Rosenheimer Str. 6-8, 83043 Bad Aibling, Germany · info@clinicum-stgeorg.de
Diagnosis
Chronic Lyme disease is diagnosed from the history, the examination and several laboratory tests read together, because the standard two-tier antibody test measures the immune response and not the organism. This page explains what the standard test can and cannot show, and which tests the hospital laboratory adds.
You remember the bite, or you do not. You remember the summer everything changed. Since then: a rheumatologist, a neurologist, a psychiatrist, and a two-tier test that came back negative twice. In a drawer at home is a folder of results that do not add up to anything.
Many patients who come to us have been symptomatic for months or years without a clear diagnosis. If you have a combination of the following symptoms, especially if they began after a known or possible tick exposure, a full Lyme work-up should be considered:
Because the two-tier test measures antibodies, not bacteria. A systematic review of North American studies found that its accuracy differs by stage of disease (Waddell et al., 2016): antibody levels can be low early in infection, after early antibiotics, or when the immune response is suppressed. The 2020 IDSA, AAN and ACR guideline itself describes Lyme disease as a diagnosis made from exposure, clinical findings and laboratory support together (Lantos et al., 2021).
The standard protocol requires a positive ELISA screening test before a Western blot is performed, and the blot needs a set number of reactive bands. A patient whose antibody response is partial, late or suppressed can fail either step and receive a negative result while still infected.
Several factors contribute:
Patients with a persisting infection are told they do not have Lyme disease. They receive other diagnoses, symptom-management medication, and often the sentence that their symptoms are psychological.
What follows from a missed diagnosis:
At St. George Hospital no patient is dismissed because of a test limitation. The clinical evaluation always accompanies the laboratory results, and a negative result from home is read, not discarded.
The work-up combines the clinical evaluation with laboratory testing in the hospital's own laboratory and immune testing to build a picture of each patient's infection status, immune function and systemic involvement. It runs in seven steps.
Detailed review of symptom onset, progression, tick exposure history, prior testing results, previous treatments, and response to antibiotics. We assess the full timeline and pattern of illness to identify characteristic Lyme disease features.
Thorough physical examination with specific attention to neurological function, joint involvement, cardiac assessment, and signs of autonomic dysfunction. We evaluate for clinical markers of active infection and systemic inflammation.
We use several methods beyond standard ELISA and Western blot: a Borrelia ELISpot (cellular immune response), a Western blot with expanded band analysis and, when indicated, direct detection methods. The ELISpot measures the T-cell response to Borrelia, which can be present when antibody levels are low.
Low CD57 counts were described in chronic Lyme disease (Stricker and Winger, 2001), but a later controlled comparison found no difference between patients with post-Lyme disease syndrome and controls (Marques et al., 2009). The evidence for CD57 as a marker is therefore limited. We measure it as one value among several and repeat it at follow-up, never as proof of infection or of response.
Testing for the common tick-borne co-infections: Bartonella, Babesia, Ehrlichia, Anaplasma, Rickettsia, Chlamydia pneumoniae, Mycoplasma pneumoniae and Yersinia. Each confirmed co-infection changes the treatment plan, because Babesia, for example, is a parasite and does not respond to the antibiotics used for Borrelia. The co-infections we test for
Evaluation of immune system markers including lymphocyte subsets, cytokine profiles, complement levels, and immunoglobulin levels to assess the degree of immune dysregulation and guide immunomodulatory treatment decisions.
Additional testing as clinically indicated, including inflammatory markers (CRP, ESR, cytokines), thyroid function, adrenal function, hormonal panels, micronutrient levels, liver and kidney function, and heavy metal screening to evaluate the full systemic impact of chronic infection.
Lyme disease remains a clinical diagnosis supported by laboratory testing, not a laboratory diagnosis alone. No single test can definitively confirm or rule out chronic Borrelia infection. Our physicians integrate the full clinical picture, patient history, symptom pattern, physical examination findings, and results from multiple laboratory tests, to arrive at a diagnosis and treatment plan.
If you have been told that your tests are negative but your symptoms persist, write a short inquiry to the International Office, free of charge; it asks for your findings afterwards. A physician reads them before the video consultation and tells you which tests are still needed. The results of the work-up decide which modules of the Lyme treatment protocol apply to you; for patients from abroad, the page on the chronic Lyme program for international patients describes how records review, video consultation and admission run.
Commonly used in conventional medical settings:
Used at St. George Hospital:
The evidence is graded, and the grade differs by test. That the accuracy of two-tier serology depends on the stage of disease is strong and comes from a systematic review and meta-analysis (Waddell et al., 2016). That ticks transmit several pathogens at once, so that a Borrelia-only work-up is incomplete, is strong (Sanchez-Vicente et al., 2019). The evidence for the ELISpot as a stand-alone diagnostic test is emerging, and the evidence for CD57 as a marker is limited (Stricker and Winger, 2001; Marques et al., 2009). This is why no single result decides the diagnosis here, and why the same markers are measured again at follow-up: a value that moves with treatment tells us more than a value read once.
A typical diagnostic evaluation at St. George Hospital includes:
The two-tier test detects antibodies, and its accuracy differs by stage of disease. Antibody levels can be low early in infection, after early antibiotics, or when the immune response is suppressed. A negative result in a long illness does not exclude Borrelia; it is one finding to be read with the history, the examination and the other tests.
A Borrelia ELISpot for the cellular immune response, a Western blot with expanded band analysis, a CD57 natural killer cell count, a panel for the common tick-borne co-infections, and markers of immune function and inflammation, all in the hospital laboratory. The physician reads them together with your history and examination.
No. Low CD57 counts were described in chronic Lyme disease, but a controlled comparison found no difference between patients with post-Lyme disease syndrome and controls. We record CD57 as one value among several and never as proof of infection or of response.
The initial physician consultation lasts about 90 minutes. Blood is taken on the first day, and results are reviewed within 5 to 10 working days; the treatment plan is written from them. You receive a full written report for your records and your home physician.
Yes, and we ask you to. A physician reads your existing results, including negative ones, before the video consultation and tells you which tests are still needed. This avoids repeating what has already been done.
Related therapies
When diagnostics reveal elevated inflammatory markers and microclots, apheresis directly filters these from the bloodstream.
Diagnostic identification of persistent Borrelia and co-infections guides hyperthermia protocols targeting heat-sensitive organisms.
Immune panel results inform ozone therapy protocols that enhance immune function and provide antimicrobial support.
NK cell activity and lymphocyte subset results guide targeted immune restoration therapy for Lyme patients.
The initial inquiry is free of charge. The International Office reviews your message and your case directly and gets back to you.
Munich Airport (MUC), about 60 minutes by car.
