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Methods for Rapid Transfer and Localization of Lyme Disease Pathogens Within the Tick Gut
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Real-world Lyme disease testing results using modified vs standard two-tier test protocols.

Yonghong Li1, Zhen Chen1, Carmen H Tong1

  • 1Quest Diagnostics, San Juan Capistrano, California, United States of America.

Plos One
|June 30, 2025
PubMed
Summary

The modified two-tier test (MTTT) for Lyme disease identifies more positive cases in adults than the standard two-tier test (STTT). Results were similar for children and adolescents, with MTTT detecting more IgM or IgM/IgG positive cases.

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Area of Science:

  • * Infectious Disease Epidemiology
  • * Clinical Laboratory Science
  • * Immunoserology

Background:

  • * Lyme disease serology testing is crucial for diagnosis.
  • * The standard two-tier test (STTT) has been the long-standing protocol.
  • * The modified two-tier test (MTTT) is a recently approved alternative.

Purpose of the Study:

  • * To compare the real-world performance of MTTT versus STTT for Lyme disease serology.
  • * To evaluate differences in test positivity rates between the two protocols across age groups.

Main Methods:

  • * Retrospective analysis of Lyme disease testing results from a US national reference laboratory (2022-2023).
  • * Construction of a matched cohort study including 66,708 individuals for MTTT and 66,708 for STTT.
  • * Comparison of positivity rates and antibody detection patterns (IgM alone, IgM/IgG) between MTTT and STTT.

Main Results:

  • * MTTT identified significantly more positive cases in adults (OR 1.88; 95% CI 1.79-1.98) compared to STTT.
  • * MTTT and STTT showed similar positivity rates in non-adults (OR 1.09; 95% CI 0.97-1.23).
  • * MTTT detected more cases positive for immunoglobulin M (IgM) antibody alone or both IgM and immunoglobulin G (IgG) antibodies.

Conclusions:

  • * The MTTT protocol demonstrates higher sensitivity for detecting Lyme disease in adults compared to STTT.
  • * MTTT may offer improved diagnostic yield, particularly for IgM or combined IgM/IgG antibody responses.
  • * Further evaluation is warranted to understand the clinical implications of these differences.