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lance Case Definition specifies a person with exposure to a potential tick habitat (within the 30 days just prior to developing erythema migrans) with (1) erythema migrans diagnosed by a physician or (2) at least one late manifestation of the disease and (3) laboratory confirmation as fulfilling the criteria for Lyme disease Laboratory confirmation requires detection of specific antibodies to B burgdorferi in serum, either by indirect immunofluorescence assay (IFA) or ELISA; the latter is preferred because it is more sensitive and specific A Western blot assay that can detect both IgM and IgG antibodies is used as a confirmatory test IgM antibody appears first 2 4 weeks after onset of erythema migrans, peaks at 6 8 weeks, and then declines to low levels after 4 6 months of illness The presence of IgM antibody in patients with prolonged symptoms persisting for several months is likely to be a false-positive result IgG occurs later (6 8 weeks after onset of disease), peaks at 4 6 months, and may remain elevated at low levels indefinitely despite appropriate therapy and resolution of symptoms A two-test approach is recommended for the diagnosis of active Lyme disease All specimens positive or equivocal by ELISA or IFA should be tested by Western immunoblot When Western immunoblot is done during the first 4 weeks of illness, both IgM and IgG should be tested If a patient with suspected early Lyme disease has negative serologic studies, acute and convalescent titers should be obtained since up to 50% of patients with early disease can be antibody negative in the first several weeks of illness A fourfold rise in antibody titer would be diagnostic of recent infection In patients with later stages of disease, almost all are antibody positive False-positive reactions in the ELISA and IFA have been reported in juvenile rheumatoid arthritis, rheumatoid arthritis, systemic lupus erythematosus, infectious mononucleosis, subacute infective endocarditis, syphilis, relapsing fever, leptospirosis, enteroviral and other viral illnesses, and patients with gingival disease (presumably because of cross-reactivity with oral treponemes) False-negative serologic reactions occur early in illness, and antibiotic therapy early in disease can abort subsequent seroconversion VlsE is an outer surface lipoprotein of B burgdorferi An ELISA test measures antibodies against a peptide that is in the invariant region of this lipoprotein The test is done in a single step (as opposed to the current two-step test recommended by the Centers for Disease Control and Prevention), is easy to standardize, and is less expensive than two-step testing The ELISA appears to be as sensitive and specific as the current two-step test in the diagnosis of late stage disease and it is more sensitive for early disease Caution should be exercised in interpreting serologic tests Serologic tests are not subject to national standards, and interlaboratory variation of results is a major problem In addition, some laboratories perform tests that are entirely unreliable and should never be used to support the diagnosis of Lyme disease (eg, the Lyme urinary antigen test, immunofluorescent staining for cell wall-deficient forms of B burgdorferi, lymphocyte transformation tests, using PCR on inappropriate specimens such as blood or urine) In addition, testing is often done in patients with nonspecific symptoms such as headache, arthralgia, myalgia, fatigue, and palpitations Even in endemic areas, the pretest probability of having Lyme disease is low in these patients, and.



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The diagnosis of late neuroborreliosis is often difficult since clinical manifestations, such as subtle memory impairment, may be difficult to document Most patients with neuroborreliosis have a history of previous erythema migrans or monarticular or polyarticular arthritis, and the vast majority have antibody present in serum When cerebrospinal fluid is sampled from patients with encephalopathy, there may be evidence of inflammation (pleocytosis or elevated protein, or both), and localized antibody production, ie, a ratio of cerebrospinal fluid to serum antibody of > 10 The role of other tests such as PCR in detection of DNA or ELISA in detecting the presence of outer surface protein A (OspA) antigen is unclear, but in difficult cases these tests can be performed and, if positive, help establish the diagnosis Patients with late disease and peripheral neuropathy almost always have positive serum antibody tests, usually have abnormal electrophysiology tests, and may have abnormal nerve biopsies showing perivascular collections of lymphocytes Because disease involves peripheral nerves, the cerebral spinal fluid is usually normal and does not demonstrate local antibody production Nonspecific laboratory abnormalities can be seen, particularly in early disease The most common are an elevated sedimentation rate of > 20 mm/h seen in 50% of cases and mildly abnormal liver function tests present in 30% The abnormal liver function tests are transient and return to normal within a few weeks of treatment A mild anemia, leukocytosis (11,000 18,000/mcL), and microscopic hematuria have been reported in 10% or less of patients





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fully for 30 days If skin lesions or a viral-like illness develop, they should be evaluated for possible Lyme disease, human granulocytic anaplasmosis, and babesiosis

Microsoft added some wrinkles to DNS servers with the introduction of Windows 2000 Server, and each subsequent version of Windows Server retains the wrinkles Windows Server can do cached lookups, primary and secondary forward lookup zones, and reverse lookup zones, just like UNIX/Linux DNS servers But it also has a Windows-only type of forward lookup zone called an Active Directory integrated zone

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Present recommendations for therapy are outlined in Table 34 4 For erythema migrans, antibiotic therapy shortens the duration of rash and prevents late sequelae Doxycycline is most commonly used and has the advantage of being active against Anaplasma phagocytophilum (formerly Ehrlichia) Amoxicillin is also effective and is recommended for pregnant or lactating women and for those who cannot tolerate doxycycline Cefuroxime axetil, is as effective as doxycycline, but because of its cost it should be considered an alternative choice for those who cannot tolerate doxycycline or amoxicil-

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