THE NEW LYME BORRELIA BLOOD TEST
Advanced Laboratory Services Inc. has developed a revolutionary new blood test for the detection of Borrelia spirochetes that clearly will change how Lyme Disease is diagnosed and treated. The methods involved in this culture are complex and proprietary and are still a trade secret, but many details will be outlined in upcoming publications. Here is the story of this new test:
Lyme Disease, an infectious disease caused by the spirochete Borrelia burgdorferi (Bb), is the most prevalent vector-borne disease, and fastest growing infectious disease in this country, surpassing even HIV/AIDS. The CDC estimates that in the USA there are more than 300,000 new cases each year, and there may be as many as four million currently infected. Many patients remain undiagnosed and misdiagnosed with other illnesses. In addition, Lyme has unfortunately become a somewhat controversial illness. The major reason for all of this is the poor sensitivity and specificity of currently available diagnostic tests.
The available serologic tests for Lyme are indirect tests- because they measure antibody levels and not the bacteria themselves, they do not indicate whether an infection with Borrelia is currently present. At best they can only indicate possible exposure to this organism at some previous point in time. It has been variously reported that the sensitivity of these assays is low and may miss anywhere from 30% to as many as 70% of cases of Lyme. There are many reasons for this poor sensitivity. They include Borrelia burgdorferi strain variation, immune complex formation which binds to and thus hides anti-Borrelia antibodies, immune suppression by longstanding infection, and the generally difficult trade-off with serologies between sensitivity and specificity.
Regarding specificity, once positive, these serologic tests tend to remain positive for variable periods, even years, even after treatment. Therefore they cannot be used as a marker for progress during treatment or for success of treatment. If a treated Lyme patient remains seropositive after treatment, does that reflect persistent infection, or just simply left-over antibody? If someone is rebitten by a tick and tests positive, does that positive result reflect antibodies left over from the prior infection, or a new infection from this bite? In addition, some acute viral infections may potentially give a false positive result.
What has been missing until now is a reliable, sensitive and specific direct laboratory test that can indeed inform whether the patient is currently infected. Attempts at using DNA-detection methods (polymerase chain reaction or PCR) have been disappointing. The sensitivity remains very low because of the low number of spirochetes in peripheral blood, urine and spinal fluid, low yield on tissue (biopsy) specimens, the possible presence of inhibitors in blood and tissues, and the issue of which DNA primer set or sets should be used as they tend to be strain-specific: use the wrong strain, and even a clinically obvious infection can be missed due to the notoriously large number of strain variations present and the possibility of genetic shifts common to Borrelia species. Concerns over false positives due to laboratory contamination have been raised as well. Finally, some believe that a positive PCR may not reflect persisting active infection but left over nucleic acid fragments.
How are most other infectious diseases diagnosed? Whenever cultures are available, they are generally preferred over serologic tests. For example, in diagnosing a urinary tract infection, do you test the blood for antibodies to E. coli, or do you culture the urine? The obvious answer also applies to diagnosing infection due to Borrelia burgdorferi (Bb). Cultures are more useful and give more information.
Unfortunately, Because Lyme Borrelia are symbionts, meaning that they need a living host to survive, trying to get them to thrive in vitro has been a nearly impossible task. In addition, they are noted for their very slow growth. Because of these difficulties and delayed growth, Borrelia cultures have not been available for clinical diagnostic purposes until now.
In developing a rapid and sensitive Borrelia culture, it was necessary to investigate and fine-tune every step of the process. ALS experimented with an unimaginable number of different parameters- incubator temperature, microatmosphere, culture media (and there were many ideas that had to be tested), and even the physical makeup of the culture tubes themselves. Finally, the scientists came up with what appears to be the winning combination, and are incredibly proud to have achieved this technological breakthrough and to be able to offer Borrelia cultures of clinical and research specimens.
THE BORRELIA CULTURE:
Culturing Bb from clinical specimens using our proprietary methods has these advantages:
- By definition, culture is a direct test and if positive, indicates that an active infection was present at the time the specimen was taken
- All known strains of Borrelia burgdorferi sensu lato can be detected
- Can replace xenodiagnoses in many instances
- Culture positivity fulfills even the strict CDC surveillance case definition
- Cultures may be positive even in an infected patient who is seronegative
- A culture that is still positive post treatment indicates ongoing infection
- Advanced methods have resulted in increased yield and decreased turn-around time
- Presently we are only accepting blood for culture. Ability to culture other body fluids and tissues is being explored.
- Will become the new Gold Standard for laboratory diagnosis of Borrelia infection
Blood is collected from patients and transported to ALS at room temperature by overnight express. Specimens are immediately placed into culture media under proprietary conditions, and after one to two weeks it is tested by darkfield microscopy, polyclonal and monoclonal immunostaining, and by multivalent nested PCR (this nested technique is tough to do, but can detect femtomoles of DNA!). If Borrelia are seen then, a final report of a positive result is generated and sent to the practitioner. If no Borrelia are seen at this time, then the sample is placed into Long Term Culture that is looked at once, at two months, and a final report is generated then. Selected positives are sent out for DNA sequencing.
So far, of the experimental samples, nearly all the CDC+, clear cut Lyme cases have been positive, and there have not been any instances of false positives or contamination. Sequencing data have shown that these all are Borrelia burgdorferi, but with wide strain variation.
WHO SHOULD BE CULTURED?
The culture, as the Gold Standard of infectious diseases, should always be considered as the primary diagnostic test. However, the following are just some examples in which culturing is essential: suspected Lyme in a seronegative patient; in those with conflicting serologic results; Lyme patients who remain symptomatic despite prior treatment; co-infected individuals in whom the presence of Borrelia is uncertain; in the newborn who may have received maternal Lyme antibodies; symptomatic Lyme-vaccinated patients in whom a serology may not be accurate; in the immunosuppressed in whom a false negative serology is more likely; in patients with concurrent illnesses that may have given rise to a false positive serology; a patient with a prior history of Lyme who got a new tick bite .
We have found that the success of culturing Borrelia can be increased by following these simple recommendations:
• The patient should not have been exposed to any antibiotics, even those not known to affect this organism, for a minimum of four weeks prior to the blood sample being drawn. Likewise, antibacterial herbs should be held as well.
• Borrelia are more likely to be recovered from patients who are symptomatic at the time of blood sampling.
• The collection kit contains three red-top Vacutainer tubes. They must be filled fully to exclude as much oxygen as possible, and mailed out immediately at room temperature. The tubes should not be spun down.
• Blood must reach the lab within 24 hours of being drawn! The specimen must be sent out the same day it is collected using the FedEx overnight mailer provided.
• A higher yield may be seen if the blood is drawn in the early afternoon, when most infected patients feel especially ill. However, be sure that FedEx will do an afternoon pickup for you.
• Do not send any samples on Friday or Saturday as the lab is not open on weekends.
WHO MAY ORDER THIS TEST?
Based on the laws of Pennsylvania where we are located, it must be ordered by a medical practitioner defined by Pennsylvania as an MD, DO, CRNP, PA-C, and Certified Nurse Midwife. If you are an ND, and even if you may order tests in the state in which you practice, you still will need to have the test ordered by the type of practitioner on Pennsylvania’s approved list. Note that it also cannot be ordered directly by the patient. The practitioner needs to request a blood drawing kit from Advanced Labs, and once the specimen is drawn, it must be received by us within 24 hours.
ABOUT ADVANCED LABORATORY SERVICES, INC.
Advanced Laboratory Services is a CLIA and COLA certified reference lab that offers a variety of quality tests for the detail oriented clinician. ALS consists of two divisions- the clinical laboratory and the research lab.
At the clinical division we focus on both basic as well as advanced testing, including hematology, chemistry, urinalysis, serologies, immunology, cytometry, PCR and histopathology. We also are known for the creation of customized testing panels designed to meet the needs of a busy practice.The research division supplies a pipeline of new testing services to the clinical lab after they are fully developed. Our recently released Borrelia culture is an example of thi
It is the policy of Advanced Laboratory Services to focus our efforts on perfecting and maintaining the high quality of our testing methods. Accordingly we are not planning to initiate clinical research; rather, we plan to leave that to the clinicians and make ourselves available to assist them in their endeavors.
As always, we appreciate your feedback and ideas. It is this type collaborative effort that will ensure that we continue to develop and deliver what is needed as quickly and efficiently as possible. Thank you!
501 Elmwood Avenue, Sharon Hill, PA 19079
Phone: (855) 238-4949 · Fax: (855) 238-4946