For the most part, diagnosing Lyme is based on clinical data, (things the doctor can observe like symptoms & medical history) more so than blood tests. This is due to several different factors, but mainly because the tests for Lyme are not fully reliable. It's also further complicated by the fact that after you've had Lyme for an extended period of time, the immune system in certain individuals becomes so overwhelmed that it simply gives up, and quits producing antibodies.
Blood Tests for Lyme
So, as I stated above, the tests for Lyme are not fully reliable for several reasons. First, they're not very accurate, ie., 30-50% of people that actually have Lyme will test negative for the Lyme antibodies due to problems with current testing methods. The only tests available right now test for presence of the Lyme antibody. Unfortunately, in people with weakened immune systems, (which applies to most people with Lyme) the immune system may not be producing enough antibodies in order for them to be picked up by the test, which is not very sensitive.
Additionally, as I also mentioned above, the body may no longer be producing antibodies after late disseminated or chronic Lyme disease has set in, causing the test to come back negative in an individual who may in fact not only be positive, but in all actuality also be extremely ill.
Clinical Data
For these reasons and others, physicians who specialize in Lyme rely not only on the test results, but also on the clinical data. When I met with my doctor for the first time we spent two hours going over my medical history including current & past symptoms, past tests, past diagnosis & past treatments. We also covered my interests and outdoor hobbies, in order to determine the risk & possibility of past exposure to Lyme disease.
If, based on your medical history, symptoms, and risk of exposure, the physician can establish a high probability that Lyme may be the culprit, they may choose to begin treatment, as my doctor did. With Lyme disease, time is of the essence, and any delay in treatment can lead to further dissemination and the appearance of additional, unnecessary symptoms.
My physician opted to begin treatment immediately, by putting me on supplements that would help to start rebuilding my immune system, as well as anti-bacterial and anti-microbial medications that would help to prep my body for antibiotic therapy, which would begin once my blood tests had come back. The blood tests included a complete work up of my immune system markers, detailing my body's ability to fight infection. This also provides a lot of information about what the body has been fighting as well.
It's interesting to look at the roughly 30 pages of test results, most of which I don't understand. There are a few actual photographs of my microscopic blood smears on slides, showing the actual bacteria that has been making me sick. It was extremely interesting, but a little creepy at the same time.
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