Departments of Pathology,1 Microbiology and Immunology,2 and Medicine,3 Division of Infectious Diseases, New York Medical College, and Westchester Medical Center,4 Valhalla, New York INTRODUCTION .......................................................................................................................................................484 CHARACTERISTICS OF B. BURGDORFERI........................................................................................................485 B. burgdorferi Genospecies .....................................................................................................................................485 LYME BORRELIOSIS: DISEASE SPECTRUM....................................................................................................486 LABORATORY DIAGNOSIS....................................................................................................................................486 Direct Detection of B. burgdorferi .........................................................................................................................486 Culture of B. burgdorferi sensu lato .................................................................................................................487 (i) Culture techniques ....................................................................................................................................487 Downloaded from (ii) Culture of clinical specimens .................................................................................................................487 (iii) Sensitivity of culture...............................................................................................................................489 (iv) Practical considerations .........................................................................................................................489 Molecular methods of detection of B. burgdorferi sensu lato .......................................................................490 (i) PCR analysis of clinical specimens ........................................................................................................490 (ii) Real-time quantitative PCR....................................................................................................................492 (iii) PCR sensitivity and specificity..............................................................................................................492 (iv) Applications and limitations of molecular methods...........................................................................492 Immunologic Diagnosis of B. burgdorferi Sensu Lato Infection.......................................................................492 http://cmr.asm.org/ B. burgdorferi sensu lato antigens of importance in immunodiagnosis.......................................................493 Antibody detection methods ..............................................................................................................................493 (i) IFA...............................................................................................................................................................494 (ii) Enzyme immunoassays............................................................................................................................494 (iii) Western IB ...............................................................................................................................................495 (iv) Two-tier testing ........................................................................................................................................496 Newer EIA antibody tests ..................................................................................................................................497 (i) Enzyme immunoassays using recombinant antigens ...........................................................................497 (ii) Peptide-based immunoassays .................................................................................................................498 on July 30, 2018 by guest (iii) Use of a combination of recombinant or peptide antigens in immunoassays ...............................498 Other antibody detection methods ...................................................................................................................499 (i) Functional antibodies: borreliacidal antibody assays ..........................................................................499 (ii) Detection of antibodies bound to circulating immune complexes.....................................................499 Detection of antibodies in cerebrospinal fluid................................................................................................499 Cellular immune response in LB: T-lymphocyte and mononuclear cell proliferation assays .................500 TEST INTERPRETATION........................................................................................................................................500 ACKNOWLEDGMENTS ...........................................................................................................................................501 REFERENCES ............................................................................................................................................................501 INTRODUCTION for LB in 1982, and the Council of State and Territorial Epi- demiologists adopted a resolution making LB a nationally no- Lyme borreliosis (LB), or Lyme disease, which is transmitted tifiable disease in 1990. LB is the most common vector-borne by ticks of the Ixodes ricinus complex, was described as a new disease in North America and represents a major public health entity in the United States in the late 1970s (318, 319, 324, 325). Many of its individual manifestations had been docu- challenge for the medical community. Since 1982, more than mented many decades earlier in Europe (355). The etiologic 200,000 LB cases in the United States have been reported to agent, Borrelia burgdorferi, was recovered first in 1982 from the the CDC, with about 17,000 cases reported yearly between vector tick Ixodes dammini (now I. scapularis) (41) and subse- 1998 and 2001 (54). In 2002 the number of cases of LB in the quently from skin biopsy, cerebrospinal fluid (CSF), or blood United States increased to 23,763, with a national incidence of specimens of patients with LB in the United States (22, 323) 8.2 cases per 100,000 population. Approximately 95% of the and Europe (3, 14, 268). In the United States, the Centers for cases occurred in 12 states located in the northeastern, mid- Disease Control and Prevention (CDC) initiated surveillance Atlantic, and north central regions (54); these states were Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsyl- * Corresponding author. Mailing address: Clinical Laboratories, vania, Rhode Island, and Wisconsin. LB is widely distributed in Room 1J-04, Westchester Medical Center, Valhalla, NY 10595. Phone: (914) 493-7389. Fax: (914) 493-5742. E-mail: m_aguero European countries and also occurs in far eastern Russia and [email protected]. in some Asian countries (128, 288, 351). 484 VOL. 18, 2005 DIAGNOSIS OF LYME BORRELIOSIS 485 During the past 20 years, notable advances have been made tiple linear and circular plasmids in a single bacterium; (ii) a in understanding the etiologic agent, B. burgdorferi, and the unique organization of the rRNA gene cluster, consisting of a illness that it causes. Many excellent reviews have been pub- single 16S rRNA gene (rrs) and tandemly repeated 23S (rrl) lished detailing progress in expanding the knowledge base on and 5S (rrf) rRNA genes; (iii) over 150 lipoprotein-encoding the microbiology of B. burgdorferi (20, 29, 50, 283, 307, 351, genes, which account for 4.9% of the chromosomal genes and 353) and on the ecology and epidemiology (12, 40, 247, 297, 14.5% of the plasmid genes, significantly higher than that of 299), pathogenesis (127, 225, 321, 335, 357), clinical aspects any other bacterial genome sequenced to date; (iv) a substan- (219, 253, 313–316, 372), and laboratory diagnosis (18, 39, 291, tial fraction of plasmid DNA that appears to be in a state of 360, 362, 365) of LB. It has been estimated that more than 2.7 evolutionary decay; (v) evidence for numerous, potentially re- million serum samples are tested each year for the presence of cent DNA rearrangements among the plasmid genes; and (vi) B. burgdorferi-specific antibodies in the United States alone a lack of recognized genes that encode enzymes required for (339). To meet the demand for laboratory-based diagnosis, synthesis of amino acids, fatty acids, enzyme cofactors, and various new tests for direct detection of the etiologic agent, or nucleotides. B. burgdorferi also lacks genes coding for tricar- for detection of specific antibodies by using whole-cell lysates, boxylic acid cycle enzymes or for compounds involved in elec- recombinant antigens, or peptide antigens in enzyme immuno- tron transport, findings which, taken together with the preced- assays (EIA), have been introduced into the clinical