Current Guidelines,Common Clinical Pitfalls,and Future Directions for Laboratory Diagnosis of Lyme Disease,United States

In the United States, Lyme disease is caused by Borrelia burgdorferi and transmitted to humans by blacklegged ticks. Patients with an erythema migrans lesion and epidemiologic risk can receive a diagnosis without laboratory testing. For all other patients, laboratory testing is necessary to confirm the diagnosis, but proper interpretation depends on symptoms and timing of illness. The recommended laboratory test in the United States is 2-tiered serologic analysis consisting of an enzyme-linked immunoassay or immunofluorescence assay, followed by reflexive immunoblotting. Sensitivity of 2-tiered testing is low (30%–40%) during early infection while the antibody response is developing (window period). For disseminated Lyme disease, sensitivity is 70%–100%. Specificity is high (>95%) during all stages of disease. Use of other diagnostic tests for Lyme disease is limited. We review the rationale behind current US testing guidelines, appropriate use and interpretation of tests, and recent developments in Lyme disease diagnostics.     

新疆石油探区职工莱姆病血清流行病学调查

目的 :查明本局所属新疆石油探区职工的莱姆病感染与发病情况。方法 :IFA和ELISA ,并结合个案流行病学调查结果及临床表现确诊。结果 :12 0 1名职工 ,感染 12 1人 ,感染率10 .0 7% ;确诊病人 81例 ,患病率 6.74%。结论 :首次证实天山南部石油探区为莱姆病重要流行区。     

Feedback on difficulties raised by the interpretation of serological tests for the diagnosis of Lyme disease

Objectives

We had for objectives: i) to evaluate the accuracy of serologic testing for Lyme borreliosis performed in a private medical laboratory (PML); ii) to evaluate the impact of these tests on the practices of infectious diseases specialists (IDS).

Patients and method

This study was performed in two steps: i) retrospective study of patients followed in a university hospital infectious diseases outpatient clinic for suspected Lyme borreliosis, tested (ELISA and Western blot) by both the PML and the National Reference Center (NRC); ii) national survey on IDS practices concerning patients consulting for suspected Lyme borreliosis.

Results

Between July 2008 and July 2011, 128 patients consulting for suspected Lyme borreliosis were tested by both laboratories. Serological tests came back positive in 91% of cases from the PML versus 8% of cases from the NRC. Lyme borreliosis was the IDS's final diagnosis for 3.6% of patients. The survey on practices revealed that: i) the modal duration of consultation for suspected Lyme borreliosis was 30–60 minutes; ii) for 33% of patients, serologic test results performed at the PML were the only reason to suspect Lyme borreliosis; iii) 60% of patients had no indication for antibiotics.

Conclusion

The serological test performed in the PML were positive most of the time, but were not confirmed by tests performed at the NRC. This discrepancy lead to multiple and prolonged consultations in infectious diseases clinics, and discordance in the indications for antibiotics.     

Healthcare access and burden of care for patients with Lyme disease: a large United States survey

Objective

To evaluate the challenges faced by Lyme disease patients in obtaining adequate healthcare.

Methods

A web-based survey conducted over nine months was analyzed for the study. The survey focused on medical status, access to healthcare, and burden of illness. For inclusion in the study, survey respondents had to reside in the United States, be more than 10 years old, and have clinically diagnosed Lyme disease with chronic symptoms and positive laboratory testing.

Results

Responses from 2424 patients were included in the study. Half of the respondents reported seeing at least seven physicians before the diagnosis of Lyme disease was made. Nearly half had Lyme disease for more than 10 years and traveled over 50 miles to obtain treatment. Most respondents experienced symptoms lasting six months or more despite receiving at least 21 days of antibiotic treatment. A quarter of respondents had been on public support or received disability benefits due to Lyme disease symptoms, and over half had visited an emergency room at least once as a result of these symptoms.

Conclusions

Lyme disease patients frequently endure extensive delays in obtaining an initial diagnosis, have poor access to healthcare and suffer a severe burden of illness.     

牡丹江林区莱姆病分布的地理特点

1989年在牡丹江林区对4个不同地理地貌的林场进行了莱姆病的调查。在访问和检查的2 718人中,发现74例患者,其中54例是慢性游走性红斑,12例是神经系统损伤,8例是关节炎。从深山区到丘陵地均有莱姆病患者存在和发生。4个林场的患病率分布在11.6~45‰,深山区莱姆病的患病率明显高于丘陵地带。
从1例精神紊乱病人血液中分离到1株莱姆病螺旋体。
全沟硬蜱季节消长曲线和慢性游走性红斑病例曲线相一致,确证全沟硬蜱的媒介作用。     

Management of patients presenting with generalized musculoskeletal pain and a suspicion of Lyme disease

Lyme disease is caused by bacteria of the B. burgdorferi sensu lato complex, and can give polymorphic clinical manifestations that can affect several organs such as the skin, the central nervous system, or the joints. In recent years, patients’ associations and physicians have been supporting the hypothesis that this infection would manifest as chronic generalized musculoskeletal pain symptoms, named “chronic Lyme disease”. Fibromyalgia is a clinical presentation characterized by chronic generalized musculoskeletal pain with a major impact on quality of life and social and psychological functioning. We analyzed existing literature data on pain syndromes associated with Lyme disease (post-treatment Lyme disease syndrome) or tick bites (polymorphic symptoms after a tick bite). We also analyzed existing data on the diagnosis, pathophysiology, and treatment of fibromyalgia. Our review shows that post-treatment Lyme disease syndrome has characteristics very close to post-infectious fibromyalgia. On the other hand, patients presenting for Lyme disease screening because of chronic generalized musculoskeletal pain symptoms after a tick bite should also be screened for fibromyalgia to allow appropriate management. Antibiotics are not recommended here.     

新疆地区神经系统莱姆病的临床特征分析

目的：探讨神经系统莱姆病的临床特征及诊断方法。方法：采用间接免疫荧光法（IFAT）、酶联免疫吸附试验（ELISA）进行血清和CSF莱姆病特异性IgM、IgG抗体检测，同时做神经放射学、影像学和电生理检查。结果：4年内在神经系统疾病患者中检出莱姆病特异性IgG、IgM抗体阳性者56例。结论：神经系统莱姆病临床表现多样化，当病因不明时，神经莱姆病应作为鉴别诊断之一，进行血清学检测，力争早发现，早治疗。     

四川省南川县莱姆病的调查

四川东部南川县是莱姆病流行区。本文对300例居民进行了血清学调查,抗莱姆病螺旋体IgG抗体阳性54人,人群自然感染率为18%。35例经临床和血清学确诊的莱姆病患者,其临床表现为慢性游走性红斑7例,关节炎13例,面神经麻痹7例,多发性神经炎7例,脑膜炎2例和心脏异常1例。47只微小牛蜱的中肠标本,有3只检出了螺旋体,带菌率为6.4%。     

福建省莱姆病的发现

血清学调查证实福建省8个县(市)林区人群存在莱姆病感染。根据流行病学、临床学和血清学确诊莱姆病典型病例6例,疑似病例9例。从蜱类中肠涂片见到典型的莱姆病螺旋体。     

我国莱姆病的流行病学和病原学研究

１９８７－１９９６年对２２个省市（市、区）的６０个县、区进行了莱姆病的调查研究。血清流行病学证实２２个省市（市、区）林区人群均存在莱姆病感染，感染率平均为５．０６％（１７２４／３４１０４）。病原学证实１７个省（市、区）存在莱姆病自然疫源地。１１个省（市、区）有典型病例存在。     

天津市蓟县莱姆病流行情况调查

目的 了解天津市蓟县莱姆病的流行病学特征.方法 采用间接免疫荧光试验对该县居民进行血清流行病学调查,并用PCR方法和病原分离培养对临床确诊的莱姆病患者进行病原检测.结果 天津市蓟县人群莱姆病感染率为5.97％,学生感染率为5.28％.山区和半山区感染率高于平原地区;40-49岁年龄组感染率最高.经临床和血清学诊断为莱姆病患者25例,其主要临床表现为关节炎、慢性游走性红斑、面神经麻痹、多发性神经炎、脑膜炎和心脏损害等.收集25例患者的尿液,进行PCR检测,1例阳性.从1例多发性神经炎患者血液中分离出莱姆病螺旋体.结论 首次从天津地区莱姆病患者分离到莱姆病螺旋体.天津蓟县人群中有莱姆病的发生和流行,可能存在莱姆病的自然疫源地,为莱姆病防治提供依据.     

海南省东北部地区某类就诊患者莱姆病抗体检测结果分析

目的 了解海南省东北部地区人群莱姆病感染状况,为临床医生诊断莱姆病提供参考,为本省莱姆病的流行病学调查提供可靠的理论依据。 方法 收集海南省东北部地区三家医院1 334例有关节症状和(或)神经症状的患者血清,采用两步法检测莱姆病抗体,使用间接免疫荧光法(indirect fluorescent antibody test,IFA)初筛血清, 对IFA检测阳性血清用免疫印迹法(Western blot,WB)确证。 结果 IFA法筛查海南省东北部地区1 334例患者莱姆病抗体阳性60例,阳性率4.50%。海口、文昌和琼海地区的三家医院该类就诊患者莱姆病抗体阳性率分别为4.25%、1.40%和8.28%(IFA)。三家医院阳性率比较差异有统计学意义(χ²=25.640,P<0.05)。按不同性别、年龄分组海南省东北部地区三家医院莱姆病抗体阳性率比较差异均无统计学意义(χ²=2.306,P>0.05; χ²=1.015,P>0.05)。 WB法确证莱姆病抗体阳性28例,其抗体以31 KD的外膜蛋白A、33 KD-36 KD外膜蛋白B、39 KD膜脂蛋白、41 KD鞭毛蛋白和60 KD热休克蛋白抗体为主。 结论 海南省东北部地区存在人群感染莱姆病,应加强当地疾病预防和监测。     

IFA、ELISA和WB用于莱姆病血清学诊断的比较研究

目的比较研究间接免疫荧光试验（IFA）、酶联免疫吸附试验（ELISA）和蛋白免疫印迹试验（WB）3种检测方法对莱姆病血清学的诊断效果。方法收集临床疑似莱姆病患者血清标本及其流行病学和临床资料,分别采用IFA、ELISA和WB进行血清抗伯氏疏螺旋体抗体（IgM和IgG）检测,结合流行病学和临床资料进行综合分析。结果实验共检测莱姆病疑似患者血清398份,ELISA阳性86例,阳性率21.61%,其中IgM阳性27例,IgG阳性59例;IFA阳性82例,阳性率20.60%,其中IgM阳性26例,IgG阳性56例;WB阳性83例,阳性率20.85%,其中IgM阳性31例,IgG阳性52例;并且实验表明,在对于游走性红斑病例的诊断上,WB法阳性率明显高于ELISA和IFA（χ2=6.34,P〈0.05）。结论在莱姆病的实验室诊断中,IFA、ELISA和WB3种方法结合运用,可提高诊断的灵敏性和特异性;WB在排除ELISA和IFA的假阳性结果中有着重要作用。     

Lyme disease and post-treatment Lyme disease syndrome: the neglected disease in our own backyard

Objectives

A survey was developed to assess experience and opinions about Lyme disease and post-treatment Lyme disease syndrome (PTLDS) among faculties in public health. No previous surveys of public health faculties have been found in the literature.

Study design

This is a cross sectional study of public health school faculty members designed to measure knowledge and experience with Lyme disease and PTLDS using an internet survey instrument.

Methods

Participants were recruited using all the publicly available e-mail addresses of faculty members in all the 50 accredited Schools of Public Health in the United States.

Results

A 15% response rate was seen for the survey. 50% of respondents were from Lyme endemic states. Less than 5% of faculty members consider themselves expert in Lyme or PTLDS. Many faculty members had known someone with Lyme disease or PTLDS, but few had been diagnosed themselves. Most believe that PTLDS can be severe and chronic, is not easy to treat, and does not resolve on its own, but were uncertain about its aetiology. Most respondents also felt that the incidence of Lyme disease will increase and that more education is needed.

Conclusions

The need for further understanding and communication presents an opportunity for public health research and education in Lyme disease and the sequelae of PTLDS.     

山东省莱姆病调查研究

本文于1990～1991年在山东省境内6个县(市)林区及山区首次进行了莱姆病血清学调查,结果证实省内部分林区及山区人群中存在莱姆病感染。经个案流行病学调查,结合血清学及临床症状,共确诊典型病人19例。山区及平原林区均存在和发生莱姆病患者,各年龄组间莱姆病感染无显著性差别(P>0.05)。     

福建省莱姆病的调查研究

1990年以来,从血清学、流行病学、临床表现和病原体分离与鉴定等方面对福建莱姆病进行了调查研究,证实该病在福建林区的流行面很广,发现部份典型病例,从蜱类、鼠类都分离出莱姆病螺旋体。     

大兴安岭南段莱姆病的调查

1991年4～6月,我们在大兴安岭南段林区,对莱姆病进行了调查,应用间接免疫荧光抗体法检测496人居民血清,38人血清中抗莱姆病螺旋体IgG抗体效价≥1:128。根据临床表现和血清学调查,确诊莱姆病病例22例;从26只全沟硬蜱分离出4株莱姆病螺旋体。     

莱姆病的诊断与治疗进展

莱姆病是一种主要发生在温带地区经蜱叮咬传播的人兽共患自然疫源性疾病。近年来,随着蜱媒宿主范围的不断扩大,莱姆病在我国的发病率呈不断上升态势。该病系全身性疾病,可影响皮肤、关节、神经系统和心脏等。患者如得不到早期诊断和及时治疗,致残率较高,对人类健康危害甚大。鉴于莱姆病的临床表现多样,诊断困难,为了提高临床一线医护人员对莱姆病的认知,现将其临床研究进展作一综述。     

青海省部分林区莱姆病流行病学调查

目的了解青海省莱姆病流行状况和疫源地分布,系统收集莱姆病主要传播媒介（蜱）及其主要宿主动物（鼠）的带菌情况,掌握人群莱姆病的感染水平,为进一步开展莱姆病监测和有效防治莱姆病提供依据。方法莱姆病螺旋体检测,采用聚合酶链反应;血清抗体（IgG）检测采用间接免疫荧光法。结果共调查1108人,阳性167例,平均感染率为15．07％;其中牧业区林场人群莱姆病平均感染率7．98％,农业区林场人群为21．21％,显示地区问差异有统计学意义（X^2=36．68,P〈0．001）;不同性别、年龄人群莱姆病感染率差异不明显;主要传播媒介为青海血蜱,带菌率为23．93％;主要宿主动物以小家鼠为优势种,占46．08％,鼠的总带菌率为20．59％。结论调查地区不仅有莱姆病感染存在,而且人群感染率还较高,平均感染率高于全国水平。不同地区由于生态环境、生产方式和生活习惯的差异,两地感染程度差别很大,农业区林场人群莱姆病平均感染率明显高于牧业区;青海血蜱为青海省主要传播媒介,可能存在莱姆病自然疫源地。