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Viral testing in ME/CFS
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The viruses most commonly found in myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) patients as chronic infections are the two enteroviruses [[Coxsackie B virus|coxsackievirus B]] and [[echovirus]]; the three herpesviruses [[Epstein-Barr virus]], [[HHV-6]] and [[cytomegalovirus]]; and the coronavirus [[SARS-CoV-2]]. These are the infections that ME/CFS doctors will typically test for. Usually ME/CFS patients will have chronic infections with one or more of these viruses. More rarely, ME/CFS may involve chronic infections with the following viruses, bacteria and protozoa: [[varicella zoster virus]], [[parvovirus B19]], [[Chlamydia pneumoniae]], [[Human herpesvirus 7|HHV-7]], [[Coxiella burnetii]], [[Giardia|Giardia lamblia]], [[Ross River virus]] and [[West Nile virus]]. ME/CFS doctors normally employ antibody tests (which measure the immune response to the infection) in order to detect these chronic infections, rather than PCR blood tests (which directly detect the presence of the pathogen in the blood). This is because in ME/CFS, infections may be widespread in the body tissues (and so may elicit an antibody response), but usually very little virus is found in the blood; thus PCR blood tests will often come back negative, even though there may be an ongoing low-level infection in the tissues. Certainly enterovirus is commonly found in the tissues of ME/CFS patients, as [[List of enterovirus infection studies|numerous studies]] have directly detected this virus in muscle, stomach and brain tissue biopsies (whereas the [[Non-cytolytic enterovirus#Detection of non-cytolytic infections|levels of enterovirus in the blood are so low]] that the virus often cannot be detected by blood PCR). Unfortunately there has been less interest in looking for herpesviruses in ME/CFS patient tissues; so although chronically high antibody levels to enteroviruses and/or herpesviruses are often found in ME/CFS, the bodily locations of the herpesvirus infections that may be eliciting this antibody response are less clear. The enterovirus infections found in ME/CFS are proven to involve the [[Non-cytolytic enterovirus|non-cytolytic form of this virus]], rather than just the productive form. Non-cytolytic enterovirus lives inside host cells on a long-term basis, as an intracellular infection of naked viral RNA which does not kill the cell. Similarly, one theory postulates the herpesvirus infections found in ME/CFS could involve an [[Abortive infection theory of ME/CFS|abortive form of herpesvirus]] (which has some commonalities to non-cytolytic infection), rather than just regular productive or latent/reactivated virus. Note that ME/CFS doctors may interpret antibody results differently to regular infectious disease specialists: the latter tend to ignore chronic highly elevated IgG, dismissing this as just evidence of a past and now dormant infection (provided IgM is low); whereas ME/CFS doctors may view chronic highly elevated IgG as evidence of an ongoing low-level infection in the body tissues. In the following sections, the testing protocols employed by leading ME/CFS doctors are detailed for each ME/CFS-associated virus and bacterium. ===== Coxsackievirus B and echovirus testing ===== [[Coxsackie B virus|Coxsackievirus B]] and [[echovirus]] have been linked to ME/CFS in [[List of enterovirus infection studies|over 30 studies]]. There are 6 coxsackievirus B (CVB) serotypes and 32 echovirus (EV) serotypes. All are part of the [[enterovirus]] genus. Enterovirus expert [[John Chia|Dr John Chia]] says that the most common enterovirus serotypes found in his ME/CFS patients are CVB3 and CVB4 first and foremost, then CVB2, EV6, EV7 and EV9, and then much less EV11.<ref>{{Cite web|url=http://quixoticmeblog.blogspot.com/2014/10/dr-c-recommends-new-treatment-plan.html|title=Quixotic: My M.E. Blog: Dr. C Recommends New Treatment Plan|last=Calvin|first=Patrick W.|date=2014-10-12|website=Quixotic|access-date=2024-05-17}}</ref> Testing for these enteroviruses presents some difficulties, as in ME/CFS, there are hardly any viruses in the blood. Rather the virus is mainly found as a chronic low-level [[Non-cytolytic enterovirus|non-cytolytic infection]] in tissue areas such as the stomach, muscles and brain. Dr Chia finds in whole blood samples, sensitive reverse transcription PCR blood tests are positive only about 30% of the time in patients with enterovirus ME/CFS.<ref>{{Cite web|url=https://me-pedia.org/wiki/Non-cytolytic_enterovirus#Detection_of_non-cytolytic_infections|title=Non-cytolytic enterovirus}}</ref> So antibody tests are used to detect enterovirus in ME/CFS patients rather than blood PCR tests. However, Dr Chia found that tests using the [[wikipedia:Plaque_reduction_neutralization_test|neutralisation]] method of antibody measurement can more reliably detect the chronic low-level enterovirus infections found in ME/CFS, compared to other antibody measurement techniques such as CFT, ELISA and IFA, which may not be sensitive enough (these techniques are fine for acute enterovirus infections, where there is plenty of virus, but detecting low-level chronic infections requires a test with more sensitivity). The CFT test is particularly insensitive for chronic infections.<ref>{{Cite web|url=https://www.youtube.com/watch?v=YSgcNSqssTI&t=27m54s|title=Invest in ME Conference 2009, Dr John Chia's Presentation|last=Chia|first=John|at=Timecode 27m 54s|quote=The typical antibody that the laboratory would do is called the complement fixation test, which is neither sensitive nor specific. That means if you get a positive test, it's worthless. And if you get a negative test, it's worthless. Well that's wonderful.}}</ref> Antibody tests via the neutralisation method however are only offered in a small number of pathology labs worldwide. For his own ME/CFS patients, Dr Chia uses the ARUP Lab micro-neutralisation [https://ltd.aruplab.com/Tests/Pub/0060055 tests for coxsackievirus B] and [https://ltd.aruplab.com/Tests/Pub/0060053 echovirus]. These are the tests recommended for testing chronic infections by the [https://www.enterovirusfoundation.org/treatments-1/ Enterovirus Foundation]. Antibody titers of '''1:160''' to '''1:320''' and higher in the ARUP tests are good indicators of chronic infection, Dr Chia found.<ref>{{Cite web|url=https://www.enterovirusfoundation.org/treatments-1|title=Diagnose & Treat|website=Enterovirus Foundation|language=en-US|access-date=2024-05-17}}</ref> In [https://www.youtube.com/watch?v=Xz7CaxWtCUU&t=10m34s this video], Dr Chia explains how he calibrated the ARUP Lab tests to derive this 1:160 to 1:320 threshold for ME/CFS usage.<ref>{{Cite web|url=https://www.youtube.com/watch?v=Xz7CaxWtCUU&t=10m34s|title=The International Symposium on Viruses In Chronic Fatigue Syndrome and Post-Viral Fatigue. June 2008, Baltimore, Maryland, USA.|last=Chia|first=John|date=June 2008|at=Timecode 10m 34s}}</ref> Note that in such neutralisation tests, the levels of IgM and IgG antibodies are usually pooled together, so the test result reflects the combined IgM + IgG antibody level. Other pathology labs which offer coxsackievirus B or echovirus neutralisation tests include: [https://kgu.de Institute of Medical Virology], University Hospital Frankfurt am Main, Germany; [https://www.pasteur.gr/en Hellenic Pasteur Institute] in Greece, [https://torlak.rs/en/serological-diagnosis/ Torlak Institute of Virology] in Serbia, and [https://www.fleury.com.br/medico/exames/coxsackie-b-anticorpos-soro Fleury Lab] in Sao Paulo, Brazil. ===== Epstein-Barr virus testing ===== [[Epstein-Barr virus]] (EBV) has been linked to ME/CFS in [https://me-pedia.org/wiki/List_of_herpesvirus_infection_studies many studies]. There is a high 95% prevalence of EBV in the general adult population,<ref>{{Cite journal|title=Epidemiology of Epstein-Barr virus infection and infectious mononucleosis in the United Kingdom|date=2020-06-12|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291753/|journal=BMC Public Health|volume=20|pages=912|last=Kuri|first=Ashvin|last2=Jacobs|first2=Benjamin Meir|last3=Vickaryous|first3=Nikki|last4=Pakpoor|first4=Julia|last5=Middeldorp|first5=Jaap|last6=Giovannoni|first6=Gavin|last7=Dobson|first7=Ruth|doi=10.1186/s12889-020-09049-x|pmc=7291753|pmid=32532296|issn=1471-2458}}</ref> so most adults will have this virus in their system, but usually in a latent (inactive) state. However, in ME/CFS patients this virus may exist in a reactivated state. After [[mononucleosis]] (glandular fever), which is mostly caused by EBV, ME/CFS was found as a sequelae in 9% of cases.<ref>{{Cite journal|title=Incidence, risk and prognosis of acute and chronic fatigue syndromes and psychiatric disorders after glandular fever|date=1998-12|url=https://pubmed.ncbi.nlm.nih.gov/9926075/|journal=The British Journal of Psychiatry: The Journal of Mental Science|volume=173|pages=475β481|last=White|first=P. D.|last2=Thomas|first2=J. M.|last3=Amess|first3=J.|last4=Crawford|first4=D. H.|last5=Grover|first5=S. A.|last6=Kangro|first6=H. O.|last7=Clare|first7=A. W.|doi=10.1192/bjp.173.6.475|pmid=9926075|issn=0007-1250}}</ref> Another study found that at 6, 12 and 24 months after mononucleosis, 13%, 7% and 4% of patients respectively met the criteria for CFS,<ref>{{Cite journal|title=Chronic fatigue syndrome after infectious mononucleosis in adolescents|date=2009-07|url=https://pubmed.ncbi.nlm.nih.gov/19564299/|journal=Pediatrics|volume=124|issue=1|pages=189β193|last=Katz|first=Ben Z.|last2=Shiraishi|first2=Yukiko|last3=Mears|first3=Cynthia J.|last4=Binns|first4=Helen J.|last5=Taylor|first5=Renee|doi=10.1542/peds.2008-1879|pmc=2756827|pmid=19564299|issn=1098-4275}}</ref> indicating that in the first year or so, post-mononucleosis ME/CFS can clear up over time in some individuals, though it becomes a permanent illness in others. [[A Martin Lerner|Dr Martin Lerner]] asserts that ME/CFS patients have an chronic EBV infection if there are high antibody levels in the EBV '''VCA IgM''' and/or '''EA IgG diffuse''' tests;<ref name=":0">{{Cite journal|title=Subset-directed antiviral treatment of 142 herpesvirus patients with chronic fatigue syndrome|date=2010-05-24|url=https://www.dovepress.com/subset-directed-antiviral-treatment-of-142-herpesvirus-patients-with-c-peer-reviewed-fulltext-article-VAAT|journal=Virus Adaptation and Treatment|volume=2|pages=47β57|last=Lerner|first=A. Martin|last2=Beqaj|first2=Safedin|last3=Fitzgerald|first3=James T.|last4=Gill|first4=Ken|last5=Gill|first5=Carol|last6=Edington|first6=James|language=English|doi=10.2147/VAAT.S10695}}</ref> a study<ref>{{Cite journal|title=Investigation of Long COVID Prevalence and Its Relationship to Epstein-Barr Virus Reactivation|date=2021-06-17|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233978/|journal=Pathogens|volume=10|issue=6|pages=763|last=Gold|first=Jeffrey E.|last2=Okyay|first2=Ramazan A.|last3=Licht|first3=Warren E.|last4=Hurley|first4=David J.|doi=10.3390/pathogens10060763|pmc=8233978|pmid=34204243|issn=2076-0817}}</ref> confirms that high antibody levels in either of these tests indicates EBV reactivation. Note that: EA = early antigen; VCA = virus capsid antigen (also denoted by CA), EBNA = Epstein-Barr nuclear antigen. Note that the chronic EBV infections thought to exist in ME/CFS are not the same as those found in the rare and often fatal illness chronic active Epstein-Barr virus (CAEBV). In CAEBV, high EBV viral loads are found in the blood by PCR, whereas in ME/CFS, blood PCR tests are often negative for EBV. ===== HHV-6 testing ===== [[Human herpesvirus 6|Human herpes virus 6]] (HHV-6) has been linked to ME/CFS in [https://me-pedia.org/wiki/List_of_herpesvirus_infection_studies many studies]. HHV-6 is found in nearly 100% of adults, normally in a latent (inactive) state. However, ME/CFS patients may have a reactivated HHV-6 infection. Dr Martin Lerner asserts that if ME/CFS patients have both high HHV-6 '''IgM''' antibodies and high HHV-6 '''IgG''' antibodies, that indicates a reactivated HHV-6.<ref name=":0" /> The HHV-6 Foundation state that in an IFA antibody test, if HHV-6 '''IgG''' is highly elevated relative to healthy controls, it indicates a recent infection or a smoldering chronic reactivated infection.<ref>{{Cite web|url=https://hhv-6foundation.org/patients/hhv-6-testing-for-patients|title=HHV-6A/B Testing {{!}} HHV-6 Foundation {{!}} HHV-6 Disease Information for Patients, Clinicians, and Researchers {{!}} Apply for a Grant|website=hhv-6foundation.org|access-date=2024-05-17}}</ref> ===== Cytomegalovirus testing ===== [[Cytomegalovirus]] (CMV) has been linked to ME/CFS in [https://me-pedia.org/wiki/List_of_herpesvirus_infection_studies many studies]. CMV is found in around 58% of adults in the US,<ref>{{Cite journal|title=National prevalence estimates for cytomegalovirus IgM and IgG avidity and association between high IgM antibody titer and low IgG avidity|date=2011-11|url=https://pubmed.ncbi.nlm.nih.gov/21918114/|journal=Clinical and vaccine immunology: CVI|volume=18|issue=11|pages=1895β1899|last=Dollard|first=Sheila C.|last2=Staras|first2=Stephanie A. S.|last3=Amin|first3=Minal M.|last4=Schmid|first4=D. Scott|last5=Cannon|first5=Michael J.|doi=10.1128/CVI.05228-11|pmc=3209034|pmid=21918114|issn=1556-679X}}</ref> normally in a latent inactive state. But ME/CFS patients may have a reactivated CMV infection. Dr Martin Lerner states that high levels of CMV '''IgG''' antibodies indicate a reactivated infection in ME/CFS. Dr Lerner says testing CMV '''IgM''' levels has no relevance in ME/CFS.<ref>{{Cite web|url=http://web.archive.org/web/20190929163222/http://www.treatmentcenterforcfs.com/documents/MECFSTreatmentResourceGuideforPractitioners.pdf|title=ME/CFS Treatment Resource Guide for Practitioners|last=Lerner|first=A. Martin|quote=A diagnosis of cytomegalovirus (CMV) infection is made with an elevated CMV IgG titer. The IgM titer for CMV is inaccurate and insensitive. The higher the CMV IgG titer, the greater the viral load.}}</ref> ===== SARS-CoV-2 testing ===== Since the COVID pandemic, the [[SARS-CoV-2]] coronavirus has become a new addition to the set of viruses linked to ME/CFS. But no blood testing protocols for SARS-CoV-2 have yet been validated by ME/CFS researchers as a means to associate this virus to ME/CFS patients. However, patients whose ME/CFS appeared immediately after an acute COVID infection (as detected by a COVID lateral flow test or COVID PCR) will naturally assume their illness was triggered by SARS-CoV-2. ===== Varicella zoster virus testing ===== [[Varicella zoster virus]] (VZV) is found in 63% to 100% of the population.<ref>{{Cite journal|title=Varicella zoster virus latency|date=2011-3|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118253/|journal=Future virology|volume=6|issue=3|pages=341β355|last=Eshleman|first=Emily|last2=Shahzad|first2=Aamir|last3=Cohrs|first3=Randall J|pmc=3118253|pmid=21695042|issn=1746-0794}}</ref> VZV causes [[chickenpox]], and VZV can reactivate later in life to cause [[shingles]], a painful or itchy skin rash. Dr John Chia finds a very small percentage of ME/CFS cases are due to reactivated VZV, and this type of ME/CFS can be treated easily with antiviral drugs such as [[acyclovir]], which improve the ME/CFS after just a few weeks.<ref>{{Cite web|url=https://www.youtube.com/supported_browsers?next_url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DNhU-G0loqtY&t=6m58s|title=MECFS Alert Episode 38 - Interview with Dr. John Chia, Part 1|website=www.youtube.com|at=Timecode 6m 58s|access-date=2024-05-17}}</ref> The shingles rash caused by VZV is distinctive enough on its own to make a diagnosis of VZV reactivation. Even the appearance of just one or two shingles blisters can indicate VZV reactivation. '''PCR''' testing of the shingles blister contents can confirm VZV reactivation, if confirmation is needed.<ref>{{Cite web|url=https://www.cdc.gov/chickenpox/php/laboratories/index.html|title=Laboratory Testing for Varicella-Zoster Virus (VZV)|last=CDC|date=2024-05-10|website=Chickenpox (Varicella)|language=en-us|access-date=2024-05-18}}</ref> VZV usually lives in a latent state in the nerve ganglia, but when it reactivates it typically leads to shingles; it has been hypothesized VZV reactivation in the nerve ganglia may cause ME/CFS.<ref>{{Cite journal|title=Does varicella-zoster virus infection of the peripheral ganglia cause Chronic Fatigue Syndrome?|date=2009-11|url=https://pubmed.ncbi.nlm.nih.gov/19520522/|journal=Medical Hypotheses|volume=73|issue=5|pages=728β734|last=Shapiro|first=Judith S.|doi=10.1016/j.mehy.2009.04.043|pmid=19520522|issn=1532-2777}}</ref> ===== Parvovirus B19 testing ===== [[Parvovirus B19]] is a rarer cause of ME/CFS.<ref>{{Cite journal|title=Chronic fatigue syndrome and arthralgia following parvovirus B19 infection|date=2002-03|url=https://pubmed.ncbi.nlm.nih.gov/11911112/|journal=The Journal of Rheumatology|volume=29|issue=3|pages=595β602|last=Kerr|first=Jonathan R.|last2=Bracewell|first2=Janice|last3=Laing|first3=Ian|last4=Mattey|first4=Derek L.|last5=Bernstein|first5=Robert M.|last6=Bruce|first6=Ian N.|last7=Tyrrell|first7=David A. J.|pmid=11911112|issn=0315-162X}}</ref><ref>{{Cite journal|title=Antibody to parvovirus B19 nonstructural protein is associated with chronic arthralgia in patients with chronic fatigue syndrome/myalgic encephalomyelitis|date=2010-04|url=https://pubmed.ncbi.nlm.nih.gov/20007355/|journal=The Journal of General Virology|volume=91|issue=Pt 4|pages=893β897|last=Kerr|first=Jonathan R.|last2=Gough|first2=John|last3=Richards|first3=Selwyn C. M.|last4=Main|first4=Janice|last5=Enlander|first5=Derek|last6=McCreary|first6=Michelle|last7=Komaroff|first7=Anthony L.|last8=Chia|first8=John K.|doi=10.1099/vir.0.017590-0|pmid=20007355|issn=1465-2099}}</ref> This virus is found in 61% of adults,<ref>{{Cite journal|title=The prevalence of antibody to parvovirus B19 in hemophiliacs and in the general population|date=1996-07|url=https://pubmed.ncbi.nlm.nih.gov/8837383/|journal=Zentralblatt Fur Bakteriologie: International Journal of Medical Microbiology|volume=284|issue=2-3|pages=232β240|last=Eis-HΓΌbinger|first=A. M.|last2=Oldenburg|first2=J.|last3=Brackmann|first3=H. H.|last4=Matz|first4=B.|last5=Schneweis|first5=K. E.|doi=10.1016/s0934-8840(96)80098-3|pmid=8837383|issn=0934-8840}}</ref> normally in a latent (inactive) state. But ME/CFS due to parvovirus B19 involves an active infection. Dr John Chia diagnoses active parvovirus B19 infection when the '''PCR''' test is positive, or when there are high '''IgM''' antibodies.<ref>{{Cite journal|title=Diverse Etiologies for Chronic Fatigue Syndrome|date=1 March 2003|url=https://academic.oup.com/cid/article-pdf/36/5/671/1244019/36-5-671.pdf|journal=Clinical Infectious Diseases|volume=36|pages=671|last=Chia|first=John|last2=Chia|first2=Andrew}}</ref> Note that an acute parvovirus B19 infection can cause false positive IgM antibody test results with blood tests for Epstein-Barr virus, cytomegalovirus, HHV-6, herpes simplex and Borrelia burgdorferi and others.<ref>{{Cite journal|title=Acute parvovirus B19 infection frequently causes false-positive results in Epstein-Barr virus- and herpes simplex virus-specific immunoglobulin M determinations done on the Liaison platform|date=2009-03|url=https://pubmed.ncbi.nlm.nih.gov/19116304/|journal=Clinical and vaccine immunology: CVI|volume=16|issue=3|pages=372β375|last=Berth|first=Mario|last2=Bosmans|first2=Eugene|doi=10.1128/CVI.00380-08|pmc=2650871|pmid=19116304|issn=1556-679X}}</ref><ref>{{Cite journal|title=False-Positive Results for Immunoglobulin M Serologic Results: Explanations and Examples|date=2013-03|url=https://pubmed.ncbi.nlm.nih.gov/26619450/|journal=Journal of the Pediatric Infectious Diseases Society|volume=2|issue=1|pages=87β90|last=Woods|first=Charles R.|doi=10.1093/jpids/pis133|pmid=26619450|issn=2048-7193}}</ref> This is because parvovirus B19 IgM antibodies cross-react with the IgM antibodies of these other pathogens. ===== Chlamydia pneumoniae testing ===== Dr John Chia finds the intracellular bacterium [[Chlamydia pneumoniae]] is an uncommon but treatable cause of ME/CFS, and says that most ME/CFS patients with active Chlamydia pneumoniae will have high '''IgG''' antibody levels, with IgM being negative; however some patients with this infection will have low IgG levels. Thus low IgG levels do not necessarily mean you do not have active Chlamydia pneumoniae.<ref>{{Cite journal|title=Chronic Chlamydia pneumoniae Infection: A Treatable Cause of Chronic Fatigue Syndrome|date=August 1999|url=https://cid.oxfordjournals.org/content/29/2/452.full.pdf|journal=Clinical Infectious Diseases|volume=29|last=Chia|first=John}}</ref> 74% of adults have antibodies to Chlamydia pneumoniae, and about 10% of adults have a persistent active infection, according to an Israeli study.<ref>{{Cite journal|title=Prevalence of antibodies to Chlamydia pneumoniae in an Israeli population without clinical evidence of respiratory infection|date=2002-05|url=https://pubmed.ncbi.nlm.nih.gov/11986341/|journal=Journal of Clinical Pathology|volume=55|issue=5|pages=355β358|last=Ben-Yaakov|first=M.|last2=Eshel|first2=G.|last3=Zaksonski|first3=L.|last4=Lazarovich|first4=Z.|last5=Boldur|first5=I.|doi=10.1136/jcp.55.5.355|pmc=1769655|pmid=11986341|issn=0021-9746}}</ref> === Learn more === [https://mecfsroadmap.altervista.org/#first-round-tests Viral testing section] of the [https://mecfsroadmap.altervista.org ME/CFS Roadmap for Testing and Treatment]. === See also === * [[Enterovirus]] * [[Non-cytolytic enterovirus]] * [[Coxsackie B virus|Coxsackievirus B]] * [[Echovirus]] * [[John Chia|Dr John Chia]] * [[List of enterovirus infection studies]] * [[Epstein-Barr virus]] * [[Human herpesvirus 6|HHV-6]] * [[Cytomegalovirus]] * [[List of herpesvirus infection studies]] * [[Severe acute respiratory syndrome coronavirus 2|SARS-CoV-2]] * [[Varicella zoster virus]] * [[Parvovirus B19]] * [[Chlamydia pneumoniae]] === References ===
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