Cerebrospinal Spinal Fluid (CSF)
To Test For Lyme Or Not To Test?
Dr. Kenneth Liegner (1993)
"For example, the patient described above was seronegative for the first 5 years of her illness, during which time she sustained severe and irreversible neurologic injury. Western immunoblot serologic results were inconclusive at the time B. burgdorferi was isolated from the CSF, highlighting the fallacy of the use of this test as a "gold standard" for the confirmation of Lyme disease."
Dr. Joseph Burrascano
"Spinal taps are not routinely recommended, as a negative tap does not rule out Lyme. Antibodies to Bb are mostly found in Lyme meningitis, and are rarely seen in non-meningitic CNS infection, including advanced encephalopathy.
Even in meningitis, antibodies are detected in the CSF in less than 13% of patients with late disease! Therefore, spinal taps are only performed on patients with pronounced neurological manifestations in whom the diagnosis is uncertain, if they are seronegative, or are still significantly symptomatic after completion of treatment.
When done, the goal is to rule out other conditions, and to determine if Bb (and Bartonella) antigens or nucleic acids are present. It is especially important to look for elevated protein and white cells, which would dictate the need for more aggressive therapy, as well as the opening pressure, which can be elevated and add to headaches, especially in children."
Dr. Joseph Burrascano
"Considerable evidence suggests that in all disseminated Lyme infections, seeding of the central nervous system occurs early (possibly within hours after the bite), yet a recent study has shown that antibodies to Bb can be detected in the cerebrospinal fluid (CSF) in only 20% of such patients."
Infectious Diseases Society of America (IDSA) Lyme Disease Guidelines
"The proportion of polymorphonuclear leukocytes in the CSF of patients with Lyme meningitis is typically <10% and is significantly lower than that observed in viral meningitis [158, 159].
Amplification of B. burgdorferi DNA in CSF using PCR by a laboratory with excellent quality control can also be useful [103, 124, 167], but few laboratories are capable of accurately performing this test.
Sensitivity of PCR for detection of B. burgdorferi DNA in the CSF of such patients is extremely low.
Lyme encephalomyelitis may be confused clinically with a first episode of relapsing-remitting multiple sclerosis or primary progressive multiple sclerosis...
Because the pathophysiologic process usually occurs outside the subarachnoid space, CSF findings are often normal, without evidence of intrathecal antibody production to B. burgdorferi.
The latter study also cultured 128 CSF specimens for B. burgdorferi and evaluated blood specimens and CSF specimens by PCR. None of the 843 specimens tested in total was either culture or PCR positive...
OspA was detected in the CSF in only 16% of the patients in this study..."
Johns Hopkins- 2005
"Of the three CSF specimens, one grew B. burgdorferi, one culture had no growth, and one culture was contaminated and unable to be analyzed."
Wormser (IDSA), et. al
"When performed using CSF, positive results from these assays do not establish the presence of intrathecal antibody production to B. burgdorferi and therefore should not be offered."
TRANSCRIPT: HHS Federal Research Update on Lyme Disease Diagnostics Activities
"The erythema migrans rash and blood have sensitivities in early disease of about 50% sometimes a little higher. And then in much decreasing amount we’ve isolated Borrelia burgdorferi from synovial tissue of Lyme arthritis cases and CSF in neuroborreliosis cases."
Neurology Department- Germany
"Because the oligoclonal bands present in the CSF of patients with neuroborreliosis are anti-Borrelial antibodies, CSF oligoclonal band testing provides little additional diagnostic value from a Lyme disease perspective. We view measurement of CSF CXCL13 levels as similarly nonspecific. Several studies have described elevated CSF CXCL13 in persons with neuroborreliosis, with decline identified following appropriate antimicrobial therapy.
This test may be valuable in distinguishing active neuroborreliosis from subjective neurocognitive symptoms thought potentially attributable to B burgdorferi infection. However, a number of other conditions, including tick-borne encephalitis and neurosyphilis, are associated with elevated CSF CXCL13 levels.3,6
At present, CSF CXCL13 levels do not adequately discriminate neuroborreliosis from other neuroinflammatory conditions to justify diagnostic CSF testing for assessment of this parameter alone.3
However, antibodies to B burgdorferi in CSF may be negative during early infection.3 Furthermore, while patients with facial nerve palsy attributable to Lyme disease often have a lymphocytic CSF pleocytosis, CSF analysis is not needed for patients without signs or symptoms of meningitis who are suspected to have this diagnosis owing to its excellent response to treatment with oral doxycycline.4
Late Lyme encephalomyelitis—meaning genuine infection of the brain parenchyma and/or spinal cord by B burgdorferi—is exceptionally uncommon.5 ... While CSF study results for such patients are abnormal, given the rarity of this entity, initial Lyme disease–related testing should include only peripheral blood serologic testing, as such patients will be B burgdorferi seropositive.
Laboratory confirmation of LNB is hampered by the low sensitivity of culture and polymerase chain reaction (PCR) in CSF . Presence of BB-specific antibodies in the CSF with evidence of intrathecal production is the traditional diagnostic gold standard but has limitations such as low sensitivity in the very early phase of the disease [1, 2, 4] and can persist for years after eradication of the infection [8, 9]."
NY- Department of Neurology
"However, seroreactivity only indicates exposure to the organism and does not establish that Bb is the cause of encephalopathy. CSF pleocytosis is present in 5% and protein content is increased in 20–45% of cases.
While abnormal CSF in a seropositive person helps confirm that a neurologic syndrome is due to Bb, normal CSF should not be used to exclude Lyme neuroborreliosis.
Since a positive CSF culture is seen in less than 10% of Lyme neuroborreliosis cases, isolation of Bb is less useful diagnostically.
PCR-based methods can detect less than 10 Bb organisms in the biologic samples and such detection is highly specific. However, PCR has two important drawbacks. First, the extreme sensitivity of PCR can result in false positive result due to contamination. This problem can be controlled in a research laboratory by careful attention to controls and to laboratory technique. Second, the presence of PCR-detectable organisms does not prove the presence of clinically active disease because the organisms may be dead or alive.22
In other studies, however, PCR was found to have methodological problems and was positive in only 25–50% of cases.
Until a ‘gold standard’ diagnostic test is established, it is reasonable to accept a less restrictive criteria for the diagnosis of Lyme neuroborreliosis, for example, a compatible neurologic abnormality without other cause, and either serum immunoreactivity to Bb with no demonstrable rise in the antibodies, or tick bite or travel or residence in an endemic area.25
Failure to treat these probable or possible cases in time, may have far reaching consequences.26"
Last Updated-March 2019