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J Pediatric Infect Dis Soc. 2019 Feb 22. pii: piy133. doi: 10.1093/jpids/piy133. [Epub ahead of print]

Two-Tier Lyme Disease Serology Test Results Can Vary According to the Specific First-Tier Test Used.

Author information

Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island.
Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
Division of Emergency Medicine, A. I. Dupont Hospital for Children, Sidney Kimmel Medical College Thomas Jefferson University, Wilmington, Delaware.
Division of Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts.
Harvard Medical School, Boston, Massachusetts.



Variability in 2-tier Lyme disease test results according to the specific first-tier enzyme immunoassay (EIA) in children has not been examined rigorously. In this study, we compared paired results of clinical 2-tier Lyme disease tests to those of the C6 peptide EIA followed by supplemental immunoblotting (C6 2-tier test).


We performed a prospective cohort study of children aged ≥1 to ≤21 years who were undergoing evaluation for Lyme disease in the emergency department at 1 of 6 centers located in regions in which Lyme disease is endemic. The clinical first-tier test and a C6 EIA were performed on the same serum sample with supplemental immunoblotting if the first-tier test result was either positive or equivocal. We compared the results of the paired clinical and C6 2-tier Lyme disease test results using the McNemar test.


Of the 1714 children enrolled, we collected a research serum sample from 1584 (92.4%). The clinical 2-tier EIA result was positive in 316 (19.9%) children, and the C6 2-tier test result was positive or equivocal in 295 (18.6%) children. The clinical and C6 2-tier test results disagreed more often than they would have by chance alone (P = .002). Of the 39 children with either a positive clinical or C6 2-tier test result alone, 2 children had an erythema migrans (EM) lesion, and 29 had symptoms compatible with early disseminated Lyme disease.


Two-tier Lyme disease test results differed for a substantial number of children on the basis of the specific first-tier test used. In children for whom there is a high clinical suspicion for Lyme disease and who have an initially negative test result, clinicians should consider retesting for Lyme disease.


Lyme disease; diagnostics; enzyme immunoassay; serology


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