When Lyme disease causes a positive test for mononucleosis
False positive serologies for Lyme disease have been previously reported in patients with acute infectious mononucleosis. However, a recent paper describes two cases in which Lyme disease was misdiagnosed as mono based on false positive serologies for the Epstein-Barr virus (EBV).
by Daniel J. Cameron, MD MPH
In the article, published in the journal Clinical Infectious Diseases, Pavletic, from the National Institute of Mental Health, reports “two cases of false positive Epstein-Barr virus (EBV) serologies in early-disseminated Lyme disease.”
In the first case, a 16-year-old male from Virginia developed fatigue, myalgias and three brief episodes of fevers over an 18-day period. He was diagnosed with acute infectious mononucleosis based on a positive viral capsid antigen (VCA) IgM and negative VCA IgG.
It was not until 17 days later with the onset of multiple erythematous rashes and right-sided peripheral facial nerve palsy that doctors diagnosed the young man with Lyme disease. Laboratory evaluation revealed a positive C6 peptide ELISA index of 6.02 and a positive IgM immunoblot. He was prescribed a 4-week course of doxycycline and recovered.
“Repeat VCA IgG, VCA IgM and EBNA were negative, indicating that the initial VCA IgM was falsely positive,” according to Pavletic.
In the second case, an avid biker from Maryland presented with a six-day history of fatigue, fever, myalgias and headache. Lyme disease was diagnosed the next day based on multiple erythematous rashes. Lyme serologies were positive by ELISA, IgG and IgM immunoblots.
Twelve days into her illness she tested positive for mononucleosis with a positive VCA IgM, VCA IgG, EBV early antigen, EBNA IgG, and positive monospot.
The fever resolved and the rashes faded with a 21-day prescription of doxycycline. The recovery was complicated by a right upper trunk brachial plexopathy. “The pain resolved and the weakness improved over the next six months,” according to Pavletic.
“Three and a half years later, repeat VCA IgG and EBNA were positive, and VCA IgM was negative.”
According to the authors, both cases were initially misdiagnosed. “Here we present two cases where early manifestations of Lyme disease were initially misdiagnosed as acute EBV infection due to positive VCA IgM results.”
The authors touched on the difficulties interpreting acute mononucleosis testing. “While isolated VCA IgM may indicate early acute mononucleosis, the test can be nonspecific, especially when the likelihood of acute EBV infection is low.” Pavletic adds, “Immune activation with other pathogens can also result in a false positive VCA IgM.”
The second case was difficult to interpret given the positive monspot, heterophile and VCA IgM tests. “In this case, we cannot exclude that the positive VCA IgM could be due to subclinical EBV reactivation, which has little clinical relevance in immunocompetent individuals,” states Pavletic, adding, “Heterophile antibody tests are known to have false positives due to acute infections, autoimmune diseases and cancer.”
In practice, Lyme disease and mononucleosis are common conditions that share similar symptoms. The authors’ two cases remind the reader of the need to consider Lyme disease even if initial serologies suggest mono.
References:
- Pavletic AJ, Marques AR. Clin Infect Dis. 2017 Apr 4. doi: 10.1093/cid/cix298.
Daniel
03/20/2019 (12:10 am)
Dr. Cameron,
I need help understanding the following:
Sept. 2017 I was very fatigued for a couple of weeks, went to ENT who ordred EBV:
Result IGM 46.50, IGG 74.10
Both positive.
Eventually I got much better within a couple of weeks with proper care.
A couple of months later, I had a couple of odd symptoms, a finger twitching every once in a while and another a finger feeling “heat”. I thought I had a pinched nerve in the elbow or perhaps carpal tunnel.
Went to see neurologist, he ordered Lyme test:
Lyme WB Blot, Serum:
Lyme AB IgG
everything negative BUT IgG41 Present Abnormal
Lyme Ab IgM
IgM p41 Absent
IgM p39 Present Abnormal
IgM p23 Present Abnormal
The doctor not being convinced ordered another test a month later:
However a month later I did a Lyme Total Ab Test/reflex:
Lyme IgG/IgM Ab Result <0.91 Negative
I dont have any pain or other symptoms except anxiety that has been present since late 2016.
What do you make of these results that are conflicting? Moreover, EBV can falsify Lyme test from what I have read.
thank you kindly.
Dr. Daniel Cameron
03/20/2019 (4:00 pm)
There are so many causes of anxiety in addition to Lyme disease. Your doctor will have to use clinical judgment.
Kent
01/16/2019 (10:01 pm)
I have been diagnosed with ebv
Huge allergies that set it off. That being said i have had what i believe to be lyme 2 or 3 times now and had west nile in 07. First lyme in 03. Every symptom was text book. No doctor where i live knew about it at the time so i found one that would give me doxy. 28 days. Got rid of all symptoms. Twice more every 5 to 7 years i jave had this. Last in sept. 18. Doxy again. Had blood teat in jan 19 for the first time for Any of this as it is now becoming debilitating
No tidors for lyme. Ebv present. I still say lyme. Why would symptoms disappear with doxy if it has been ebv. Ebv is a virus. I say its lyme. I want help.
Dr. Daniel Cameron
01/16/2019 (10:41 pm)
I have seen the same situation in my practice. You should include a doctor with experience treating Lyme disease with other approaches.
Jane Woods
01/16/2019 (6:40 am)
Mono is a contagious illness that’s caused primarily by the Epstein-Barr virus (EBV). Most of the time, medications will not help speed recovery (though some painkillers may ease symptoms). But knowing what precautions to take during the healing process can go a long way in helping you feel better sooner and avoid complications. It’s not known exactly how long someone can be contagious after they get the virus. People can shed the virus in their oral secretions for several years, and the shedding is intermittent. You can also refer to this article which states all the necessary details about mononucleosis https://www.everydayhealth.com/mononucleosis/
Dee
01/11/2019 (5:31 pm)
Tick bite (thought spider bite) back in 1992. Weeks later slurred speech, intense head vise like pressure, weakness in limbs, thinking off dizzy(sea sickness feeling)These symptoms plus a drofoot lasted on and off for over 20 years with no explanation. In and out of emergency rooms and over 6 months at Mayo, UCSF, Stanford, Cedars still with no diagnosis. 50+ docs mostly neurologists, Multiple abnormal EMG’s, Abnormal Spect showing brain vasculitis but normal brain MRI. I was NEVER tested for infectious causes (viral or bacterial) during this time only MS which was ruled out. Finally IGENEX IGM pos. I8,31,34,41,45 and IGG 31,34,39,41,58. Pos. Babesia D. On Fish test and andAdvanced lab. Pos. Treated on IV antibiotics. Much better but now pos thru Quest western blot IGG 18,93and DNA pos. FOR CMV IGG >10.00 AND IGM 102> and EBV POS> dna 26,000 copies and EBV VCA IGG >750.00 IGM >160.00and EBNA IGG405.00. I’v now been diagnosed with having both CMV and EBV disease. Is band 31 on Igenex test the only band that can be altered by active EBV infection or can the other bands be altered as well? If so, could I never have had Lyme and alway EBV instead? PCR DNA pos. doesn’t lie.The doctors want to do aggressive treatment with Valcyte and Ganciclovir but I feel that these are bandaids to primary problem which is still Lyme . When I am on AZith my symptoms decline radically. My symptoms come in flares lasting days and months. I go from feeling great to within an hour having Head pressure, behind eyes (vise like) sweating, dropfoot worse, lower back pain, dizzy, vision blurred, burning skin, fluish , exhausted and arthritic like joint and tendon pain throughout my body. Right knee numb .
Dr. Daniel Cameron
01/13/2019 (10:30 pm)
It can be difficult to find a path to wellness. You should include a second look at a tick borne illness including Babesia.
Scetin
12/21/2018 (4:07 am)
I got sick in the beginning of December and went to the doctor. She did flu and strep tests as i had muscle pain headache and sore throat. They were both negative and she order more tests. A week later test results came back with positive mono and elevated CRP. My doctor said you don’t look like you have mono and we should check Lyme. A week later i was diagnose with Lyme. IGG all negative and 39 and 23 bands on igm were positive. Could this be false positive? I suspect that i have undiagnosed arthritis since i have been having joint pain since February. I found a Lyme specialist who ordered some more advanced tests but i wont be getting the results for another 2 Weeks. I would l like to hear your opinion. Thanks
Dr. Daniel Cameron
12/21/2018 (3:24 pm)
I also look for more than one cause of any illness. It is difficult to base the diagnosis solely on a test. I often have to use clinical judgement if the tests are mixed.