7Īs in the U.S., Lyme disease has attracted much attention in Europe, where guidelines warn of public misconceptions 6 and unwarranted testing. 12,13 Two-tier testing is usually conducted in a "reflex" manner such that positive or equivocal results on a first-tier immunoassay are followed by the automatic performance of a Western immunoblot to test for immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies. While 2-tier serologic testing for Lyme disease is the standard of care in the U.S.,7 Germany, 9 and some other parts of Europe, 6,8,10 immunoblot band interpretation differs between North America 11 and Europe because of variable surface protein expression among the genospecies. 6–8 Testing parameters, however, should follow local guidelines. Irrespective of location, laboratory testing should be reserved for patients with an intermediate pre-test probability of disease. This pattern of universal commonality and regional disparity also applies to the diagnostic workup. Lyme neuroborreliosis, acrodermatitis chronica atrophicans, and borrelial lymphocytoma, for example, are mostly restricted to Europe. 1 Although erythema migrans is a frequent manifestation of Lyme disease worldwide, less common clinical syndromes are geographically heterogeneous. Regardless of the infecting genospecies, Lyme disease can be classified into 3 stages: 1) early localized disease, which occurs days to weeks after the vector tick bite and is often characterized by erythema migrans (i.e., an expanding erythematous skin lesion that may develop central clearing) 2) early disseminated disease, which can follow weeks to months after untreated infection and may present as multiple erythema migrans, Lyme carditis, or neuroborreliosis and 3) late disease, which may follow months or years after untreated infection and may include arthritis and other dermatologic and neurologic manifestations. spielmanii are established contributors to the burden of human disease. 2–5 Pathogen diversity is greater in Europe, where B. burgdorferi sensu stricto, 1 although other presumably pathogenic genospecies have been isolated. In North America, the vast majority of Lyme disease is caused by B. who practice internationally or who commonly treat international travelers should understand the universal commonalities and region-specific differences in the microbiology, presentation, and diagnosis of Lyme disease. as Lyme borreliosis, is caused by infection with tick-borne spirochetes of the Borrelia burgdorferi sensu lato complex. Lyme disease, known commonly outside the U.S. Overreliance on serologic testing, given its low positive predictive value in certain contexts, can lead to misdiagnosis, wasted expenditure, and antibiotic misuse. Early diagnosis and treatment are essential to prevent complications from disseminated disease. Lyme disease is the most commonly diagnosed vector-borne illness in the U.S. What Is the Impact on Readiness and Force Health Protection? Thirty patients with true-positive IgM immunoblots could have been diagnosed and treated without laboratory testing. Air Force MTF laboratories in Germany between 20, 40 (48.2%) were deemed false positives after standardized chart review, and 32 of these patients were prescribed antibiotics. Of the 83 positive Lyme disease IgM immunoblots conducted at U.S. Understanding the use and limitations of 2-tier diagnostic criteria, as well as the common pitfalls in diagnosing Lyme disease, may help prevent overdiagnosis, reduce unnecessary testing, and promote antibiotic stewardship. Additionally, 30 patients with uncomplicated erythema migrans could have been treated without laboratory confirmation. Thirty-two patients with false-positive tests were treated with an antibiotic. Eighty-three positive IgM immunoblot tests were adjudicated using modified published criteria, of which 40 (48.2%) were deemed false positives. Of the 1,176 first-tier immunoassays, 1,114 (94.7%) were negative, and of the 285 immunoglobulin M (IgM) immunoblots, 242 (84.9%) followed a negative first-tier assay or were performed without an antecedent first-tier assay. Air Force military treatment facilities (MTFs) in Germany between 20 were assessed to determine the appropriateness of laboratory testing and antibiotic prescriptions. service members and their dependents at U.S. Lyme disease diagnostic workups conducted on active and retired U.S. Medical Surveillance Monthly Report Abstract
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