Positive c22 band RIBA negative PCR

Hello gang,

I've had 3 positive hcv screenings (ELISSA) with a fairly low signal-to-cut-off ratio.  These tests were followed by negative RIBAS and negative PCRs.

Recently repeated the RIBA and I am positive for one of the 5 bands, the C22p.  I remain negative for the quantative PCR that measures viral load.

My question is is the PCR 100% accurate?  I assume since it measures the amount of virus in the blood that there must be some low levels of virus that are undetectable at some point.

Can anyone address this?

I have read that the sero-conversion window can extend as long as a year.

Does anyone know if one is still undergoing sero-conversion if the PCR test could still be negative and one band of the RIBA positive?

This new RIBA result represents a change from last year and scares me.

Please help.

Blue

[Bill1954]

Hi Blue,

Roughly 15-20% of those exposed to HCV will clear the virus spontaneously within six months of exposure; this leaves the patient HCV antibody and RIBA positive, HCV RNA (PCR) negative.

This presumably is your situation; you likely cleared the virus during the acute phase with the assistance of your own immune response.

“My question is is the PCR 100% accurate?  I assume since it measures the amount of virus in the blood that there must be some low levels of virus that are undetectable at some point.”

Yes; a PCR test is considered very specific for infection. Regarding very low levels of infection below the limit of quantitation; this is a very unlikely scenario; patients not currently on antiviral therapy would be expected to have viral load figures in the 100,000’s or 1,000,000’s. Even the older, less sensitive PCR testing uses a lower limit of detection of 50 IU/mL.

Congratulations; take care—

Bill

[blue365]

Thanks Bill.  I'm still suspicious - guess that comes with the territory.

I don't know yet if I had a PCR qualitative test or PCR quantatative test.

I'm wondering if I should get a RNA qualatative test using PCR tecnique that is sensitive to 10 UI/ml.

I have read that PCR's can give false negatives.  I have an autoimmune disease and a connective tissue disorder which I understand could produce false negatives.

Does anyone know anything about the reliability of an RNA qualitative test?

What troubles me most about my test results is that I was RIBA negative last year with 3 positive ellisas and now I am positive on the RIBA CC2 band.

Thanks.  Blue

[Jakied]

I received your email and will respond to your qs tomorrow.  I have the information at home.

May i ask what was your risk? If  sexual, hep c is transmitted through sex VERY rarely.

Transmission is usually from sharing needles or works for IVDU or a bood transfusion

before 1991 or so.

I could not open your email, for some reason.

[blue365]

HI Jakied,

Don't know why you couldn't open my email.  My risk is indeterminate because of an assault during which I had open and bleeding hives from an allergic reaction to a tens unit.  Also have other possible risk factors from my ex-husband that I won't go into now.

I do have a connective tissue disorder (Ehler-Danlos Syndrome) and an autoimmune disease (Sjogren's).

Have read that both of these types of disorders can suppress hcv antigen and antibody titers.

Will review that I had 3 positive hcv elissa hcv tests last year. Had several PCR's (don't know if they wer quantatative or qualatative or Real Time PCRs) and several RIBAS.  All wer negative.

We repeated the RIBA and PCR (have a call in to doctor to determine which type of PCR I had, but I suspect quantatative and I don't know if it was Real Time test either)

The RIBA came back indeterminate which represents a change from last year.  The C22p band was reactive.

After much research I am confused re the particulars of the tests.

Is an HCV RNA using PCR method the same as a PCR?  Are  HCV PCRs Real Time? Would I get a qual of quant test.  I've read the RNA tests only meausre levels at 50Ul/ml.

I read somewhere but can't find it that there is a test that measures at levels as low as 10IU/ml.   Do you know what test that is?

Should I have an RNA?  I've seen that recommened when RIBA is indeterminate.

Do RIBA's have false positive c22 bands? Do PCRs have false negatives?

Here's what I know so far:

Indeterminate c22 reactivity can respresent non-specific cross-reactivity
Single band indeterminate c22 indicates "waning humoral immunity to remote HCV as also suggested by older age."  (not sure what this means) I'm over 60.
Indeteminate c22 can be present in patients "with very low titers of anti-HCV non-structural proteins."
HCV antibodies and antigens can be suppressed in the presence of connective tissue disease and auto immune disease.
15-20% of people resolve HCV on their own and can retain detectable antigens for life

Will post againa as I learn more.

Thanks everyone.
Blue

[Trinity4]

A PCR is very specific for detecting the HCV virus by RNA. Quantitative or qualitative - it doesn't matter, they are both the same except a quant will take it one step further and measure the viral load if the virus is present.  Low viral loads like 18 IU/mL or 40 IU/mL  occur when people are undergoing antiviral therapy which is actually suppressing the virus.  If either quant or qual are negative you do not have HCV.

Trinity

[Bill1954]

I believe you’re over thinking all this. Once all the data is condensed, the key point is that you have negative HCV RNA; this was demonstrated by PCR testing.

As Trin mentioned, this test is considered very specific for infection. If you’re doctor somehow feels additional testing is indicated (I imagine he won’t), you can continue to test for years if you like, and I suspect the end result will remain the same; negative for virus.

Because you are not currently on antiviral therapy, the sensitivity of PCR testing isn’t important; an ultra sensitive test will be expected to yield the same results as an HCV bDNA test that uses a lower limit of 615 IU/mL; negative.

Good luck to you; I’m sorry to hear you have other health issues; it appears HCV isn’t one of them though, thankfully.

--Bill

[blue365]

Thanks everyone.

Here's what I found out.  Quest Diagnostics has a highly sensitive test called the HCV Viral RNA, Qualatative TMA.

It can measure viral levels as low as 10 IUL/ml possible as low as 5 UI/ml.

It is used to confirm hcv infection.

It can be of particularl use in detecting viral levels that are very low such as
when a person is immunosuppressed and can't produce signifcant antibodies, as I am with two disorders, and when the RIBA is indeterminate which mine is with the c22 band out of the 5 bands being positive

This qualatative test is more sensitive for detection.

Quest gives a list of their tests and this HCV RNA, Qualatative TMA test is listed separately from HCV RNA by PCR Quantatative and HCV RNA by PCR Qualatative and HCV RNA Quantatative Real-Time PCR.

The HCV RNA Qualatative TMA can also differentiate between past and current infection and may be useful for detecting acute infection prior to serconversion and when aminotransferase levels (liver enzymes) are normal or only slightly increased.

Searching Quest Diagnositic with the specific name on each test produces a fact sheet that designates when the tests should be used and for whom and under what circumstances.

TMA stands for transcription-mediated amplification.  Because of the sensitivity of the test there may be some false-positives particularly in blood specimens that are contaminated from some other procedure.  "Not detected" is consistent with no HCV or HCV RNA levels below the detectable limit of the test.

While the fact sheet said the HVC RNA Qual TMA could differentiate between past and current infections, the sheet did not specifiy how this is done.

This test is also very sensitive to testing the effects of anti-viral therapy.

TMA is supposed to reveal low levels of HCV that other tests miss.

I've learned PCR is a technique used that can be applied to many different types of testing in microbiology and is not an actual test in itself, but rather a methodology.

Has anyone else heard of the TMA?

Thanks.
Blue

[Trinity4]

TMA is not going to show you anymore positive or negative than the qual RNA you had.
Again, you do not need a highly sensitive PCR.  The virus replicates so quickly you would not have a viral load of only 10 or 15.  What are you not understanding about this?

Trinity

[Bill1954]

Yes, TMA and PCR are both nucleic acid test methods. TMA methodology is frequently used for HCV management *when indicated*.

Quest Diagnostics offers a PCR/TMA qualitative test that has a lower limit of sensitivity of 5 IU/mL.

Labcorp offers an HCV qualitative test: NGI Quantasure #LC 140639. This test can quantify virus to 2 IU/mL.

However…. there are times when these tests have clinical relevance; I wouldn’t think your doctor would consider them for your application. Without antiviral therapy on board, you’d be expected to have viral loads in the 100’s of thousands, if not millions. I understand you have some autoimmune issues, but even people that are HIV/HCV coinfected and have a profoundly suppressed immune response have viral loads well in excess of the limits of any NAT test.

You don’t have HCV according to the data you’ve provided; I’m pretty certain you’re doctor will suggest likewise.

Do you WANT hepatitis C?

--Bill

[James10500]

You are describing a Heptamax test, I've had one.  My understanding was that it first uses a PCR < 43, if that is UND a TMA < 5 is used.  I never heard anything about past and current infection.

[James10500]

*Heptimax* Is the correct spelling.

[blue365]

Yes, Bill, I WANT HCV - can't wait :) Please let me have it.

Sorry I might not be as informed as you guys about viral loads since i'm new to this.

I didn't know that the virus replicates so quickly that Iwould never have a level of 5 UI/ml.

However, because I have a very rare genetic connective tissue disorder that I have read in peer-reviewed journals can suppress PCR viral loads to undetectable levels, I want to know.

(To Trin - I haven't had a qualatative PCR, just a quantatative one.)

Add an autoimmune disease to that that can also suppress the creating of antibodies and yes, I'd like to know with the greatest degree of certainty possible.

Sorry if that's irritating.

Once you're dealing with a rare genetic disorder it is very difficult to find a body of research that has been replicated and is reliable expecially adding c22 reactive band in RIBA.

So, does anyone know why I've had 3 reactive elissa's and a RIBA tht has gone from negative to indeterminate in a year?

Here's a quote from the Journal of Viral Hepatits:  "It can be concluded that the RIBA-2 indeterminate group is epidemiologically similar to the RIBA 3 positive series although with a lesser prevalence of laboratory test alterations, a lower vial replication index and are more likely (but not definitively) to have benign diseas - particularly in subjects without viral replication."

Here's what Questi Diagnostics has to say about HCV, Qualatative TMA:  "This test can also be used to confirm HCV diagnosis when viral loads are potentially very low. eg. in immunosuppressed ...individuals who have elevated liver enzymes and indeterminate RIBA."  My liver enzyme test in pending.  However, another study said HCV individuals with connective tissue disease or autoimmune may have liver enzyme tests at normals or near normal levels.

Also Quest says the PCR Qualatative is " especially usefor for confirming diagnosis in people with indeterminate HCV immunoblot (RIBA results as well as immunosuppressed or immunoincompetent individuals."  I haven't had a qualatative test.

The J of Clin Microbiol says that "highly positive C22 indeterminate 3rd generation RIBA may persist when used with some patients with very low titers of anti-HCV nonstructural protein antibodies."  Whatever that means.

With that said, you guys make me feel better.  Thanks.

Blue

[Trinity4]

Hey, if you want to blow all that money on needless testing, your prerogative but why consult with us?  How many of us do you think know about your rare disorder?  And what do think a hepatologist would say?  Trust me, you aren't going to have a viral load appear even with the most sensitive test regarless of the fact that your disorder suppresses the virus to very low levels.  Did you know very low viral load is considered below 400,000 IU/mL?  And you think your viral load could be below 50 IU/mL at this point?  Ridiculous.  Just get tested because you obviously feel it's necessary.  My bet is you don't have HCV.  This is my last response, I think you're barking up the wrong tree.

Trinity

[blue365]

No, I didn't  know that a very low viral load is below 400,000 Iu/ml.  I don't' know much about viral loads or how fast they replicate.  So, that's very helpful information

I'm sorry that you think that my thinking process is ridiculous.  Like I said, I'm new to this so just trying to figure out stuff as I go along.

Thanks for your help.  Sorry to have put  you out.

Have a great evening!
Blue

[Bill1954]

Blue, the negative nucleic acid (PCR/TMA) test result renders other antibody test results redundant for clinical purposes; don’t be concerned about the RIBA and antibody results now. If you are negative for HCV RNA by PCR, that’s all that is required to determine you’re not infected.

HCV replicates at high rates; left un-mucked with by our immune response, we’d turn out over 10^11 (one trillion) copies per 24 hours. Granted our immune system responds, but the resulting viral load is generally greater than 100,000 IU/mL.

I admire you’re research efforts, but it’s highly unlikely you’re infected with active virus; I’m nearly positive your doctor will agree based on your test results.

PCR testing is an expensive resource, costing roughly USD $500; doctors are responsible for cost control, and don’t write lab orders indiscriminately. If they feel a test is warranted *and will somehow change the course of disease management*, they will consider using the resource; if not, they likely won’t.

Have a pleasant evening,

-Bill

[James10500]

If you've been exposed to hep c and cleared it yourself you will have no VL, but will always have the antibodies or for a very long time.  Antibodies mean you've been exposed to the virus it doesn't mean you have it. Relax and talk to your Doc, because no one in a chat room can give you a satisfactory answer.  You have a bad case of the " ya buts" why put yourself through that.

[blue365]

Thank you for your thoughtful and also kind and patient replies - much nicer to receive than the other kinds.

As a chronically ill person already, I understand suffering and the stress it brings.

Being a newbie it's all kind of freaky,  but your knowledge and advice is much appreciated.
Blue