Summary: the medical workup (labs, etc.) to rule out Lyme disease (and its relatives).

Lumbar puncture

• Some won't diagnose neuroborreliosis without a positive spinal tap. Others make the diagnosis clinically.
• Spinal tap results are particularly helpful if the criteria one uses is directed at helping the patient by being able to report the disease to the Center for Disease Control.
• If one's emphasis is directed at being able to help the patient foremost, then positive spinal tap results may be less rewarding.

(remember it is the same criteria for the spinal fluid as for the serum i.e. a positive ELISAtest and Western Blot on spinal fluid after adjusting for differences in fluid composition)
• These tests may be more helpful in the first three months of neuroborreliosis when there is more often an active meningitis
• with 100 to 3000 white blood cells predominantly lymphocytes and monocytes,
• elevated opening pressures and
• occasionally elevated protein.
• sugar is normal.
• thus the typical picture of a "viral" meningitis.

• fever,
• positive brudzinski test or
• babinski,
• maximum headache level,
• emesis, and
• cortical confusion or
• somnolence,

More often it is just

• headache,
• some stiff neck or spasms, and
• perhaps other cns abnormalities such as autonomic dysregulation.

• moves away from meninges into perivascular sites in the brain stem,
• moves intracellular and
• alters its form to wall deficient or membrane wall-less forms (which continue to replicate),
• modulates its outersurface protein expressions and
• takes on wall membranes from host cells,

• less and less immune response and meningeal inflammation and
• more of a basilar brain chronic dysfunction.

This may explain Andrew Pachner's observation ( JAMA symposium on LD in 1995) that he often finds POSITIVE PCR DNA spinal fluid in neuroborreliosis patients who are NEGATIVE by ELISA and Western Blot in serum and spinal fluid ( at least negative for reporting criteria- maybe they are positive by specific bands such as 23 (OspC), 31 (OspA), 34 (OspB)).

Thus the doctors could do

• a spinal tap for PCR DNA,
• antibody responses, and even a
• BSK culture ( which the FDA recs should not be replaced by antibody testing, but few university centers offer the test).

• PCRs can be done on any monocyte layers from spinning down the csf- but this is done at a research level.
• Variant form culturing of csf might be the right direction to find Brorson's blebs. This is on hold. No one in high places wants to believe it.
• However, SPECT scans do have a high yield (50%) and
• MRIs enhanced have some yield (an MS like pattern) especially if there are brain stem hard focal findings on exam).
• A sleep study can demonstrate failure to enter deep REM levels.
• Tests of neuroendocrine dysfunction can be done such as TSH response to TRH ( can be extremely high or nothing),
• ACTH stimulation of cortisol (no change), or
• Human Growth Hormone response to GH releasing factor. It is expected that the autonomic dysregulation from central nervous system disease would often be reflected in abnormal regulatory responses not detected by systemic TSH baseline or cortisol baseline static testing.
• Advanced neurocognitive testing can be done (about 2500 dollars around here) which appears to yield little more than impaired organizational memory in many victims.

• a subacute encephalopathy secondary to chronic basilar vasculitis and perivasculitis,
• circulating cytokines and neurotoxins (with a somewhat anticholingergic like pattern),
• demylination or disruption of white matter interbrain stem pathways, and
• perhaps autoimmune attack upon synapse receptor sites
• mixed in with neuroendocrine dysregulation,

A more reasonable approach all said is perhaps doing

• Western Blots on serum IgG and IgM looking for specific band patterns supportive of Bb infection systemically ( as reported by Bingnam in 1992),
• urine antigens for specific wall fragments at IGENEX,
• a buffy coat acridine orange stain for motile spirochetes concentrated in the cellular layer,
• a detailed neurological exam and history for cranial nerve dysfunction beyond Bell's palsy, and
• a brain SPECT scan.
• PCR on
• serum,
• urine,
• spinal fluid or
• skin sites
of chronic Borrelia infection manifestations may be rewarding but appear somewhat insensitive as first level testing.

• VDRL,
• AIDS,
• Toxoplasmosis,
• cytomegalovirus,
• and things like mad cows

• Thyroid profile is fundamental but flawed.

• chronic disseminated Borreliosis often causes a persistent blood picture of 8-12 % circulating monocytosis (an increased amount) which looks just like mononucleosis.
• EBV virus studies for active infection status might be helpful when negative.
• (Paul Duray 20 years ago described in his writings that Lyme Disease masquerades as mono. Monocytes have the duty of eating large microbes such as Borrelia and arise from stimulating stem cells in the marrow. Unfortunately for us, Borrelia can coil and live in the monocytes without being destroyed. Kind of like the enemy's aircraft sharing tie down spots on our own aircraft carriers.

IgM should be done as well as IgG since IgM is constantly stimulated by new antigen expressions from the same and new generations of Bb.

Urine antigen (LUAT) at IGENEX often inversely parallels the Western Blot results

• since it measures free specific antigen it will be high when the free specific antibody is low or not detectable.

• Since the antibodies are polyvalent, it can require a large load of excess borrelia antigen to be measurable independent of the complexes.

Steve Schutzer demonstrated this fact 10 years ago and repeated it recently in JAMA. Still no one tests the complexes in precipitated samples as it should be done from his work.

Not many have done acridine orange stains on buffy coat samples of white blood cell concentrates but it looks easy and rewarding from Lida Mattman's work in Cell Wall Deficient Forms- Stealth Pathogens Third edition CRC Press 2000.

PCR testing of tissue samples is more rewarding in sensitivity that fluid samples such as blood.  I think the likelihood of a positive blood PCR is probably about 15-20% on first testing of a patient with Bb. This might indicate a need for serial PCR DNA out to 6 or 7 samples before offering the patient much in the way of confidence that Bb was unlikely to be present.

If you find the site discussing a full work up of the cns microbes please share it.

Harold

Diagnostic Labs in Germany (von J. Gr mailto:Joachim.Gruber@acamedia.info uber):
 

• Institut Lempfrid

An der Wachsfabrik 25
50996 Köln (Rodenkirchen)
Tel.:   02236/3911-0
FAX:   02236/3911-99
http://www.labor-koeln.de/
• Nationales Referenzzentrum für Borrelien (NRZ) am Max von Pettenkofer-Institut, München, Leitung PD Dr. med. Bettina Wilske

Of related interest (added by J. Gruber):

• Testing for Neurotoxins - Visual Contrast Sensitivity Test (VCS) in Chronic Lyme

The VCS Exam demonstrates the effect of neurotoxins on the optic nerve and the array of connected nerves in the cortex of the brain. Additionally, we can use VCS Exam to monitor improvement with therapy.