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There is no point in being tested. You have the bite and the rash. The only sane thing to do is to immediately begin taking the appropriate antibiotics, probably doxycycline or amoxicillin.

Presence of a rash trumps a negative test. Lyme tests are notoriously unreliable. What are you going to do if the test is negative? Not take the antibiotics? Then you would most likely get Lyme, and possibly never be able to get rid of it.

Unfortunately, your doctor will be working with recommendations that have been produced for dealing with this situation, based on a cost/benefit analysis that assumes that if you get Lyme, it's no biggie, because you can always get rid of it with 30 days of Ceftriaxone.

There are three problems with this reasoning. First, 30 days of Ceftriaxone in the U.S. costs tens of thousands of dollars, even though the drug itself costs only a few thousand dollars in other countries.

Second, nobody can get 30 days of Ceftriaxone, because all the anti-chronic-Lyme campaigning has resulted in doctors becoming very conservative in treating it, and nobody will give you Ceftriaxone unless you're near death, and they'll take you off it as soon as you start to get better, even though there is no special risk associated with it. They'd rather treat you for 10 years with doxycycline or amoxicillin than 30 days with Ceftriaxone, even though the side-effects with the first are worse.

Third, the debate about chronic Lyme is really a debate about the methods of testing for Lyme. The people who say there's no chronic Lyme believe that immunoassays are the most reliable test. The people who say there is say that PCR and histology are the better tests. The former are wrong and the latter are right, though honestly all of the tests suck.

The recommendations of the CDC are based on the recommendations of the NIH. The recommendations of the NIH are based on the recommendations of the ANA and the IDSA. The the recommendations of the ANA and the IDSA were both made by the same people, who (according to the Connecticut Attorney General's investigation) were hand-picked to agree with the opinion of the committee chair, who believes in immunological tests.

Every histological study of chronic Lyme--that's one where they do an autopsy of some person or animal who's been treated with antibiotics for chronic Lyme, then died, to see if there are still Borrelia spirochetes present--has found that antibiotic treatment eliminated spirochetes in 0.0% of people or animals treated. These studies are usually done with animal models, because it's difficult to find a lot of newly-dead humans known to have been chronically infected with Lyme and then treated for it.

The bottom line is that your doctor will almost certainly treat you based on an incorrect understanding of Lyme (or based on a correct understanding that she will lose her license if she treats people based on a correct understanding of Lyme).

The immunological test is designed to have a high false-negative rate. That's because it wasn't designed for testing patients for treatments; it was designed by the CDC for tracking the spread of Lyme, so it was more important to eliminate false positives.

(Golightly MG, Thomas JA, Viciana AL. The laboratory diagnosis of Lyme Borreliosis. Lab Med 1990; 21: 299-304) reported a 70% false-negative rate with the test for early cases. Later treatment resolves all symptoms permanently roughly 85% of the time. So if you get treated only if the test is positive, you may have a .7 * .15 = 10.5% chance of winding up with a permanently-debilitating, incurable disease.

Unfortunately, you have no legal alternatives in the U.S.

Prophylaxis with a single dose of 200mg of doxycycline can be effective if taken within 72 hours of finding the tick; see Nadelman et al., New England J of Med 2001:345:79-84. But if it were my health at risk, and I had the rash, I'd take more.

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