Case records of the Massachusetts General Hospital. Case 11-2007. A 59-year-old man with neck pain, weakness in the arms, and cranial-nerve palsies

Lyme Disease Diagnosis: Serology

Serology is the mainstay of confirmation of Lyme borreliosis; direct detection has limited application. Because standardized 2-tier testing (STTT) has been commonly used since the mid 1990s, standardization and performance have improved. STTT detection of early, localized infection is poor; that of late disease is good. The best indicator of stage 1 infection, erythema migrans, is presented in the majority of US cases and should prompt treatment without testing. Clinical and epidemiologic correlates should be carefully assessed before ordering STTT. STTT has great value in confirming extracutaneous infection. Recent developments promise to improve performance, particularly in early disease detection.

Meningeal carcinomatosis from cervical cancer: a case report and review of the literature

Meningeal carcinomatosis (MC) from cervical cancer is rare. Diagnosis of this disease is often delayed due to variable presentation. We report an interesting case of MC from the uterine cervix and review general diagnostic and treatment considerations. The patient received chemotherapy and radiotherapy for stage IIB cervical cancer with resolution of symptoms for 3 years. Metastatic lesions were found in the right lung and paraaotic nodes on follow-up positron emission tomography scan, which completely resolved with subsequent chemotherapy. Unfortunately, the patient developed neurological symptoms consistent with MC, which was confirmed by cerebrospinal fluid cytology. Because of her poor cognition, available options were discussed with her family. She died peacefully in palliative care.

Prospective study of serologic tests for lyme disease

BACKGROUND

Tests to determine serum antibody levels-the 2-tier sonicate immunoglobulin M (IgM) and immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) and Western blot method or the IgG of the variable major protein-like sequence-expressed (VlsE) sixth invariant region (C6) peptide ELISA method-are the major tests available for support of the diagnosis of Lyme disease. However, these tests have not been assessed prospectively.

METHODS

We used these tests prospectively to determine serologic responses in 134 patients with various manifestations of Lyme disease, 89 patients with other illnesses (with or without a history of Lyme disease), and 136 healthy subjects from areas of endemicity and areas in which the infection was not endemic.

RESULTS

With 2-tier tests and the C6 peptide ELISA, only approximately one-third of 76 patients with erythema migrans had results that were positive for IgM or IgG seroreactivity with Borrelia burgdorferi in acute-phase samples. During convalescence, 3-4 weeks later, almost two-thirds of patients had seroreactivity with the spirochete B. burgdorferi. The frequencies of seroreactivity were significantly greater among patients with spirochetal dissemination than they were among those who lacked evidence of disseminated disease. Of the 44 patients with Lyme disease who had neurologic, heart, or joint involvement, all had positive C6 peptide ELISA results, 42 had IgG responses with 2-tier tests, and 2 patients with facial palsy had only IgM responses. However, among the control groups, the IgG Western blot was slightly more specific than the C6 peptide ELISA. The differences between the 2 test systems (2-tier testing and C6 peptide ELISA) with respect to sensitivity and specificity were not statistically significant.

CONCLUSIONS

Except in patients with erythema migrans, both test systems were sensitive for support of the diagnosis of Lyme disease. However, with current methods, 2-tier testing was associated with slightly better specificity.