Recommended tests in different stages of infection

Stage of illnessClinical featuresPrimary testing recommendedAdditional testing
Stage 1Early localized disease
(< 4 weeks)
Erythema migrans
No serologic testing
Stage 2Early disseminated disease
Lymphocytic meningitis Facial palsy
Radiculoneuropathy or carditis
Two-tiered testing
If initial test is negative, useacute and convalescent phase serology
Stage 3Late Lyme disease (> 4 weeks)
Lyme arthritis
Two-tiered testingSynovial fluid polymerase chain reaction (PCR) if no improvement after 2 months of oral antibiotics
Lyme neuroborreliosisCerebrospinal fluid (CSF) anti-bodies and 2-tiered testingCSF PCR or CSF culture