Evaluation of Modified 2-Tiered Serodiagnostic Testing Algorithms for Early Lyme Disease.
The conventional 2-tiered serologic testing protocol for Lyme disease (LD), an enzyme immunoassay (EIA) followed by immunoglobulin M and immunoglobulin G Western blots, performs well in late-stage LD but is insensitive in patients with erythema migrans (EM), the most common manifestation of the illness. Western blots are also complex, difficult to interpret, and relatively expensive. In an effort to improve test performance and simplify testing in early LD, we evaluated several modified 2-tiered testing (MTTT) protocols, which use 2 assays designed as first-tier tests sequentially, without the need of Western blots.



The MTTT protocols included (1) a whole-cell sonicate (WCS) EIA followed by a C6 EIA; (2) a WCS EIA followed by a VlsE chemiluminescence immunoassay (CLIA); and (3) a variable major protein-like sequence, expressed (VlsE) CLIA followed by a C6 EIA. Sensitivity was determined using serum from 55 patients with erythema migrans; specificity was determined using serum from 50 patients with other illnesses and 1227 healthy subjects.



Sensitivity of the various MTTT protocols in patients with acute erythema migrans ranged from 36% (95% confidence interval [CI], 25%-50%) to 54% (95% CI, 42%-67%), compared with 25% (95% CI, 16%-38%) using the conventional protocol (P = .003-0.3). Among control subjects, the 3 MTTT protocols were similarly specific (99.3%-99.5%) compared with conventional 2-tiered testing (99.5% specificity; P = .6-1.0).



Although there were minor differences in sensitivity and specificity among MTTT protocols, each provides comparable or greater sensitivity in acute EM, and similar specificity compared with conventional 2-tiered testing, obviating the need for Western blots.
Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.
John A
JA
Branda
Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Klemen
K
Strle
Division of Emergency Medicine, Boston Children's Hospital, Massachusetts, USA.
Lise E
LE
Nigrovic
Departments of Medicine and Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.
Paul M
PM
Lantos
Nantucket Cottage Hospital, Nantucket, Massachusetts, USA.
Timothy J
TJ
Lepore
South County Internal Medicine, Wakefield, RI, USA.|Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
Nitin S
NS
Damle
Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.|Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Mary Jane
MJ
Ferraro
Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Allen C
AC
Steere
D000465:Algorithms; D042241:Early Diagnosis; D006801:Humans; D007118:Immunoassay / Q000379:methods; D008193:Lyme Disease / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D012698:Serologic Tests / Q000379:methods*
Borrelia burgdorferi; C6; Lyme; VlsE; serology