Should a patient with back pain and knee pain, without a history of inciting trauma, be tested for Lyme disease (Lyme borreliosis) in a region with low disease prevalence?

From the Guidelines

I would not recommend testing for Lyme disease in this situation, as back pain and knee pain without a history of trauma in a low prevalence area are not typical presentations that warrant Lyme testing. According to the clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) 1, testing for Lyme disease is recommended in patients with specific acute disorders such as meningitis, painful radiculoneuritis, or mononeuropathy multiplex, but not for nonspecific symptoms like back and knee pain. The guidelines suggest against screening for Lyme disease in patients with neurologic syndromes other than those listed, in the absence of a history of other clinical or epidemiologic support for the diagnosis of Lyme disease 1.

Lyme disease typically presents with a characteristic bull's-eye rash (erythema migrans), flu-like symptoms, and sometimes joint pain that is usually migratory rather than fixed. Testing in low prevalence areas leads to a higher rate of false positives, which can result in unnecessary treatment with antibiotics like doxycycline 100mg twice daily for 10-21 days. Instead, I would recommend evaluating for more common causes of back and knee pain such as:

• Osteoarthritis
• Muscle strain
• Inflammatory conditions If the patient has specific risk factors like recent travel to endemic areas or known tick exposure with compatible symptoms, testing might be reconsidered. The two-tier testing approach (ELISA followed by Western blot) is recommended if testing is ultimately pursued, but in this case, pursuing other diagnostic avenues would be more appropriate and cost-effective.

From the Research

Diagnostic Considerations for Lyme Disease

• The diagnosis of Lyme disease is typically based on objective clinical manifestations supported by laboratory evidence of infection with Borrelia burgdorferi sensu lato 2.
• Lyme disease can present with a variety of symptoms, including arthritis, which is a major clinical feature, and can affect various organs in the body 3, 4.
• The clinical diagnosis is highly likely based upon appropriate serology and clinical manifestations, but serologic features are often misinterpreted and may have false positives if confirmatory laboratory testing is not performed 3.

Testing for Lyme Disease

• The Centers for Disease Control and Prevention (CDC) recommends a 2-tiered serologic testing algorithm for the evaluation of patients with suspected Lyme disease 5.
• The diagnosis of Lyme disease can be challenging, especially if there is no tick bite or erythema migrans in the patient's history, due to the many differential diagnoses 6.
• In a region with low disease prevalence, the likelihood of a patient having Lyme disease without a history of inciting trauma is low, and alternative explanations for back pain and knee pain should be considered.

Musculoskeletal Manifestations of Lyme Disease

• Lyme arthritis is the most prevalent manifestation of late-stage Lyme disease and presents as a monoarthitis or oligoarthritis in large joints, often involving the knee 6.
• A clinical presentation of monoarthitis or oligoarthritis in large joints, together with positive Lyme serologies or polymerase chain reactions from synovial fluid/tissue, is considered diagnostic for Lyme arthritis 6.
• In the absence of a history of inciting trauma, a patient with back pain and knee pain in a region with low disease prevalence should undergo a thorough diagnostic evaluation to rule out other causes of their symptoms before considering Lyme disease testing 2, 3, 4, 5, 6.