Who's Had Their Coxsackie B Virus and Echovirus Antibody Titers Tested at ARUP Lab?

[halcyon]

@halcyon @Hip and @jstefl

I am reviving this old thread to get some more info about these enterovirus tests.

I did these specific tests through ARUP labs and it took over a month to get the results back but I finally got them today. I was wondering if you guys could offer your interpretations (and I of course will be speaking with my doctor and am not taking anything here as medical advice.)

On Coxsackie B Virus, Type 4, my titer is 1:40 (and all other Coxsackies are negative at <1:10 per range)

On Echovirus 11, it was flagged as abnormal with titer at 1:160 (and it should be under 1:40 per range.) All other echoviruses are negative at <1:10 per range.

Thank you for any feedback.

As @Hip mentioned, I've always read everywhere that 1:320 or greater is very likely an active infection. With that said, if you read the notes after the result, they consider a fourfold increase strong evidence of a current or recent infection, and I believe 1:160 would be a fourfold increase. The question then is did you recently acquire this infection, secondary to your ME, or has it been active since the ME started. Unfortunately it's not a question that's easy to answer at this point. One option would be to try treating the infection and seeing if it improved your symptoms at all. As you're on a different treatment path presently this probably isn't a good option right now. You may think about getting a consult with Dr. Chia though to see what his opinion would be.

 

[Gingergrrl]

Thanks to everyone for all the info and links and I am going to look at everything and try to reply later this evening. It is giving me a lot to think about!

ETA: Will have to respond tomorrow but very appreciative of all the info!

 

[halcyon]

oK, which docs are ordering these labs thru Arup other than Chia?

Any doctor can order the ARUP labs through LabCorp using the following test codes:

• 816869 - Coxsackie B Virus Abs

• 823361 - Echovirus (Frozen) Serum Ab Panel

 

[Hip]

One option would be to try treating the infection and seeing if it improved your symptoms at all. As you're on a different treatment path presently this probably isn't a good option right now.

Yes, quite a few people try Dr Chia's oxymatrine protocol just on their own. The tablets can be bought online. There's plenty of info on how to do the protocol on these forums

 

[Gingergrrl]

Reciting which entroviruses my son has always sounds like calling out Bingo letters "Coxsackie B7", always makes me laugh a little.

On a serious note, if you are anywhere near Torrance, CA, and I think you are, why not go see Dr. Chia, the king of Enteroviruses? He has very strong opinions about which enteroviruses make people sick, and in which ways each one makes people sick. He is really helping my son to improve. Good luck.

@Never Give Up You made me laugh with the Coxsackie bingo numbers- thank you! . You are correct that I am not too far from Torrance so this is certainly an option to get a consultation in the future. For now, I spoke with my own doctor and we have a plan how to proceed. I am really glad to hear that your son is improving! Is he taking Equilibriant?

According to the Enterovirus Foundation website, in these ARUP Lab tests for coxsackievirus B and echovirus, titers of 1:320 and higher are indicative of a significant active infection.
Titers from ARUP Lab are measured on the following scale (in which I have put the titers that indicate an active infection in red):

1:10 ... 1:20 ... 1:40 ... 1:80 ... 1:160 ... 1:320 ... 1:640 ... 1:1280... etc. Higher titers in this direction -->>

So your results would suggest that your CVB4 at 1:40 is not an active infection, but your EV11 at 1:160 is on the borderline of being a significant active infection, and so I guess this EV11 possibly might be contributing or causing your ME/CFS symptoms. However, Dr Chia is the expert in interpretation of these ARUP Lab results.

@Hip Thank you for all of this info. I looked through the Enterovirus Foundation website link and for some reason, I could not find the section that talks about 1:320 and higher showing an active infection. Where on the site do I find that info? I was relieved to hear so many interpret it as 1:320 as an active infection vs. 1:160 which I have on EV11.

My doctor wants to re-run the ARUP test when I am able to check if the titer is moving up or down. If it has moved up with the second test to 1:320 then we know it is a current, active infection vs. if it has moved down. At least this is my interpretation (which could certainly be wrong!)

As @Hip mentioned, I've always read everywhere that 1:320 or greater is very likely an active infection. With that said, if you read the notes after the result, they consider a fourfold increase strong evidence of a current or recent infection, and I believe 1:160 would be a fourfold increase.

The question then is did you recently acquire this infection, secondary to your ME, or has it been active since the ME started. Unfortunately it's not a question that's easy to answer at this point. One option would be to try treating the infection and seeing if it improved your symptoms at all. As you're on a different treatment path presently this probably isn't a good option right now. You may think about getting a consult with Dr. Chia though to see what his opinion would be.

@halcyon Thank you for giving me the codes so I could do these ARUP tests and for all your feedback. I really appreciate it. You are totally correct that the results sheet said that a "fourfold increase" could be a current or recent infection which is what I have on EV11 at 1:160. So this is why we are going to repeat the test b/c it also talks about a single titer being high vs. a bunch of them being high.

As far as when I got this infection, I truly have no idea. I have never been tested for any Enteroviruses before so I have no basis of comparison. It is possible that EBV & mono lowered my immune system so other infections re-surfaced or it is possible that the second infection that I had about ten months after mono was an enterovirus? I really don't know except in my case, neither were GI infections.

As far as my treatment path, you are right, that I recently started on Valcyte and am building up the dose, so it wouldn't be the right time to add anything else into the mix. I am having several improvements and don't want anything that could confound the results. I also have Hashimoto's disease and my understanding is anyone with any autoimmune issue should not take Equilibriant. Does that match with your understanding of Equilibriant (I am asking everyone not just Halcyon!)

Thanks again to everyone for all the info!

 

[halcyon]

My doctor wants to re-run the ARUP test when I am able to check if the titer is moving up or down. If it has moved up with the second test to 1:320 then we know it is a current, active infection vs. if it has moved down. At least this is my interpretation (which could certainly be wrong!)

It sounds like a good plan. If it goes up or stays at 1:160 that would be pretty decent evidence of a chronic infection.

I also have Hashimoto's disease and my understanding is anyone with any autoimmune issue should not take Equilibriant. Does that match with your understanding of Equilibriant (I am asking everyone not just Halcyon!)

This is my understanding, and while it's unfortunate that you can't take it, there are other treatment options such as inosine, Epivir, AZT, and some others.

 

[Hip]

I looked through the Enterovirus Foundation website link and for some reason, I could not find the section that talks about 1:320 and higher showing an active infection. Where on the site do I find that info?

It's in the following quoted section of this page of the Enterovirus Foundation website:

Micro-neutralization test - Persistently elevated antibody levels for one or more enteroviruses over years can suggest a chronic enteroviral infection. The Micro-neutralization test is a very sensitive, specific test and only 11 enteroviruses, coxsackie B1-6 and echoviruses 6, 7, 9, 11, and 30 can be tested using this method. Titers of 1:320 and higher are good indicators of current infection.

It is important to note that only one commercial laboratory in the United States is recommended for this test: Associate Regional University Pathologist Laboratory (ARUP), Salt Lake City, Utah. These tests can be ordered directly from ARUP or ordered through Labcorp. If ordered through Labcorp, write on the form to specifically state to send this test to ARUP.

For more information:

• Echovirus test
• Coxsackie B test

This is my understanding, and while it's unfortunate that you can't take it, there are other treatment options such as inosine, Epivir, AZT, and some others.

Oh yeah, I forgot you have Hashimoto's, @Gingergrrl.

I just had quick check on inosine, and this letter indicates that while inosine is safe for autoimmune diseases such as rheumatoid arthritis and diabetes mellitus, inosine caused some adverse effects in the autoimmune disease polymyositis. What that means for Hashimoto's, I don't know.


I compiled a list of antiviral drugs and herbs for coxsackievirus B and echovirus here. All the antivirals in that list were found in published studies to have efficacy against these enteroviruses. I did not myself notice much improvements in symptoms when I took some of these antivirals, but I only took them for a month, and you'd probably need to take them longer than that to get some benefits.

 

[Gingergrrl]

Thank you @halcyon and @Hip for the additional information .

 

[Never Give Up]

@Never Give Up You made me laugh with the Coxsackie bingo numbers- thank you! . You are correct that I am not too far from Torrance so this is certainly an option to get a consultation in the future. For now, I spoke with my own doctor and we have a plan how to proceed. I am really glad to hear that your son is improving! Is he taking Equilibriant?!

Yes, he's taking Equilibrant and it's helping. He has no personal or family history of autoimmune disease so it's far simpler for him than it is for you. I'm sure all of the setbacks must be difficult for you to bear. I'm glad that you are keeping at it though. I hope that you collect many improvements while waiting for a cure.

 

[Gingergrrl]

Yes, he's taking Equilibrant and it's helping. He has no personal or family history of autoimmune disease so it's far simpler for him than it is for you. I'm sure all of the setbacks must be difficult for you to bear. I'm glad that you are keeping at it though. I hope that you collect many improvements while waiting for a cure.

@Never Give Up I am so glad your son is doing well on Equilibriant. In addition to having Hashimoto's which means I can't take it, I googled it and it has two ingredients I have been told not to take- OLE (which can lower BP and mine already runs very low) and Licorice root. My former ND and my current ME/CFS doctor said it would not be good for me to take licorice root (but now I can't remember why!)

Thank you for the support and it has been tough dealing with so many setbacks like you said. But I am trying to find different things to bring improvements until the cure is found (again exactly like you said!) You are very wise!

 

[Hip]

To clarify, we don't have low levels we actually have very high levels of antibodies to these viruses. It's just that the other commonly available test methods used besides what ARUP uses require large amounts of virus in the blood which we don't have.

I thought I would reply to your point here, rather than in the another thread where you wrote the above post.

You might be right: Dr Chia said this in his video presentation at the Invest in ME London 2010 ME/CFS Conference:

But the immune response — one of which is the neutralizing antibodies, which we can measure in the blood — this is a paradox I finally figured out: because I said: why is there a persistent virus infection, when there is so much neutralizing antibody in the blood? The antibodies should neutralize any viruses, right? Well not when they are inside the cell. If they are hiding inside the cells, it can't touch it. So, but the viral protein being produced is triggering all those neutralizing antibodies, which allow us to diagnosis this disease by looking at these antibody levels.

But then if enterovirus-associated ME/CFS patients have high levels of antibodies to enteroviruses, I do not understand why only highly sensitive antibody lab tests like ARUP's can detect enterovirus antibodies in ME/CFS patients. If ME/CFS patients have high antibody levels, any old lab should be able to detect and measure them.

I don't think you need large amounts of virus in the blood drawn for the antibody testing, because those antibody test don't look for viral particles; they look for antibodies.

 

[halcyon]

I do not understand why only highly sensitive antibody lab tests like ARUP's can detect enterovirus antibodies in ME/CFS patients.

We have to examine what these tests do.

The ARUP test is a microneutralization assay. There is a good description of this type of assay on Vincent Racaniello's site. Essentially they make dilutions of the patients blood, add virus to the diluted blood, and then add each dilution mixture into a series of cell cultures. What they then measure is at what dilution (and thus at what antibody concentration) is the patient's blood able to neutralize the virus before being introduced to the cell culture, saving it from infection. This test is an indirect measure of neutralizing antibody concentration in the blood.

The Labcorp/Quest test is a complement fixation assay. If I understand this assay correctly, what is done is a substance is introduced to the patient's blood sample that depletes all the complement. Then a standardized amount of complement is added back in and what is measured is the quantity of complement that has bound to antibody present in the sample. If I understand correctly, this complement will only bind to antibody that has bound to antigen. So this test is a direct measure of antibody bound viral antigen in the blood.

Of course the other often used assay would be PCR. As you know this assay is designed to amplify and measure directly the amount of viral antigen in the blood.

I'm sure there are labs that offer other antibody detection methods (such as EIA/ELISA/etc.) but I have not seen these in the US for echovirus or Coxsackie B, just Coxsackie A.

So knowing what we do from research, there is copious enterovirus present in tissue samples, but little to no virus present in the blood of ME patients. It's not hard to see why PCR and complement fixation would fail to detect this, while an antibody based test would. Antigen presenting cells will be coming in constant contact with infected tissues and will be presenting this antigen to B cells, thus leading to clonal expansion and production of large amounts of antibodies.

 

[concepcion]

Our local hospital lab here in Vancouver Canada cannot send to ARUP for these tests, so they are wanting to send to Mayo. Does anyone know what the difference is?

 

[halcyon]

Our local hospital lab here in Vancouver Canada cannot send to ARUP for these tests, so they are wanting to send to Mayo. Does anyone know what the difference is?

Based on what I'm seeing so far on Mayo's test menu, they just forward the samples for coxsackie B and echovirus antibodies on to Quest/Focus. So it will be done using complement fixation and likely won't be helpful if you have a chronic infection.

 

[Hip]

@halcyon
I've been having more brain fog over the last few days, so I am struggling to understand things. But in terms of the operation of the complement fixation test (CFT), I don't think this depends on having microbial antigens present in the patient's blood. I think antigens from the microbe you are testing for are obtained from an external source, and then added to the patient's blood sample, so that these antigens will attach to the patient's antibodies (if present), which is then the cue for the complement to attach itself to the antigen-antibody complex. I read that complement will attach itself to almost any antigen-antibody complex.

So as far as I can see, having low levels of enterovirus and its antigens in the blood would not stop the CFT from working. There are a few tutorial introductions to the complement fixation test here, here and here.



Certainly though Dr Chia never mentions the complement fixation test in his list of testing methods useful for detecting chronic enterovirus infections, so presumably he considers the CFT to be too insensitive for chronic enterovirus infections.

He does not mention the ELISA either, so guess the sensitivity of that for chronic enterovirus may also be less than adequate.

I came across this study which compared CFT and ELISA testing sensitivity in coxsackievirus B1 infections, which found that the CFT is less sensitive than the ELISA:

The sensitivity is clearly related to the time when serum samples are taken.

When serum samples are taken within 3 days after the onset of symptoms, the sensitivity is low (5 of 22 [23%]). When serum is drawn later than 3 days after onset, the sensitivity is good (20 of 24 [83%]).

The CFT with the antigen mixture is less sensitive than the ELISA (44% versus 81%)

In the first few days of acute coxsackievirus B infection, the study found that CFT was more sensitive than ELISA. But after that, ELISA is the more sensitive.

So I should think that for chronic enterovirus antibody testing:

Microneutralization sensitivity > ELISA sensitivity > CFT sensitivity.



If you look at @Emootje's two enterovirus test results posted earlier in this thread, these were done at European labs: the first test at a Belgium lab, and the second test in a Dutch lab, both tests showing elevated CVB3 antibody titers. The second test looks like it is a neutralization test (not sure about the first — would you know, @Emootje?).

One type of neutralization test is a plaque reduction neutralization test (PRNT). A micro-neutralization test is another type, and similar to PRNT.

My own coxsackievirus B and echovirus CFT tests that I had done in the UK were negative, but that may just be down to the insensitivity of the CFT for chronic enterovirus infections.



Enterovirus is probably the most important virus to test for in ME/CFS, yet I get the impression only a few patients on this forum have been properly tested for this virus, using appropriately sensitive lab tests like neutralization. Presumably this is down to cost factors (the two ARUP Lab micro-neutralization tests for coxsackievirus B and echovirus costs around $500 each), or possibly because insurance does not cover these ARUP tests.

It would be good if we could find some labs that offer a neutralization / micro-neutralization test for coxsackievirus B and echovirus at more reasonable prices.

Perhaps the Dutch lab, the University Medical Center (UMC) Utrecht, might be one good lab that ME/CFS patients might use. @Emootje, do you remember how much the UMC coxsackievirus B neutralization test cost?

There may be other labs in the Europe which do coxsackievirus B and echovirus neutralization testing. It would be a case of Google searching in different languages in order to find them.

 

[jstefl]

I had an experience with Mayo in Rochester, MN.

I had my doctor order a test to be sent to ARUP. Instead, the lab sent the samples to Focus. The results came back, and showed no virus detected. I knew that wasn't correct, as I had my test results from Dr. Chia, who did a tissue sample test on me.

I finally had Mayo agree to send the blood sample to ARUP, and the results came back showing two coxsackie and one Echo virus present.

As far as I am concerned, the Focus test is a complete waste of time and money.

John

 

[halcyon]

I think antigens from the microbe you are testing for are obtained from an external source, and then added to the patient's blood sample, so that these antigens will attach to the patient's antibodies (if present), which is then the cue for the complement to attach itself to the antigen-antibody complex. I read that complement will attach itself to almost any antigen-antibody complex.

Actually that makes sense otherwise it would be more difficult to determine the serotype. I have a really poor understanding of CF testing I guess.

It would be really nice to know why this test doesn't work then. I can confirm it doesn't. I had a CF test for coxsackie B and echovirus about 4 months after becoming ill with ME and it was totally negative. A month before this I had the stomach biopsy test done that was positive for VP1 and dsRNA. Three months later I had the microneutralization test from Cambridge Biomedical and was 1:320 for echovirus 30. Almost a year later I had the microneutralization test from ARUP and was 1:640 for echovirus 30.

I wonder if it comes down to the type of antibody being detected then, binding versus neutralizing and/or IgM versus IgG? @Jonathan Edwards can probably answer this; do neutralizing antibodies fix complement?

Enterovirus is probably the most important virus to test for in ME/CFS, yet I get the impression only a few patients on this forum have been properly tested for this virus, using appropriately sensitive lab tests like neutralization. Presumably this is down to cost factors (the two ARUP Lab micro-neutralization tests for coxsackievirus B and echovirus costs around $500 each), or possibly because insurance does not cover these ARUP tests.

In the US I think it just comes down to availability and/or knowing which tests to order. It seems most doctors only know about or have access to the CF tests. I was only able to receive a requisition for the proper tests once I became a patient of Dr. Chia. The tests are available through Labcorp but they don't advertise the proper test codes in their testing menu at all.

I did a poll a while back and a decent amount of people had been tested for coxsackie B (though I have no way to confirm that everyone that answered did indeed have the microneutralization test) but very few people had been tested for echoviruses. And then there's the issue that we can test for all coxsackie B but only a handful of echovirus and none of the numbered enteroviruses. I wish that more ME clinicians would get on board with doing this testing on all their patents, but places like OMI don't even test for them at all.

It would be good if we could find some labs that offer a neutralization / micro-neutralization test for coxsackievirus B and echovirus at more reasonable prices.

It would be nice to know what lab(s) were doing all of the enterovirus testing in the UK back in the day that people like John Richardson used because I'm almost certain those were microneutralization tests and they were finding elevated titers in patients all the time.

 

[Hip]

It would be nice to know what lab(s) were doing all of the enterovirus testing in the UK back in the day that people like John Richardson used because I'm almost certain those were microneutralization tests and they were finding elevated titers in patients all the time.

A quick check on some of those early UK papers on enteroviruses in ME/CFS finds ones like this 1990 study, which observed elevated coxsackievirus B titers in 50% of ME/CFS patients using neutralization tests. The study refers to these neutralization tests as the Microtitre method, and searching online, I found what I think are synonyms for "Microtitre", namely: micro-metabolic inhibition test, metabolic inhibition test and microtitre metabolic inhibition test.

They also talk about the micrometabolic inhibition method used for the estimation of coxsackievirus B neutralizing antibodies in this 1984 Scottish study of coxsackievirus B infections (which found that in well-documented cases of ME/CFS, 41% of patients had elevated neutralizing antibody titers, compared to 4% of healthy controls).

By the name, this sounds similar to microneutralization.


Then there was a whole flurry of British studies in the 1990s which used PCR testing on muscle tissue samples taken from ME/CFS patients, and found a much higher prevalence of enterovirus RNA in the muscles of ME/CFS patients compared to healthy controls (some of these studies listed in this post).

This finding of enteroviral RNA in ME/CFS patient's muscle tissue is similar to Dr Chia's studies finding enteroviral RNA (and enterovirus VP1 capsid protein) in the stomach tissues of ME/CFS patients.

 

[consuegra]

Hi,

I have done coxsackie B antibody testing on my daughter since 2004.

By chance, I did first did them at ARUP in 2005. For ten years the ARUP has come back consistently very high for Cox b3 and b4. Coxsackie B4 is often >1:640. I showed these to Dr. Chia and he said his son's antibodies at ARUP were the same.

I have over the years sent other samples to Quest or Focus labs. These labs come in much lower levels and with no consistency.

Once I sent the same blood draw to Focus and ARUP, and they did not line up at all.


I have spoken to a number of physicians about these tests, urging them to test their patients at ARUP. They showed no interest.

Chris

 

[concepcion]

Based on what I'm seeing so far on Mayo's test menu, they just forward the samples for coxsackie B and echovirus antibodies on to Quest/Focus. So it will be done using complement fixation and likely won't be helpful if you have a chronic infection.

Thanks for looking at this Halcyon.