From the Guidelines
For lumbar puncture (LP) testing in suspected multiple sclerosis (MS) and Lyme disease, I recommend ordering cerebrospinal fluid (CSF) analysis including cell count with differential, protein, glucose, IgG index, oligoclonal bands, and VDRL, while ensuring that the patient does not have any contraindications to LP, such as signs of severe sepsis, respiratory or cardiac compromise, anticoagulant therapy, infection at the site of LP, focal neurological signs, presence of papilloedema, or continuous or uncontrolled seizures, as outlined in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
LP Order for MS and Lyme Disease
The following tests should be included in the LP order:
- Cell count with differential
- Protein
- Glucose
- IgG index
- Oligoclonal bands
- VDRL
- Opening pressure measurement
- Gram stain
- Bacterial culture
For MS specifically, add myelin basic protein and request oligoclonal band testing with paired serum samples to detect intrathecal antibody production. For Lyme disease, include Lyme-specific antibody testing in CSF with paired serum samples to calculate the antibody index, as recommended by the Infectious Diseases Society of America (IDSA) guidelines 1.
Contraindications to LP
It is essential to assess for contraindications to LP, such as:
- Signs of severe sepsis or rapidly evolving rash
- Respiratory or cardiac compromise
- Anticoagulant therapy or known thrombocytopenia
- Infection at the site of LP
- Focal neurological signs
- Presence of papilloedema
- Continuous or uncontrolled seizures
- GCS ≤12, as outlined in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
Importance of Antibody Index Calculation
The antibody index calculation is crucial for Lyme diagnosis to differentiate between blood contamination and true CNS infection, as recommended by the IDSA guidelines 1. This calculation compares CSF/serum antibody ratios to determine the presence of intrathecal antibody production.
Recent Guidelines
The most recent guidelines for the prevention, diagnosis, and treatment of Lyme disease, published in 2021, recommend using IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline for the treatment of acute neurologic manifestations of Lyme disease without parenchymal involvement of the brain or spinal cord 1.
From the Research
Lumbar Puncture Order for Multiple Sclerosis (MS) and Lyme Disease
- The order for lumbar puncture in patients with suspected MS is not always recommended, as MRI remains the most sensitive and specific marker to validate dissemination in space and in time 2.
- Cerebrospinal fluid (CSF) analysis is not recommended by the 2010 McDonald criteria for the diagnosis of MS, and the presence of oligoclonal bands is not a surrogate marker for individual prognostic purposes 2.
- For Lyme disease, a lumbar puncture is usually mandatory for confirmation of the suspected diagnosis, especially in cases of Lyme neuroborreliosis (LNB), where CSF analysis can detect lymphocytic pleocytosis and intrathecal Borrelia burgdorferi-specific antibody production 3.
- The diagnosis of LNB is based on a compatible clinical picture, such as meningitis, cranial neuritis, or radiculoneuritis, and CSF analysis is essential for confirmation 3.
- Oligoclonal bands can be present in both MS and Lyme disease, but their presence and pattern can help distinguish between the two conditions, with CSF-restricted oligoclonal bands being a hallmark of MS 4.
Diagnostic Considerations
- For MS, the diagnosis is primarily based on clinical presentation and MRI findings, with CSF analysis playing a secondary role 2.
- For Lyme disease, serology testing is the primary laboratory tool employed to aid in diagnosis, with a two-tiered algorithm recommended for optimization of specificity while maintaining high sensitivity 5.
- In cases of suspected Lyme neuroborreliosis, a lumbar puncture is essential for diagnosis, and CSF analysis should be performed in conjunction with serology testing 3, 6.