searched this out from an old Tincup post:From Dr. C in Missouri
Explaining Borreliosis (Lyme) Western Blot Tests
There is no universal agreement on what defines a positive Western blot.
Good laboratories use different criteria to interpret borreliosis blots. At the 1999
international borreliosis and tick-borne infection conference, Sam Donta, M.D. lectured.
Dr. Donta is a full professor of Infectious Disease at Boston University School of
Medicine. He said that if a patient has just one borreliosis-associated antibody on their
Western blot, you may assume they have borreliosis. Richard Horowitz, M.D. said the
same thing in his lecture, at that same conference.
Research I presented in 1998 involving over 400 borreliosis patients, showed an 87%
response rate to antibiotics. This was if they had one borreliosis-associated antibody on
their blot. So if there is enough suspicion that Lyme borreliosis is the cause of a patient's
symptoms, so much so that a Western blot is ordered, then if only one
borreliosis-associated antibody is found, it is significant!
Medical literature is replete with statements about false positive test results for Lyme
borreliosis. Since 1988, I have diagnosed and treated well over 600 borreliosis patients.
Only 2 of those patients with a positive borreliosis test did not respond to antibiotics.
This is a 99% success rate!
So in the trenches of day-to-day medical practice, false positive borreliosis tests are not
an issue. In retrospect, those 2 patients that did not respond to antibiotics may have also
had babesiosis. In my practice, many borreliosis patients also have babesiosis, another
tick-borne infection that causes the same symptoms as Lyme borreliosis.
Babesiosis is caused by a protozoa, which is a different germ type than a bacteria, virus,
fungus or yeast. The placebo effect would not explain a 99% response rate. Those
borreliosis associated antibodies should not be there, in patients with symptoms.
A placebo is like a sugar pill, that has no effect. A placebo effect occurs because patients
believe in the pill they are taking, even though it is a sugar pill. The human mind causes
the response. Placebo effects should more likely be about 20-30%, not a 99% response
rate.
False negative test results are the real problem in diagnosing borreliosis. Research has
shown that you have to do the right test (the Western blot), done at the right laboratory
(one that specializes in testing borreliosis), and done the correct way (shipped express
delivery early in the week). The right test to screen for borreliosis is the Western blot.
Research I presented in Bologna, Italy in 1994 at the international borreliosis conference
showed this.
Other screening tests, such as the IFA, EIA, ELISA, and PCR DNA probe were often
negative when the Western Blot was positive! Other doctors like myself who diagnose
and treat a lot of borreliosis patients, go straight to the Western blot as their screening
test.
Medical articles abound stating that it is best to do a screening test, such as an ELISA,
and if it is positive, then confirm it with a Western blot. But the ELISA is often negative
when the Western blot is positive so, the right test is the Western blot.
It lets you see exactly which antibodies are present. The "right laboratory" means one that
specializes in borreliosis testing. In the past, I have done head to head comparisons with
3 different regular labs. Western blots were drawn and sent on the same day to 2 different
labs. The labs that specialize in borreliosis testing typically found borrelia-associated
antibodies, that the regular laboratories missed. If these specialty labs find a borrelia
antibody, I trust it to be significant, because patients respond to antibiotics.
You get what you pay for, so use a lab that specializes in borreliosis. The right way to
process the Western blot specimen means for the blood to be drawn and express mailed
early in the week. Research shows the borrelia antibodies have the potential to clump
together, resulting in false negative test results. So far, unclumping has not been practical
for laboratories to do.
The fresher the specimen, the more accurate the test results. Patients at our office are
scheduled Monday, Tuesday, or Wednesday if testing is to be done. This way, express
shipping will assure that the specimen does not spend the weekend sitting at the post
office. This is the right way to test and ship borreliosis specimens.
Western blots look for antibodies. These antibodies are made by your immune system. In
this case, the antibodies are made to fight against different parts of the Lyme bacteria,
which is called Borrelia burgdorferi, and other Borrelia species. In other words, your
immune system does not make one big antibody against the whole bacteria. So, when you
see a number on a borreliosis Western blot, it corresponds to a specific part of the
bacteria.
Compare it to the old story of different blind people touching an elephant. Based on the
part of the elephant each one touched, each person had their own perception. Likewise,
the antibodies attach to different and specific parts of Borrelia burgdorferi.
Numbers on Western blots correspond to weights. Kilodaltons (kDa) are the units used
for these microscopic weights. Think of it like pounds or ounces. An 18 kDa antibody
weighs 18 kilodaltons. To do a Western blot, thin gel strips are impregnated with the
various parts of Borrelia burgdorferi. Each of the numbers, 18 through 93, on the test
result form, is a part of the bacteria.
Blood is made up of red blood cells and serum; Spinning blood in a centrifuge separates
serum from red blood cells and other things, like white blood cells and platelets.
Serum contains antibodies made by the immune system. Electricity is used to push the
serum through the thin gel strips for the Western blot. If there are any antibodies against
parts of Borrelia burgdorferi present in your serum, and these parts are impregnated on
the strip, the antibody will complex (bind) to that part.
When antibodies form a complex, it is called an antigen-antibody complex. Anything
foreign in the body is an antigen, such as a ragweed pollen particle, germ, cancer, and
even a splinter.
In the case of borreliosis, the various parts of Borrelia burgdorferi are all antigens.
Though each antigen is different, they all come from the same bacteria. So all the
numbers that are positive on the test report are due to antigen-antibody complexes.
If enough of the complexes are formed, eventually it may be seen with the naked eye as a
dark band. - Band intensity reflects how dark or wide it is. Controversy exists about band
intensity. Many would say the " +/-" equivocal bands are not significant. The problem I
have with that, is that there are "-" negative bands. The lab has no trouble calling some
bands negative. So they must be seeing something when they put "+/-" at some bands.
The only thing that makes sense, is that there is a little bit of that antibody present in your
serum. If the "+/-" equivocal is reported on the borrelia associated bands, it is usually
significant, in my clinical experience. This is a strong clue that I am on the right track.
Instead of ignoring these, they should be a red flag to keep pursuing a laboratory
diagnosis. Giving patients 4 weeks of antibiotics (usually tetracycline, 500 mg, 3 times a
day), will convert a negative or equivocal Western blot to positive in about 36% of cases.
As mentioned, if these positive blots are found by specialty labs, over 99% of those
patients will respond to antibiotics.
Sometimes multiple antibiotics have to be tried before the patient feels better. Antibiotics
may actually help with the laboratory diagnosis. But patients need to be off antibiotics
about 10 to 14 days before the Western blot is repeated. This sounds like a contradiction.
Antibiotics may help convert the test to positive, but patients need to be off antibiotics
when the specimen is drawn.
It is well documented in medical literature that the presence of antibiotics may cause
false negative borreliosis testing. Therefore, your system should be free of all antibiotics
for an accurate blot result.
When the Lyme borrelia are alive, they are geniuses at avoiding the immune system.
They may do things like go inside your white blood cells, and come out enclosed by the
cell membrane of your own white blood cells! This may partly explain why antibodies
against Borrelia burgdorferi are often not found when patients are tested.
What may happen when patients are given 4 weeks of tetracycline (or other antibiotics) is
that some of the bacteria die. When Borrelia burgdorferi dies, it is less efficient at
avoiding the immune system. That's when antibodies may be formed against Borrelia
burgdorferi, converting the negative or equivocal Western blot to positive, in about 36%
of cases.
If a borreliosis Western blot is going to be positive, it is usually the first one that is
positive. The second blot is the next most likely to be positive, and so on, until the fifth
blot.
After that, the curve levels off for conversion to positive. This is based on research I
presented in Bologna, Italy in 1994. Some patients had borrelia-associated antibodies
finally show on their tenth Western blot! Two Western blots from a reliable lab usually
gives the answer.
If a third test is needed, a Lyme Urine Antigen Test (LUAT) is done instead of a third
Western blot. Positive LUATs correspond very highly to patients getting better with
antibiotics. False positive LUATs have not been a problem in my practice. The LUAT
finds the actual antigen (Borrelia burgdorferi itself), so arguably it should be the test of
choice, but the Western blot is rn6re widely accepted, even though it looks for the
antibodies against Borrelia burgdorferi.
The presence of antibodies are indirect evidence of an infection, not direct evidence like
shown in the LUAT. On the Western blot test result form, please note what is "considered
positive" and "considered equivocal." Equivocal is another way of saying suspicious or
almost positive.
Below this are the ASTPHLD/CDC recommendations. The CDC stands for the Center for
Disease Control. I have been in attendance at the international borreliosis conferences
when the CDC said their recommendations are for disease surveillance, not day-to-day
clinical medical practice. I am not in the business of disease surveillance. My job is to try
to help sick people.
The CDC recommendations do not include the 31 and 34 Kda bands of the blot test.
These two bands correspond to outer surface proteins A and B respectively (ospA and
ospB). In the world of borreliosis, these are two of the classic hallmark Lyme antibodies.
But the CDC does not even have them in their recommendations.
You may see why I and other borreliosis clinicians do not agree with using the CDC
criteria in everyday medical practice. Other bacteria besides Borrelia burgdorferi may
produce the 45, 58, 66, and 73 kDa bands. These bands may be produced by Borrelia
burgdorferi, but are not nearly as specifically associated with Lyme borreliosis as the
starred bands. These starred bands are classic hallmark borrelia-associated
antigen-antibody complexes.
An example of the CDC's criteria of a blot test, is if a patient has the band pattern of 41,
45, 58, 66, and 93, the CDC would call it positive. But if a patient has a 23-25, 31, 34,
and 39 band pattern, they would call it negative. This is despite the fact that this second
pattern of antigen-antibody complex bands is much more specifically associated with
Borrelia burgdorferi than the first pattern.
As you can see, borreliosis is very controversial. It would be alarming if I was the only
clinician who thought that the CDC recommendations should not be used for day-to day
medical practice. Many borrelia clinicians do not use the CDC criteria. This is obvious
by the fact that the IgX laboratory uses different criteria for positive. Again, in my
opinion and others', even one borrelia-associated antibody is significant, if symptoms
exist. The classic triad of symptoms for borreliosis is fatigue (tiredness, exhaustion),
musculoskeletal pain (joints, muscles, back, neck, headache), and cognitive problems
(memory loss, trouble concentrating, difficulty remembering what you read, depression,
disorientation, getting lost).
But there are about 100 symptoms on the borreliosis questionnaire I use. Borreliosis may
mimic or imitate virtually any disease. Patients often tell me that other physicians they
have seen use the CDC recommendations. This is unfortunate, in my opinion, since these
physicians are not in the business of disease surveillance, like the CDC is.
But I am biased. After seeing patients with borreliosis since 1988, attending many
conferences, talking with experts, and doing research on borreliosis testing, there is
absolutely no question in my mind that physicians need to not blindly accept any
recommendations.
One of my hopes is that doctors will someday realize that this controversy is a signal for
them to search for the truth. Why is there such conflict in this very "political" disease if
there is not substance for disagreement? Both IgG and IgM Western blots should be done
for borreliosis.
With most infections, your immune system first forms IgM antibodies, then in about 2 to
4 weeks, you see IgG antibodies. In some infections, IgG antibodies may be detectable
for years. Because Borrelia burgdorferi is a chronic persistent infection that may last for
decades, you would think patients with chronic symptoms would have positive IgG
Western blots.
But actually, more IgM blots are positive in chronic borreliosis than IgG. Every time
Borrelia burgdorferi reproduces itself, it may stimulate the immune system to form new
IgM antibodies. Some patients have both IgG and IgM blots positive. But if either the IgG
or IgM blot is positive, overall it is a positive result.
Response to antibiotics is the same if either is positive, or both. Some antibodies against
the borrelia are given more significance if they are IgG versus IgM, or vice versa.
Since this is a chronic persistent infection, this does not make a lot of sense to me. A
newly formed Borrelia burgdorferi should have the same antigen parts as the previous
bacteria that produced it. But anyway, from my clinical experience, these borrelia
associated bands usually predict a clinical change in symptoms with antibiotics,
regardless of whether they are IgG or IgM. In regard to the outer surface proteins, think
of it like the skin of a human.
On the outer surface of the Lyme bacteria are various proteins. As they have been
discovered, they have been assigned letters, such as outer surface proteins A, B, and C.
The following is a brief explanation of the test results. Again, each band is an antigen
complexed (bound together) with an antibody made by the immune system, specifically
for that antigen (part) of Borrelia burgdorferi.
18: An outer surface protein.
22: Possibly a variant of outer surface protein C.
23-25: Outer surface protein C (osp C).
28: An outer surface protein.
30: Possibly a variant of outer surface protein A.
31: Outer surface protein A (osp A). 34: Outer surface protein B (osp B).
37: Unknown, but it is in the medical literature that it is a borrelia-associated antibody.
Other labs consider it significant.
39: Unknown what this antigen is, but based on research at the National Institute of
Health (NIH), other Borrelia (such as Borrelia recurrentis that causes relapsing fever), do
not even have the genetics to code for the 39 kDa antigen, much less produce it. It is the
most specific antibody for borreliosis of all.
41: Flagella or tail. This is how Borrelia burgdorferi moves around, by moving the
flagella. Many bacteria have flagella. This is the most common borreliosis antibody.
45: Heat shock protein. This helps the bacteria survive fever. The only bacteria in the
world that does not have heat shock proteins is Treponema pallidum, the cause of
syphilis.
58: Heat shock protein.
66: Heat shock protein. This is the second most common borrelia antibody.
73: Heat shock protein.
83: This is the DNA or genetic material of Borrelia burgdorferi. It is the same thing as the
93, based upon the medical literature. But laboratories vary in assigning significance to
the 83 versus the 93.
93: The DNA or genetic material of Borrelia burgdorferi.
In my clinical experience, if a patient has symptoms suspicious for borreliosis, and has
one or more of the following bands, there is a very high probability the patient has
borreliosis.
These bands are 18, 22, 23-25, 28, 30, 31, 34, 37, 39, 41, 83, and 93. This is true
regardless of whether it is IgG or IgM.. But again, there is no universal agreement on the
significance of these bands. Betina Wilska, M.D. from Germany is one of the world's
experts on outer surface protein A (31 kDa).
At the international borreliosis conference in Vancouver, British Columbia, I asked her
personally about the 30 kDa band. She told me it was the same as the 31 kDa band (osp
A). When you have the opportunity to talk to borreliosis experts, this helps in assigning
significance to findings, on an imperfect test. As a medical doctor, I am stating all of this
with no axe to grind, no professorship to protect, and no preset opinions. Patients,
personal research, and conferences have helped me interpret the borreliosis medical
literature in regard to testing. Nobody would like to have available a bullet-proof, 100%
reliable Lyme borreliosis test more than I would. But we must use what is currently
available. I always welcome second opinions.
UBBFriend: Email this page to someone!
oops! 
Printer-friendly view of this topic