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Interesting Cases
CASE # 1A.B. is a 55 y.o. female referred to rule in or out Lyme disease. She complains of many years of tension type headaches, myalgias, depression, fatigue and “I just don’t feel right”. Learning about Lyme disease on the Internet, she suspects this as her diagnosis, and has seen 5 doctors for these symptoms, having been tested for Lyme disease numerous times. Most of her tests at commercial labs are entirely negative. Twice, however, there was a borderline ELISA. All IgG WB’s were negative, with only an occasional single faint 41 kDa band seen. Multiple IgM WB’s were also done, some reported as “borderline” or “positive”. Twice, a single IgM 41 kDa band was noted, once a 41 and a 23 kDa band, and once a 41 and 18 kDa bands. Multiple courses of antibiotics resulted in no significant change in her symptoms.
At IMUGEN her Lyme serologic results showed:
Antigen Isotype Results B. burgdorferi IgM < 1 B. burgdorferi IgG < 1 B. burgdorferi IgA < 1 WESTERN BLOTTING: 1 faint band at 41 kDa
Comment: Refer to myths and misbeliefs This patient has symptoms not particularly suggestive or characteristic of Lyme disease, and no laboratory evidence of Bb infection. These patients are not rare. Patients and physicians become frustrated because no definite diagnosis is emerging. A.B. is unlikely to be helped by telling her she has Lyme disease, or by further testing or treatment for this. Reliable tests with proper interpretation and clinical correlation can assist her and her physicians from continued focus on this diagnosis.
CASE # 2
P.A. is a 33 y.o. man who frequently camps on Cape Cod. On 8/13/99 he saw his physician for headaches and a stiff neck, with a low grade fever, and was re-assured. On 8/14/99 he worsened and went to the ER.
A spinal tap was done and showed a normal opening pressure, 425 WBC’s (90%L), protein = 193. A Lyme test was ordered and he was discharged home pending the results on no treatment. On 8/17 he noted altered taste on the right side of his mouth. On 8/18 he developed a 7th cranial nerve palsy. On 8/20 his physician called him with these test results:
Antigen Isotype Serum Results CSF Results B. burgdorferi IgM >10.0 >10.0 B. burgdorferi IgG 3.8 >14.6 B. burgdorferi IgA 4.0 >15.8 WESTERN BLOTTING: 10 very faint bands
He refused hospitalization or intravenous antibiotics, and was treated with oral amoxicillin (2 gm/d x 30 d), and has done very well. Follow-up serum test results 2 months later showed persistence of the IgM and IgG levels, but total disappearance of the IgA, and no further expansion of reactivity or new bands on WB.
Comment: This patient had classic neuroborreliosis without antecedent EM. The gold standard for this diagnosis is CSF:serum ratios, and the clinical setting. The high CSF IgA is characteristic, as is the disappearance of serum IgA after successful treatment. Oral vs intravenous antibiotics are controversial, and there are no controlled studies in such patient groups, although most experts favor IV in this setting.
See the CNS sections under guidelines
CASE # 3
L.L is a middle-aged woman who has admitted she has never really felt well. She participated in the Lyme vaccine trials, and received 3 doses of recombinant OspA vaccine. There is a question that some of her non-specific complaints might have been more noticeable after vaccination. She has always suspected that she has had Lyme disease despite many negative evaluations. After vaccination, she presented to a local “Lyme expert” who tested her and found that her ELISA was borderline, so he ordered a WB which showed weak bands at 16, 31, 34, 40, and 58, and a strong band at 30 kDa. He told her that she probably had both Lyme vaccine and true Lyme disease, and began chronic antibiotic treatment. When IMUGEN received many of her sera for testing, we found:
Antigen Isotype Result traditional Result OspA-free
Antigen Isotype Serum Results CSF Results B.burgdorfer IgM 1.1 < 1 B.burgdorfer IgG 2.3 < 1 B.burgdorfer IgA < 1 < 1 WESTERN IMMUNOBLOTTING (traditional): 16,18,30,31,34,40,58,66
WESTERN IMMUNOBLOTTING (OspA-free): 40
Comment: L.L. does not have Lyme disease, and there is no laboratory evidence of Bb infection. The vaccine response is easily seen. Multiple bands by WB following Lyme vaccination have been published. Using test reagents lacking OspA totally eliminates background reactivity from vaccine exposure, and allows one to accurately and clearly distinguish this from true Bb reactivity. See the section on lyme vaccine.
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