Did I get the wrong tests?

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I got my naturopath to agree to run EBV tests. These were the only options for tests.

EBV VIRAL CAPSID AG (VCA) AB (IGM)

EBV VIRAL CAPSID AG (VCA) AB (IGG)

and

EBV NUCLEAR AG (EBNA) AB (IGG)

The CAPSID AG came back at > 750 and the NUCLEAR AG EBNA was 325. Positive for both of these are above 21.

My naturopath says this isn't significant and I don't have an active infection. . I've tried to do some digging on my own but it's really overwhelming and I'm hoping someone can help. Years ago I had different EBV tests done but I couldn't remember what they were, my titers were very high then too. Should I have asked for something else? Thanks for the help.
 

nerd

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He should have run IgM against Early Antigen (EA). This is the only marker that is sensitive for reactivations.

Now that you know your antibody levels for VCA and EBNA, you know that you had an initial infection just like ca. 90% of the population and that you don't have acute infectious mononucleosis from your initial EBV infection. But it is clear that your IgG antibody levels are very high (even beyond the upper bound). This means your initial infection was very long and/or severe or you had acute reactivations after that. EBV severity correlates with EBV-induced conditions such as CFS/ME. There is no need to test this ever again. IgG will only increase and the chance for a positive VCA IgM during reactivation is maybe 5%. Many physicians and laboratories still don't know how to test EBV properly in adults. The VCA approach is outdated.

Another possibility is to test for lymphocyte transformation. However, this is still experimental and it's unclear if this kind of test is sensitive in CFS/ME patients and other immunologically dysfunctional conditions.
 

Hip

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I've tried to do some digging on my own but it's really overwhelming and I'm hoping someone can help.
Dr Martin Lerner says ME/CFS patients have an active EBV infection if there are high antibody levels in the VCA IgM and/or EA IgG diffuse tests. Refs: 1 2


EBV is not the only virus linked to ME/CFS though. There is also coxsackievirus B, echovirus, cytomegalovirus, HHV-6 and parvovirus B19.
 

nerd

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EA-D IgG would also work, I forgot.

But VCA IgM are outdated because the cost isn't worth the 5.8% sensitivity. VCA IgM makes sense for children because these are the ones with prevalent initial EBV infections.

Obel N, Høier-Madsen M, Kangro H. Serological and clinical findings in patients with serological evidence of reactivated Epstein-Barr virus infection. APMIS. 1996 Jun;104(6):424-8. doi: 10.1111/j.1699-0463.1996.tb00737.x. PMID: 8774671.

IgM directed against Epstein-Barr virus (EBV) early antigen (IgM-EA) has been established as an early marker of EBV infection and IgG directed against Epstein-Barr virus nuclear antigen I (IgG-EBNA-1) as a late marker. Simultaneous seropositivity to IgM-EA and IgG-EBNA has therefore been proposed as indicating reactivation of latent EBV infection. We have studied 191 patients with serological evidence of reactivated EBV infection with regard to clinical presentation, antibodies directed against EBV viral capsid antigen (IgM-VCA, IgG-VCA), cytomegalovirus (IgM-CMV), human herpesvirus 6 (IgM-HHV-6). IgM rheumatoid factor (IgM-RF), anti-nuclear or anti-cytoplasmic antibodies (ANA/ACA), and total IgM. The clinical manifestations varied considerably, but a diagnosis was established in 121 of the patients. The diversity of the clinical diagnosis probably reflects common reasons for requesting an EBV serological test rather than clinical manifestations of reactivated EBV infection. Only 5.8% of the patients with "serological EBV reactivation" gave a positive result for IgM-VCA. We conclude that "serological EBV reactivation" does not represent an entity relating to clinical manifestations, but probably reflects a non-specific activation of the immune system.
This study is from 1996. Quite surprising that VCA is still in the guidelines but EA isn't, or physicians and laboratories don't follow the guidelines.
 

Hip

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But VCA IgM are outdated because the cost isn't worth the 5.8% sensitivity. VCA IgM makes sense for children because these are the ones with prevalent initial EBV infections.
Surely the sensitivity of VCA IgM for acute or reactivated EBV infection must higher that 5.8%?
 

nerd

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Surely the sensitivity of VCA IgM for acute or reactivated EBV infection must higher that 5.8%?
Surely, it is much higher for initial infections. But reactivations are a different topic.

Only 5.8% of the patients with "serological EBV reactivation" gave a positive result for IgM-VCA.
The reason for this can be found in the pathogenesis of EBV. The acute phase rarely happens in reactivations because they already have antibodies against the acute genes of EBV, i.e. VCA and EBNA. In order to develop IgM against VCA and EBNA again, there has to be a heavy reactivation or reinfection impulse. In most cases, the existing immunity against these genes will suppress the acute phase before it can reach serologically significant IgM sensitivity.

The EA, however, is released during lysis, which is the (re)activation signal of EBV. For various reasons, there is no sustainable IgG immunity against the EA. As soon as EBV gets a reactivation trigger, and CFS/ME pathology has various of these triggers, EBV pathology already happens during the lytic phase and causes immunological damage (especially dysregulation). Until the body redevelops IgM immunity against the EA again, this lytic pathology happens.

It even happens regardless of acute pathology because latent EBV-transfected cells will release their lytic proteins and these proteins cause havoc. It's not the active virus itself. The active virus can not propagate in the body unless they are in an environment where the immune system is so dysregulated that IgG immunity doesn't work anymore. You can still see that the VCA IgG further increases because there will be some viral residue release to break down the released viruses, but it will be difficult for them to reach other cells due to immunity.

Latent EBV infection is a real disease and it should be treated as such when it manifests with symptoms. Though there isn't really an approved treatment for latent EBV yet.
 
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He should have run IgM against Early Antigen (EA). This is the only marker that is sensitive for reactivations.
.
Thank you for your reply! This helps a lot and makes sense. I'm waiting on my HHV-6 results but I'm sure those will be interesting too. She didn't really know what to order, she says she's never dealt with this and isn't prepared to. I was just curious to see if they were still elevated after all these years.
 

Hip

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@nerd, would you know the gold standard test used to detect EBV reactivation?

If the sensitivity of VCA IgM for reactivated EBV infection is 5.8%, then that figure must have been obtained by comparing the results of VCA IgM to the gold standard.
 

nerd

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@nerd, would you know the gold standard test used to detect EBV reactivation?

If the sensitivity of VCA IgM for reactivated EBV infection is 5.8%, then that figure must have been obtained by comparing the results of VCA IgM to the gold standard.
Unfortunately, I don't have access to Wiley's paywall. But they write the following in the abstract.

IgM directed against Epstein‐Barr virus (EBV) early antigen (IgM‐EA) has been established as an early marker of EBV infection and IgG directed against Epstein‐Barr virus nuclear antigen 1 (IgG‐EBNA‐1) as a late marker. Simultaneous seropositivity to IgM‐EA and IgG‐EBNA has therefore been proposed as indicating reactivation of latent EBV infection.
Besides VCA IgM, the only acute marker they mention is EA IgM. I assume their "seropositive" definition is simultaneous EA IgM and EBNA IgG. I don't think this is considered the current gold standard, though, because most sources only mention EA-D IgA or IgG.

This paper clarifies these questions in the introduction:

De Paschale M, Clerici P. Serological diagnosis of Epstein-Barr virus infection: Problems and solutions. World J Virol. 2012;1(1):31-43. 10.5501/wjv.v1.i1.31

They mention the abovementioned study and its validity, pointing out that EA IgM is just not used because it is also sensitive to the initial (and not reactivating) infection. If you already know that you had your initial infection before because you already had a positive ENBA IgG and VCA IgG test in the past, EA IgM should still be a reliable marker because IgM have the shortest half-life and aren't oversensitive as EA-D IgG is because some patients have these antibodies for many years. So if you'd like to know if you likely had a reactivation phase in the recent time, when your initial infection is far in the past, EA-D IgG is the gold standard. If you'd like to check for a current ongoing reactivation phase, EA IgM is the better way.

But the study also mentions other types of tests and which is indicative of which EBV-induced condition. They differentiate initial infection, chronic active EBV (CAEBV), and reactivated EBV. Interestingly, they also mention other pathogens that cause IM (but usually isn't called this way).

I think in the future, we'll only have gene expression profiles because they are cheap and fast. Thanks to Illumina and other new drivers of this technology, any doctor can do these tests in their own lab and have the results while the patient can wait. Moreover, it provides extensive profiles of all cataloged diseases and pathogens in a single small blood probe. If your lytic EBV genes are elevated, you would immediately know that your EBV is reactivating again. I think this will be the future gold standard. The hardware technology already exists. It's affordable. Statistical analysis and gene matching tools already exist as well. The missing piece is a large study that provides a huge test set to enable neural networks to get sufficient significance from the data.

But I imagine that the MD lobby will try to prevent this because it will make some of their jobs obsolete or reduce their practical application. Not that it matters to them that we urgently need more MDs anyway.

You can already do such tests, I had some done of some EBV genes in my own case. But it's not in the guidelines because their indicative ranges are based on correlation studies. What does it really mean when your latent genes are 20x elevated above the average healthy range? Obviously, it is of pathological significance in some way. But it might also be associated with SLE, MS, lymphomas, and not just with IM. And due to the lack of data, there is insufficient significance for the differentiation of all these EBV-associated conditions based on gene expression.
 

Hip

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Unfortunately, I don't have access to Wiley's paywall. But they write the following in the abstract.
Most paywalled papers can be viewed for free on Sci Hub, including the one you quoted above, with DOI 10.1111/j.1699-0463.1996.tb00737.x

Sci Hub servers are now and then closed down by legal action, but ones that are currently up include:

https://sci-hub.st
https://sci-hub.ee