Asian Journal of Transfusion Science
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LETTER TO THE EDITOR Table of Contents   
Year : 2014  |  Volume : 8  |  Issue : 2  |  Page : 145-146
Diagnostic dilemmas in human immunodeficiency virus testing


1 Department of Virology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
2 Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
3 Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India

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Date of Web Publication24-Jul-2014
 

How to cite this article:
Choudhary A, Gupta E, Kumar R, Bajpai M, Sarin S. Diagnostic dilemmas in human immunodeficiency virus testing. Asian J Transfus Sci 2014;8:145-6

How to cite this URL:
Choudhary A, Gupta E, Kumar R, Bajpai M, Sarin S. Diagnostic dilemmas in human immunodeficiency virus testing. Asian J Transfus Sci [serial online] 2014 [cited 2020 Jul 5];8:145-6. Available from: http://www.ajts.org/text.asp?2014/8/2/145/137463


Sir,

Screening for human immunodeficiency virus (HIV) in India is performed using serological assays as per guidelines laid down by the National AIDS Control Organization (NACO). [1] False-positive serological results are known to occur in various diseases or situations. [2],[3] We report a case of false-positive HIV serology in a patient with chronic liver disease (CLD). The patient was diagnosed as a case of autoimmune hepatitis (AIH) in whom initial serological screening assays were reactive, while confirmatory testing, that is, HIV western blot and HIV-1 RNA real time reverse transcriptase polymerase chain reaction (RT-PCR) were both negative.

The patient, a 64-year-old woman (a housewife), was admitted to our institute on 17 th October 2010 for the evaluation of abnormal liver function tests (LFTs). She was a known case of type 2 diabetes mellitus since 10 years. She gave history of vomiting of blood on two occasions in the last 3 months. Physical examination revealed hepatomegaly, splenomegaly, ascites, finger clubbing, and palmar erythema. LFTs revealed serum bilirubin: 1.56 mg% (direct fraction 0.4%), alanine aminotransferase: 17 IU/L, aspartate aminotransferase: 20 IU/L, and serum proteins: 7.3 gm% (albumin 1.7, globulin 5.6). Serological markers for hepatitis B, C, A, and E viruses were nonreactive.

A requisition for HIV serology was received at the virology laboratory. Her sample was tested according to NACO Strategy/Algorithm III [1] and the following kits were used: R1: 4 th generation ELISA ULTRA HIV Ag-Ab kit (BioRad Genetic sys, France) (sensitivity 100%, specificity 99.1%), R2: HIV Tri-Dot assay (J. Mitra Ltd, India) (sensitivity 100%, specificity 100%), R3: SD Bioline HIV1/2 3.0 (SD Biostandard Diagnostics Pvt. Ltd, India). The results were R1+, R2+, and R3+.

Since the patient was asymptomatic with no relevant history suggestive for high risk group, confirmatory testing was performed. The sample was first tested for antibodies to HIV-1 by western blot (immunoblot assay) (New LAV Blot-1 Assay, Bio-Rad laboratories, Inc.) and was nonreactive for the same. The sample was also tested for HIV-1 RNA by real time RT-PCR (Cobas Taqman HIV-1 test, Roche Molecular Systems Inc, Branchburg, NJ, USA) and no HIV-1 RNA was detected by the same. A negative report for HIV was generated.

After ruling out viral causes for hepatitis, investigations for AIH were performed [Table 1]. Investigations also revealed hypergammaglobulinemia with serum IgG-30.1 g/L (Normal range 7-16 g/L). Based on the above results, she was diagnosed with CLD with decompensated cirrhosis due to AIH type 1.

False-positive results with enzyme immunoassays are known to occur in many diseases/situations. Important conditions include multiple blood transfusions, hypergammaglobulinemia, history of recent vaccination, multiple pregnancies, hemodialysis, antibodies to HLA antigens, autoantibodies associated with autoimmune diseases, and cross-reactivity with vector proteins, etc. [2],[4] Our patient was diagnosed as a case of AIH type 1 with hypergammaglobulinemia, both conditions being known causes of false-positive serology with HIV assays. [5],[6],[7]
Table 1: Results of autoimmune markers tested by indirect immunofl uorescence (IF)

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NACO Strategy/Algorithm III is applicable to patients who are asymptomatic and have no AIDS indicator disease symptoms. It requires three assays to be performed for HIV testing. The patient was reactive by all three screening assays (R1+, R2+, R3+). However, confirmatory tests turned out to be negative. Thus, this case is one of cross-reactive antibodies with HIV.

The Centre for Disease Control and Prevention (CDC) has also laid down guidelines regarding testing for HIV. [8] According to these; a reactive result on initial testing is retested in duplicate. If the result of either duplicate is reactive, the specimen is reported as repeatedly reactive and undergoes confirmatory testing with supplemental tests (e.g., western blot).

Ours is a tertiary care liver and biliary center. The patient population catered to includes patients with CLD, cirrhosis due to varied etiologies, 'cryptogenic' cirrhosis, etc. AIH constitutes an important fraction from the latter group. This case highlights the importance of confirmatory testing over serological testing even when all three screening assays are reactive. This approach is particularly pertinent when screening blood donors and patients, where a false-positive reactive serology result can lead to unnecessary psychological stress and mental anguish to the person and his family.

 
   References Top

1.National strategies and algorithms for HIV testing. In: Guidelines on HIV testing, National AIDS Control Organisation (NACO), Ministry of Health and Family Welfare, Government of India; March 2007.  Back to cited text no. 1
    
2.Zdeb MS. HIV screening and false-positive results. JAMA 2007;297:947-8.  Back to cited text no. 2
    
3.Mahajan VS, Pace CA, Jarolim P. Interpretation of HIV serologic testing results. Clin Chem 2010;56:1523-6.  Back to cited text no. 3
    
4.Griffith BP. Human immunodeficiency virus. In: Murray PR, editor. Manual of Clinical Microbiology. Washington, DC: ASM Press; 2007. p. 1253-81.  Back to cited text no. 4
    
5.Dewar R. Diagnosis of HIV infection. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, Bennett's Principles and Practice of Infectious diseases. 7 th ed. Philadelphia: Churchill Livingstone; 2010. p. 2323-36.  Back to cited text no. 5
    
6.Guatelli JC. Human immunodeficiency virus. Clinical Virology. 3 rd ed. Washington, DC: ASM Press; 2009. p. 737-84.  Back to cited text no. 6
    
7.Krawitt EL. Autoimmune hepatitis. N Engl J Med. 2006;354:54-66.  Back to cited text no. 7
    
8.Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor W, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55 (RR-14):1-17.  Back to cited text no. 8
    

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Correspondence Address:
Ekta Gupta
Department of Virology, Institute of Liver and Biliary Sciences,Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6247.137463

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