Diagnostic parameters of modified two-tier testing in European patients with early Lyme disease

Abstract

Modified two-tier testing (MTTT) for Lyme borreliosis (i.e. confirmation with an EIA instead of an immunoblot) has been shown to have improved sensitivity compared with standard two-tier testing (STTT) in samples from American patients, without losing specificity. The current study assesses the sensitivity and specificity of various algorithms of MTTT in European patients with erythema migrans (EM) as a model disease for early Lyme borreliosis, and in appropriate controls. Four different immunoassays were used in the first tier, followed by either an immunoblot or the C6-EIA, or were used as standalone single-tier test. These tests were performed on consecutively collected sera of 228 Dutch patients with physician-diagnosed EM in the setting of general practice, 231 controls from the general population, and 50 controls with potentially cross-reactive antibodies. All the variants of MTTT that were studied had significantly higher sensitivity compared with their equivalent STTT, while retaining comparable specificity. Within the MTTT algorithms, classifying equivocal results as positive yielded better diagnostic parameters than classifying equivocal results as negative. The best diagnostic parameters were found using the Enzygnost-2 assay in the first tier, followed by a C6-ELISA in the second tier (sensitivity 77.6%, 95% CI 71.7–82.9; specificity 96.1%, 95% CI 92.7–98.2). This algorithm performed significantly better than the equivalent STTT algorithm in terms of sensitivity (p < 0.001), while maintaining comparable specificity (population controls p = 0.617). Our results show that MTTT can be a useful tool for the serodiagnosis of European patients with early Lyme borreliosis.

The Performance of Nine Commercial Serological Screening Assays for the Diagnosis of Lyme Borreliosis: a Multicenter Modified Two-Gate Design Study

“…In contrast, IgM positivity rates were much higher and might be explained by cross-reactivity with antibodies raised against heterologous bacteria and autoimmune diseases or by polyclonal B-cell activation ( 16 ). The higher positivity rates among the cross-reactivity controls confirmed what has been published before ( 6 , 7 , 11 , 17 ) and underlined that positive IgM serology results should be interpreted with care, especially when clinical symptoms are unclear.…”

“…Over the years, many studies have compared various Borrelia serological assays on diverse sample populations ( 6 – 11 ). In some of these studies, LB patients were ill-defined, and in many of these studies, assays were compared that are no longer commercially available.…”

Classical Borrelia Serology Does Not Aid in the Diagnosis of Persistent Symptoms Attributed to Lyme Borreliosis: A Retrospective Cohort Study

“…A modified two-tier approach has recently been evaluated and proven equally sensitive and specific. This modified approach consists of two consecutive Borrelia -specific ELISAs from different commercial brands [ 20 , 21 , 22 ].…”

Linear Peptide Epitopes Derived from ErpP, p35, and FlaB in the Serodiagnosis of Lyme Disease

“…Despite extensive research, no protein-based assay has overcome this specificity problem. The use of synthetic peptides containing linear epitopes unique to B. burgdorferi as antigen targets can improve specificity [15][16][17][18][19][20][21][22][23][24][25][26][27] by eliminating nonspecific, cross-reactive epitopes [8,11,12,15,[28][29][30][31][32]. By removing cross-reactive epitopes, it is possible to improve specificity, which could lead to the development of single-tier assays that would allow for greater sensitivity.…”