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Two-tier testing for Lyme disease

About this Figure

The Two-tier Testing Decision Tree describes the steps recommended by CDC to test for Lyme disease. The first required test is the Enzyme Immunoassay (EIA) or Immunofluorescence Assay (IFA). If this test yields negative results, the provider should consider an alternative diagnosis.  Or in cases where the patient has had symptoms for less than or equal to 30 days, the provider may presumptively treat the patient and follow up with a convalescent serum. If the first test yields positive or equivocal results, two options are available: 1) if the patient has had symptoms for less than or equal to 30 days, an IgM Western Blot is performed; 2) if the patient has had symptoms for more than 30 days, the IgG Western Blot is performed. The IgM should not be used if the patient has been ill for more than 30 days.

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Understanding laboratory test results

About This Figure

Understanding Test Results for Infectious Diseases

The illustration depicts the likelihood of false positive and false negative test results based on the prior probability of a disease occurring in a given population. Clinicians should consider the likelihood of disease before performing laboratory testing. The likelihood that a patient has a disease depends on many factors:

  • Has a patient been in an area where the disease is found?
  • Does the patient have signs and symptoms typical of the disease?
  • Does the patient have risk factors for contracting or developing the disease?

In populations where disease is rare or unlikely, testing is likely to lead to false positives more frequently than true positives.

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Continuing Medical Education for Clinicians

Case Definition and Report Forms

Note: Surveillance case definitions establish uniform criteria for disease reporting and should not be used as the sole criteria for establishing clinical diagnoses, determining the standard of care necessary for a particular patient, setting guidelines for quality assurance, or providing standards for reimbursement.

Additional Reading


Halperin JJ, Baker P, Wormser GP. Common misconceptions about Lyme disease. Am J Med 2013;126(3):264.

Hu LT. Lyme disease. Ann Intern Med. 2016 May 3;164(9).

Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012;379(9814):461-73.

Lyme Carditis

Forrester JD, Mead P. Third-degree heart block associated with lyme carditis: Review of published cases. Clin Infect Dis 2014 May 30. pii: ciu411.

Three Sudden Cardiac Deaths Associated with Lyme Carditis — United States, November 2012–July 2013. MMWR Dec 13;62(49):993-6.

Pediatrics and Pregnancy

American Academy of Pediatrics. Lyme disease (Lyme borreliosis, Borrelia burgdorferi infection). In: Pickering LK, Red Book: 2012

Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am 2008 Jun;22(2):315-26, vii.

Walsh CA, Mayer EW, Baxi LV. Treatment of Lyme disease. Lyme disease in pregnancy: case report and review of the literature. Obstet Gynecol Surv 2007 Jan;62(1):41-50.


Aguero-Rosenfeld ME, Wang G, Schwartz I, Wormser GP. Diagnosis of Lyme borreliosis. Clin Microbiol Rev 2005 Jul;18(3):484-509.

Branda JA, Strle F, Strle K, Sikand N, Ferraro MJ, Steere AC. Performance of United States serologic assays in the diagnosis of Lyme borreliosis acquired in Europe. Clin Infect Dis 2013 Aug;57(3):333-40.

Concerns regarding a new culture method for Borrelia burgdorferi not approved for the diagnosis of Lyme disease. MMWR 2014;63:333.

Hinckley AF, Connally NP, Meek JI, Johnson BJ, Kemperman MM, Feldman KA, White JL, Mead PS. Lyme disease testing by large commercial laboratories in the United States. Clin Infect Dis 2014 May 30. pii: ciu397.

Johnson BJ, Pilgard MA, Russell TM. Assessment of new culture method for detection of Borrelia species from serum of Lyme disease patients. J Clin Microbiol 2014;52:721–4.

Johnson, B.J. “Chapter 4: Laboratory diagnostic testing for Borrelia burgdorferi infection” in Lyme disease: An Evidence-based Approach, J.J. Halperin, Ed. (CAB International, 2011). Complete Article Reproduced with Permission[PDF – 16 pages].

Moore A, Nelson C, Molins C, Mead P, Schriefer M. Current guidelines, common clinical pitfalls, and future directions for laboratory diagnosis of Lyme disease, United States. Emerg Infect Dis. 2016 Jul;22(7).

Notice to readers: caution regarding testing for Lyme disease. MMWR, CDC Surveillance Summary 2005;54:125.

Recommendations for test performance and interpretation from the second national conference on serologic diagnosis of Lyme disease. MMWR 1995;44:590–591.

Swanson SJ, Neitzel D, Reed KD, Belongia EA. Coinfections acquired from Ixodes ticks. Clin Microbiol Rev 2006 Oct;19(4):708-27.

Ongoing Research Studies of Lyme disease / “Borrelia Infections”.

Search the Biomedical Literature

PubMed, a service of the National Library of Medicine, includes over 15 million citations for biomedical articles back to the 1950’s. These citations are from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources.

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