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Immunoglobulin related question
Mar 11, 2011

Hey Dr Bob,

Immunoglobulins may as well be 'goblins' to me.

See my story below. Maybe you remember me?

ANyway dude, here goes...

I have been feeling tired with a few skin problems - infections, and hair thinning over the past 6 months. I have had particualrly reactive skin - first to light on my arms and occasionally itchy red bumbs - which randomly appear NOT related to insects bites.

I had a retest done nearly 10 months after initial exposure and 6 months after last Immunoglobulins test.

It showed:

IgA - 1.94 g/l (HIGH) IgG - 3.02 g/l (NORMAL) IgM - 2.25 g/l (HIGH)

Doc says 'CBC', 'C-RP' and 'ESR' are in normal range- which he said is encouraging.

Had 6 month HIV and Hep C tests which were negative.

Doc says its a raised polyclonal imunoglobulin rise' and so wants another HIv test (at 10 months)?

Is he 'off his rocker' or should I start worrying.

Another doc says it cant be HIV and that its the wrong immunogloublins to be raised.

I want to ask what you think about the results above.

And what do you suggest re a further test?

And what further tests you recommend?

Should I be concerned?

Stevie

OLD MESSAGES FORWARDED BELOW:

I did it... now the waiting game - sadly not a world cup game - questions about immunoglobulins and more Aug 12, 2010 Hi Dr Bobinino (are you playing in the next world cup - its in Brazil!!),

So I tested... up to 2 weeks to wait for the test result!

I wanted to ask for your help in the meantime, if you have time - my doctor didnt :( . I didn't sleep well at all...

I was given my preliminary blood results when I tested- see what you think:

Hb 14.5 (I think in USA thats 1.46), MCV 89.8, White Cell 5.8 (normal range 3.5-11), Neutrophils 3.1 (50%), Lymphocytes 2.23 (36%), Eosinophils 0.21, Monocytes 0.5, Basophils 0, Platelets 209 (previously 250 and 280), Potassium 4.2, Sodium 142, Urea 4.3, Creatinine 77, C-reactive protein 2, Alk Phos 60, ALT 18, Bilirubin 13, Albumin 47,

Which were all normal EXCEPT:

Immunoglobulin screen - IgG - 12.4 NORMAL (reference range 6.0-16.0), IgA - 3.35 HIGH (0.8 -2.8), IgM - 2.98 HIGH (0.45 - 1.90). Raised IgA and IgM.

My past tests have shown my lymphocyte count dipped to 1.3 (17%) five weeks after exposure - when I got lymph adenopathy and adenitis of my left breast/ axilla area and the rash. Also my ESR was high at 7 in May (it went up from 1 two weeks prior to that test). I havent got a new result.

My questions are as follows (they are quite specific, sorry - they have arisen from all my reading - they are things that havent been asked/ havent had answers - so if you can help - im sure we'd all appreciate it) :

1. Is the raised immunoglobulins - IgA and IgM- is this fitting with a early HIV infection (3-4 months post infection)? I have read things to that effect. Especially as IgA and its association to mucosa.

2. p24 antigen - thanks for your answer - some research shows it rises one week before antibodies are formed. One doctor told me that if you are infected - you either have p24 or antibodies or both. You cannot be infected and not have formed one or the other- as when p24 falls, its due to antibody rising - at the same time. I don't think this is true. I think you can not have either p24 or antibody test positive up to or beyond the 12 week in rare circumstances. Who is correct?

3. If two people are infected by the same subtype or strain of HIV - wouldn't there by some shared way in delayed seroconversion even if they are genetically different?

4. why do Health care workers seroconvert after others - ie. outside the window - is it all down to PEP? I didnt take PEP... but there are other reasons why people would seroconvert later. A research 'case study' in 2009 in UK showed a man seroconverted at 4 months well outside the window... eek! Worrying for me. What do you think about this? See the link: (http://ijsa.rsmjournals.com/cgi/content/abstract/20/3/205)

5. Is Platelets of 209 lowish? ( it was down from 280). I was looking at the 'units' on my lab report of number of platelets per mm3 of blood. and the fact it is a factor of thousands. So my decrease is of 80,000 platelets per mm3 !? That seems like a lot. I read about 'thrombocytopenia' in early HIV disease- that its generally mild. What do you say about my 209- normal but low?

6. This question is really important - one that doesnt seem to have a clear answer. Here goes, does ARS mean that you will seroconvert directly after? Certainly UK guidelines say you should be tested one week after symptoms if your initial test is negative. What do you say? Does ARS = seroconversion or not?

7. I developed and was treated for NSU after the past exposure- and now a small 'ulcer' in the inside of my foreskin I found in the last few weeks which came, went and now has come back - it looks like a tear/ hole in the lining of my inside of my foreskin - its likely if I got NSU I also got HSV - I also could have got HIV? My partner has a small fluid filled genital lesion which burst when was squeezed. My 'ulcer' is small- a few mm across and is mildly painful when touched- is this likely to be HSV?

I read that HSV lesions exude HIV viruses in infected individuals. So if its likely that if I got HSV (I should get tested now) - I have probably caught HIV?

8. I am tired (obviously with little sleep). I have dry skin. Yesterday I developed a large lesion on my right arm. It looks like an insect bite but definetely wasnt... it was a small red lesion centred on a hair in the middle of it, on my forearm. It became red with a large red swollen area around it and was very warm to touch. The doctor said it looked like 'cellulitic'. He was gonna give me antibiotics but didnt. One day later, it looks a little better - but looks infected. Is this common in early HIV disease when your immune system is being battered? - I read about 'exaggerated insect bites disease' and folliculitis etc, with HIV.

9. Also I get itchy red bumps which come up briefly and itch and then go away. What can you say about 'exaggerated insect bites' and red itchy bump disease in early HIV (3-4 months after infection)?

10. I have searched your forum. I cannot find much about Immunoglobulins. The internet unreassures me - raised levels seem to point at infection. Along with the lymphadenopathy, new problems for me and recent exposure to HIV - I can't help but think - these are all pointing (not so subtly) at HIV? Could HIV and/ or HSV explain my immunoglobulin results?

My partner has had dry skin and scalp, and now awful deep cough for the past 10 days which isn't shifting it and intermittingly feels awful - tired and ill in bed- we had to sleep for 4 hours during the day on saturday. They also have developed folliculitis on upper arms in past 2-3 months and now on forehead, all new since exposure. I am so worried for them and for us.

I feel overwhelmed by guilt and saddened beyond relief. I was hoping stress and depressive feelings to be the source of all this - but the doctor seemed pretty concerned about my immunoglobulins levels and lymphadenopathy and told me to be prepared for a positive result- he made out that despite all the negative testing I was in for a positive result with all of the above. Am I right in thinking in line with my doctor that I am in for a positive result and not a negative one?

These raised immunoglobulins seem the nail in my coffin (i know bad analogy- trying to keep smiling)- it now feels like too much stuff has happened to me and my partner for it to be anything else...

Obviously I am really worried. I am 26 years old and my blood pressure is now 139/75 and my heart pulse is 86 when Im sat doing nothing.

Thanks for your time! I'll let you know about my test in two weeks.

Stevie

********************************************

What exactly is considered '3 months' and the world cup follow up Aug 8, 2010 Hi,

In regard to the questions below- is 3 months considered 12 weeks or 13 weeks?

Does it make that much difference if your tested at 11 weeks?

And finally, why do the UK guidelines say testing at 3 months is considered conclusive but CDC guidelines say 3 and then 6 months? Is this for everyone? Why do just Americans get 6 months advice to test?

I didnt have any PEP... so surely you would seroconvert by 11 weeks - my last test.

And if two people were infected- wouldnt at least one expect to seroconvert or is (delayed) seroconversion more down to the specific subtype/ strain than down to genetics?

I still havent had a repeat test - quite scared! HELP...

Developed additional lymphadenopathy in neck (two small nodes on one side) and then got swollen lymphnodes in groin also - both sides- enlarged quickly and then went down in 2 days, but still feelable after 4-5 days - no doubt this all doesnt happen for no reason?!

Can sercoconversion happen at 16-20 weeks?

Surely P24 always has to be detected before 12 weeks mark anyway?

If your getting ANY symptoms - doesnt that mean you have to have seroconverted at or shortly after that time?

Can you convince me to test?

Realistically, what are the chances that these tests were wrong before 12 weeks (at 11 weeks).

Thanks

Stevie

PS. you were wrong about Brazil but right about Spain - so I'll double the donation!

Just a quickie - can you help us to enjoy the world cup? Jun 25, 2010 Dear Bobinino (that is if you were a brazilian soccer player),

Just a quickie.

Me and my partner are very worried and just wanna to enjoy the world cup.

One of us was exposed to HIV via heterosexual contact about 13 weeks ago and since had intercourse (unportected). Weve had the following tests:

Me - PCR RT Viral Load at about 4-5 weeks (Undetected), DUO test at 6 and 10weeks (Neg). Rapid test (negative) at 11 weeks.

Partner - DUo test at 5 weeks and 10 weeks (both negative).

Weve both been ill and had various things gowrong probably due to stress in the meantime. My partner had flu & pharyngiotis and I had chest infection, rash, oral candida and enlarged lymph nodes (confirmed by a doc). My blood results showed a dip in the lymphocyte count but now its nearly ok.

Can we stop worrying? Do we need to test anymore?

Theres too much online to know what is right or wrong...?

By the way, who do you think will win the world cup?

If your right, Ill make a double donation to your foundation.

Thanks

Stevie

Response from Dr. Frascino

Hi Stevie,

The gold standard for HIV diagnostic tests remains an HIV-antibody test at the three-month mark. The negative tests you and your partner have to date, including your negative rapid test at 11 weeks and an undetectable quantitative HIV PCR RNA viral load, are extremely encouraging. The vast majority of HIV-infected folks will have detectable levels of anti-HIV antibodies in their blood within four to six weeks following HIV primary infection. That said, you have not had a negative three-month HIV antibody test yet and most viral load tests are not FDA approved for diagnostic purposes. My advice would be to stop worrying and enjoy the World Cup games. The person who had the HIV exposure should get one additional HIV-antibody test (rapid test, ELISA, EIA, Duo, etc.) at the three-month mark. I'm quite confident the result will once again be negative.

As for who will win the World Cup, both Brazil and Spain look good to me. I guess I'll root for Brazil because I like the Bobinino name!

Good luck!

Dr. Bobinino

Response from Dr. Frascino

Hello Stevie,

Different folks calculate "3 months" differently. For instance for some 3 months x 30 days per month = 90 days while for other 12 weeks x 7 days per week = 84 days. It really doesn't matter. The immune system is not a clock or a calendar. What we know scientifically is that the vast majority of HIV-infected people will have detectable levels of anti-HIV antibody in their blood within four to six weeks following HIV primary infection. However, some folks may take a bit longer for their immune system to adequately kick into gear. Hence the "3 month" guideline is designed to make sure we don't miss those folks. As for 11 weeks, that is not considered three months by any calculation, including "fuzzy math." Certainly it's well beyond the four-to-six-weeks mark, but would not be considered three months.

As for the difference between various sets of guidelines, it's difficult to explain. No one wants to miss a case of HIV by advising someone he is HIV negative when in reality he is still in his window period. The window period has tended to get somewhat shorter as newer, more sophisticated HIV testing methods have come online. (See below.)

Delayed seroconversion has nothing to do with subtypes.

What's all this nonsense about being too scared to get retested? Come on Stevie, time to man-up, grow a pair and just go do it. You'll be glad you did. See the post below discussing "what you don't know can kill you."

Swollen glands are an extremely common occurrence and are certainly not only related to HIV. What you described is not at all worrisome for or even suggestive of HIV.

It would be very extremely unlikely to experience HIV seroconversion at 16-20 weeks.

P24 is generally detected well before the 12-week mark. However, p24 alone, either negative or positive, is not diagnostic.

Symptoms are unreliable in predicting who is and is not HIV infected.

As for can I convince you to test, I don't know. Can I? The decision is totally up to you. I do, however, suggest you carefully read the information below.

Tests taken prior to the three-month mark are not considered definitive or conclusive; therefore, there are no "chances" or "odds" I can provide.

Thanks for the double donation! In return I'm sending my good-luck karma that your definitive HIV test remains negative.

Be well. (I'm very confident you are indeed well!)

Dr. Bobinino

Response from Dr. Frascino

Hello Stevie,

1. Increases in immunoglobulins can be seen in HIV disease. However, they can be seen in numerous other medical conditions as well.

2. Both. Your doctor's comments about specific anti-HIV antibodies increasing as p24 antigen becomes less detectable on current testing assays is correct. However, you are also correct: p24 antigen can be present well beyond 12 weeks, depending on how it is assayed.

3. No.

4. Health care workers do not seroconvert later than others. The recommendation for testing out to six months for an occupational exposure in a health care worker has to do with the level of risk. A hollow-bore needle stick from a patient confirmed to be HIV positive carries a different risk level than a wham-bam-thank-you-ma'am with a cute college coed of unknown HIV status. The six-month window is a very conservative recommendation issued by the CDC to make sure an infection is not missed. The post-PEP testing guidelines are identical for both occupational and non-occupational exposures. As for the article you site, I really can't comment other than to say extremely rare things happen extremely rarely. For instance folks do get zapped dead by errant bolts of lightening, but most of us don't worry about it every time we step outside our front door, right?

5. A platelet count of 209 is not at all worrisome.

6. No. Symptoms are notoriously unreliable in predicting who is and is not HIV infected.

7. It's possible, but I wouldn't say "likely." I can't diagnose the cause of ulcers over the Internet. It could be HSV, but I have no way of knowing without seeing it. (It's worth noting that these types of mucosal ulcers may be the reasons your IgA is mildly elevated.)

8. No, skin eruptions such as you describe are not common in early HIV. If the problem persists, see your doctor or a dermatologist.

Response from Dr. Frascino

Hi Stevie,

Here is a link to my last response to you.

Have you considered changing doctors or at least getting a second opinion? It seems your current doctor is scaring you more than helping you. I agree without a rise in IgG HIV would not be the cause of your slightly elevated IgA and IgM. (Many other conditions can cause this.) Again I encourage you to stop worrying about a disease you could not possibly have.

Dr. Bob


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