Borrelia burgdorferi Antibodies With Reflex to ELISA

Content Review: June 2023 Last Update:

Preferred reflex test to diagnose Lyme disease in symptomatic individuals. Reflex pattern follows the modified two-tier testing (MTTT) approach; a positive or equivocal screen is confirmed by immunoassay.

Lyme disease is one of the most common tickborne diseases in the United States. Infection is often accompanied by a characteristic erythema migrans (EM) rash, which alongside the appropriate history of tick exposure, can be used to issue a clinical diagnosis. Although laboratory testing is not always necessary for diagnosis, it is recommended for individuals with atypical presentations or specific neurologic symptoms.  When testing is indicated, the CDC recommends two-tiered serologic testing. 

For additional information, refer to the ARUP Consult Tickborne Diseases topic or Lyme Disease - Modified Two-Tiered Testing Algorithm.

Test Interpretation

Reference Range

  • Negative: ≤0.90 IV
  • Equivocal: 0.91-1.09 IV
  • Positive: ≥1.10 IV

Results

Testing Tier Result Interpretation

Tier 1: VlsE1/pepC10 antibodies by ELISA

Negative

Antibodies to Borrelia burgdorferi were not detected. Test will not reflex to tier 2.

If suspicion of recent infection (≤14 days) remains, consider testing a new specimen after 7-14 days.

Positive/equivocal

Antibodies to B. burgdorferi were detected. Test will reflex to tier 2.

Tier 2: Reflex to IgM and IgG antibodies by ELISA

Negative IgM and IgG

Antibodies to B. burgdorferi were not detected.

If suspicion of recent infection (≤14 days) remains, consider testing a new specimen after 7-14 days.

Equivocal IgM and IgG

If tier 1 results were positive, an equivocal tier 2 result supports a diagnosis of Lyme disease.

If both tier 1 and tier 2 results are equivocal, consider testing a new specimen after 7-14 days.  

Positive IgM only

IgM antibodies to B. burgdorferi were detected, suggesting an acute or recent infection. IgM antibody results should only be considered to suggest recent or acute infection for specimens drawn ≤30 days from symptom onset.

Positive IgG only

IgG antibodies to B. burgdorferi were detected, suggesting a recent or past infection.

Positive IgM and IgG

IgM and IgG antibodies to B. burgdorferi were detected, suggesting a recent or past infection.

ELISA, enzyme-linked immunosorbent assay; Ig, immunoglobulin

Limitations

  • Serologic testing is not useful to assess treatment response.
  • IgM antibody results should only be considered for specimens drawn within 30 days of symptom onset.