Monday, September 15, 2008

Lab tests

I am getting a lot of questions about lab results lately, so I thought I would post a few remarks.
CD57: Burrascano and Sticker have published that is a good measure of Lyme disease activity. My experience has not been consistent with this finding. Many variables affect this measure. Some very sick Lyme patients have high levels. Others who are in clinical remission have consistently low levels. I obtain the test because it may be a clue, albeit a weak on.
C3a and C4a: These are sensitive indicators of complement activation. The complement system is activated when the immune system is responding to a perceived pathogen. Elevation of these levels may also be seen in autoimmune disease such as lupus.
C6 peptide antibody: This is difficult one to call. In my opinion and experience, index levels between 0.1 and 0.3 may be associated with a diagnosis of Lyme. I am fairly confident that levels of 0.4 and greater are highly significant. These levels correlate poorly with Western Blot results. So both tests are ordered.
Lyme ELISA: I am against the grain here. If the results are positive with a negative Western Blot, I can generally demonstrate exposure to Borrelia. Remember: The Western Blot assay associated with the two tier test is based on CDC surveillance criteria and was never validated as a diagnostic test. A positive serology for Lyme will come from: C6 peptide aby, IgeneX WB, or seroconversion after antibiotic therapy. I think that false positives are extremely rare and false negatives extremely common.
Lyme Western Blot: I am lucky (actually the patient) if I get a positive result with the 13 band test provided by most labs. The IgeneX test is more reliable. IgeneX still misses about 30% of cases by their own admission. Indeterminate bands should be give consideration if the clinical picture suggest Lyme.
Ehrlichia and Anaplasmosis: positive serology is very suggestive of concomitant Lyme.
Babesia: Labcorp will only test for B. microti. Specimens sent to IgeneX show a high rate of positivity for B. duncati. There is no test for most strains of Babesia. The IgeneX test costs an extra $135.00. Worth it. Babesia seems to be of increasing frequency and should be strongly considered if clinical signs are present.
Bartonella: Rarely positive. Probably very significant. There is no good test. Its significance is controversial. Some doctors believe that Lyme complex is a triad: Borrelia, Babesia and Bartonella.
B12 and Folic acid: Frequently low. Part of the syndrome. Supplementation recommended.
Vitamin D: Low levels of vit D OH 25 and high levels of vit D 1,25 suggest L-form disease. This is controversial, but it is frequently seen in Lyme patients.
Chamydia pneumonia, Mycoplasma, HHV6 and others. These are tests for other chronic infections which may contribute to chronic Lyme symptoms. LLMDS vary greatly on the significance and approach to positive results here.
Sed rate and CRP: These are markers of inflammation. There are frequently very high. If someone is diagnosed with "fibromyalgia" look out. One criteria for this diagnosis is that lab tests, including these two, are normal. These levels improve as patients improve. Sometimes levels stay high. These patients seem to have co-infections are are difficult to treat.
ANA and RA: Traditional markers of lupus and rheumatoid arthritis. These levels are frequently elevated in Lyme disease. They are associated with autoimmune reactivity. The levels usually return to normal when Lyme patients are successfully treated.
CBC: Many Lyme patients have low WBC counts. (white blood cells). They also frequently have a "right shift." This means there is an excess of cells called lymphocytes and monocytes and a deficit of cells called neutrophils. This abnormality is common. I have not seen it reported in Lyme literature. It usually corrects with treatment. Lyme patients have anemia more frequently than would be expected in the general population as well.
RBC (red blood cell) magnesium. Frequently low. Associated with leg cramps. supplementation may be helpful. Blood levels are not accurate.
C3d: A test only available from Quest. I shows circulating immune complexes which are commonly seen in Lyme disease. Not used much at this time.
Brain MRI: Shows lesions in the white matter of the brain. Correlates with significant neuroborreliosis. (brain involvement)
SPECT scan: Looks for Gray matter abnormalities in neuroborreliosis. Decreased blood flow to the cerebral cortex is frequently seen. This test may show improvement after treatment.
Western Blots, Western Blots: This tests frequently needs to be repeated several times before a positive is obtained.
EMG/NCV: these are electrodiagnostic test which can performed by a neurologist which may help confirm and quantify the presence of peripheral neuropathy seen in Lyme patients.
Most Lyme patients will show something abnormal if all of these tests are done. This is very different from what the average, non LLMD orders: A Lyme ELISA with a reflex WB of only 13 values. This test is almost worthless. Especially in chronic cases.
If you know all of this stuff it will expedite your visit with your LLMD. Lyme disease can still only be diagnosed when the history, physical exam and lab/imaging data are combined in a mosaic to confirm a clinical suspicion. Nonetheless, I have never seen a case of Lyme associated with lab tests which were 100% normal. You have to know what to order and how to interpret the results. The text book for such things has not yet been written.

11 comments:

dogdoc said...

In reference to the CD57, I haven't found the research behind it yet.
What would a low cd8-/ cd57 lymphs (% or absolute) refer to?

Lyme report: Montgomery County, MD said...

I am not an immunologist. To the best of my knowledge, a technology called flow cytometry is used to separate out the different lymphoctyes. In general, CD8 cells are killer T cells and CD4 cells are helper T cells. The assay measures a subset of NKT(natural killer T) cells. NKT cells are not the same thing as killer T cells. This specific assay was developed by Ray Stricker, the former president of ILADS. He is an immunologist. I believe that NKT cells represent a bridge between the innate immune system and the acquired immune system. The down regulation of NKT cells leads to suppresion of immune function and is associated with chronic infection, especially Lyme disease. This effect is to some extent regulated by cytokines. Lyme infection is associated with a Th2 helper T cell response which is associated with anti-inflammatory cytokines, rather than the Th1 response associated with intracellular antimicrobial activity. The particular interlekins and TNFs involved elude me at this moment. However, I do recall that Th1 responses are associated with gamma interferon, which has anti-bacterial effects. This response also is associated with the elaboration of anti-microbial peptides. Lyme reduces Th1 responses and favors Th2 responses which promote an unhelpful anti-inflammatory effect. I don't know how Lyme reduces NKTs. It may be due to a direct immunosuppressive effect, but I suspect it has to do with down regulation related to specific cytokines. The spirochetes have been busy developing tricks which suppress immunological responses which would otherwise reduce their survival. I think a google search adding Sticker to CD57 will get you the info.

dogdoc said...

You are pretty well versed in immunology anyway. Thank you for the push in the right direction. I found the specific Stricker references in conferences. I use PubMedCentral because I get fast, free in english interpretation of European and american studies. A lot of this was not published in those journels. I would think it would be hard to use clinically because of varied patient immune responses, effects of coinfections, and what is happening in the tissues/brain vs the sampled fluid.
There is a lot of pure research in this area which I had read, so I understand what you are saying. One of the current favorites is the induction of the Th2 helper response to impair immune system- induction of this pathway downregulates the Th-1 pathway via cytokines (the CMI pathway that would kill the little buggers). The favored anti-inflammatory cytokine at the moment is Interleukin-10. IL-10 downregulates Nk cell populations via IL-12. However, I think there is much we don't know- C57 mice help the study of IL-10 responses. We don't have a mouse line for every immune variable! I love immunology. Thanks for the info.

dogdoc said...

On the subject of picking Doc's brain so I can learn more... Babs is my current favorite research subject. A quick ? - Do you think its possible that our current clarithromycin/ hydroxychloroquine cocktail has any activity against Babs that we are unaware of? From mechanism of actions of current treatments for Babs, I wonder. Azithromycin/atovaquone and Clindamycin/quinine seem to have some things in common with current Lymes cocktail.

dogdoc said...

Last ?- I promise. On subject of cytokines- some of neuroborreliosis signs attributed to neurotoxic cytokines IL-6 and TNF alpha in a number of studies.
Singulair (IL-6 competitive inhibitor) temporarily reduces some signs in a neuroborreliosis patient I know. That was got me into the immunology side to start with in reading.
Have you seen anything clinically or research wise in this direction?

Avalon said...

Question from a Lyme patient-----my latest labs ordered by Rheumy( limping along until appt with LLMD) showed "abnormal serum immunofixation". She stated "trace abnormality---monochlomal band"?

Have you ever heard of this? She now thinks I DON'T HAVE LYME (ARRRRRRRGH), despite 4 bands on WB, and is referring me to Hematologist!

Lyme report: Montgomery County, MD said...

For Avalon. Are we talking about serum protein electrophoresis? This is a non specific test which is primarily usefull in diagnosing multiple myeloma. Other non specific abnormalities relate to changes in levels of immunoglobulins (antibodies) but are non specific. Monoclonal bands represent a large number of identical antibodies of a particular subset. These antibodies are made by cells called monocytes. These abnormalities are common and usually benign. I don't know of any merrit in using this test in Lyme. Your doc is following the typical discredited IDSA model Four positive bands is a lot, especially on the typical 13 band assay. I have found that rheumatologists are even less informed and less open minded to the possibility of Lyme disease than infectious disease doctors, if that is humanly possible. Rheumatologist favor putting patients on powerful immune suppresing drugs like: Enbrel, Methotrexate, Remicaide. All of these drugs at best, cover up the symptoms like a bandaid. At worst, these drugs allow Lyme to spread and increase your chance of cancer.
The problem with being a rheumatologist is that 90% of the patients you see in a given day have Lyme (in my humble opinion). To accept the chronic Lyme hypothesis would mean that everything you do and evrything you have been doing for the last ? years is wrong. Cognitive dissonance theory of social psychology blocks this from ever happening. You keep doing the same thing over and over.

dogdoc said...

Avalon- I hope you don't have too much longer to wait for your appointment. Don't you love how whenever they have no clue what's going on, you just get another specialist who ends up with no clue and so on. I feel for you and hope things get better soon.

dogdoc said...

Doc- got a good example of your cognitive dissonance theory today. Got fired by my ex- gp (had already found a new more open minded one anyway and changed over the insurance). It was priceless. This was the internist that refused to take a blot on me because "we don't know how to interpret that test". So what do the people that have the disease do? Anyway, she was very concerned I was being treated based what was in my lab findings. I pointed out I am being treated on my clinical signs based on the experience of a clinician specialized in this area. Besides, I am responding beautifully- after years of tingling and numbness and joint pain, I have virtually none of that left. Well I wouldn't have treated you based on that. Well then you wouldn't have made me any better now would you.

Lyme report: Montgomery County, MD said...

Dogdoc:
Quinine is cheap but too toxic. In particular: Ototoxiciy-hearing loss.
Plaquenil does not kill Babesiosis, as far as I can tell.
Allergies are associated with a Th2responses. I have thought that singulair might help. With limited experience, I cannot say it has helped. Allergies also cause an IgE response which is anti-parasitic. Babesia?
Big issue for you is vitamin D. Of course vit D is actually a hormone and its has potent immunoregulatory effects. Vit D receptors on macrophages and lyphocytes promote Th2 responses. This is the rationale of the Marshall protocol. LLMDs at one time jumped on this bandwagon and then jumped off: it doesn't work very well. Ostensibly, L-forms, including CPN and mycoplasmas and Bb or course, convert vit D OH 25 to vit D 1,25 at a cellular level. The first D is relatively inactive although it has the highest circulating levels in serum. The D dihydroxy 1,25 is actually the active form. Most Lyme patients have a reseversal of the normal ratio with a predominace of active D, frequently in a "toxic" range. Docs have been trained only to check inactive D. Many patients are erroneously diagnosed with D deficiency when nothing could be farther from the truth. Parenthetically, it is also possible that these high levels of active D actually cause increased osteoclastic activity causing osteoparosis! Benicar, an ARB has been used to balance vit D levels.
This works through a renal mechanism. Docs who used to tell patients: no sun, no dairy etc. are now loading patients up with vitamin D! D does have steroid like effects and has been shown to be immunsuppresive! Like steroids it provides temporary relief.
Perhaps these docs have thrown out the baby with the bath water. I don't think they understand any of these mechanisms. In fact I had this conversation with Jemsek, who is brilliant, but he refused to look at the issue. Patients who are in clinical remission frequently have persistent D dysregulation and patients who are very sick may have normal D ratios.
I have considered that optimal immune responses require a balance between Th1 and Th2 responses.
I don't give D. Some patients have had dreadful relapses after vacationing in FLA. Benciar may help some patients.
The neurolgists are giving MS patients vit D. There have been studies showing that people with low D have a higher incidence of MS and other autoimmune disease.
I think two things: They are measuring the wrong form of D and they are confusing cause and effect. Patients with low D hydroxy 25 have L-form infection. This causes MS etc. Giving D makes the patients worse! The current craze is that everyone is D deficient: load up. BIG MISTAKE.
I loose other docs when I talk like this. Research this one. You have your work cut out for you!

sloborabas said...

Just want to say that this may be the best Lyme-blog I have ever read.

One question to the DOC: one of the primary problems I developed whilst walking around (for years) undiagnosed with Lyme was hyperthyroidism / Graves disease.

I hear it is somewhat unusual to go hyperthyroid, but I am told thyroid problems in general are extremely common with Lyme. Hence I was extremely surprised that thyroid tests (hormones: TSH, T3, T4 and antibodies: Anti-TPO, TgAb) don't appear to be mentioned in your list of diagnostic criteria?