Lessons in diagnostic virology: expected and unexpected sources of error

Viral diagnostics have shown continued innovation, with serological and molecular diagnostic assays pushing the limits of sensitivity. Technology has provided new automated shared diagnostic platforms that reduce hands‐on time, while with globalisation of the diagnostic market, commercial assays are applied across epidemiologically diverse settings on different patient and viral populations. However, with these novel developments, new and often unexpected sources of diagnostic error emerge. In this review we will reflect on case studies that highlight these often underappreciated or unexpected diagnostic errors spanning pre‐analytical, analytical, and post‐analytic processes. We will also suggest approaches that could help identify error and reduce the impact on patient management.

[1]  N. Parkin Measurement of HIV-1 viral load for drug resistance surveillance using dried blood spots: literature review and modeling of contribution of DNA and RNA. , 2014, AIDS reviews.

[2]  W. Preiser,et al.  NucliSens EasyQ HIV-1 V1.2 system: Detection of human plasma-derived background signal. , 2010, Journal of virological methods.

[3]  O. Laeyendecker,et al.  High frequency of false-positive hepatitis C virus enzyme-linked immunosorbent assay in Rakai, Uganda. , 2013, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[4]  A. Puren,et al.  Poor sensitivity of field rapid HIV testing: implications for mother‐to‐child transmission programme , 2009, BJOG : an international journal of obstetrics and gynaecology.

[5]  J. Mellors,et al.  Rapid decline of HIV-1 DNA and RNA in infants starting very early antiretroviral therapy may pose a diagnostic challenge , 2018, AIDS.

[6]  T. Peter,et al.  Affordable HIV drug-resistance testing for monitoring of antiretroviral therapy in sub-Saharan Africa. , 2016, The Lancet. Infectious diseases.

[7]  M. Mizokami,et al.  Prevalence of Low Positive Anti‐HCV Antibodies in Blood Donors: Schistosoma mansoni Co‐Infection and Possible Role of Autoantibodies , 2006, Microbiology and immunology.

[8]  L. Morris,et al.  Rates of virological suppression and drug resistance in adult HIV-1-positive patients attending primary healthcare facilities in KwaZulu-Natal, South Africa , 2017, The Journal of antimicrobial chemotherapy.

[9]  R. Hayes,et al.  Association of Schistosomiasis with False-Positive HIV Test Results in an African Adolescent Population , 2010, Journal of Clinical Microbiology.

[10]  J. Ananworanich,et al.  Reduced markers of HIV persistence and restricted HIV-specific immune responses after early antiretroviral therapy in children , 2014, AIDS.

[11]  Negative rapid HIV antibody testing during early HIV infection. , 2007, Annals of internal medicine.

[12]  K. Fransen,et al.  Evaluation of a rapid and simple fourth-generation HIV screening assay for qualitative detection of HIV p24 antigen and/or antibodies to HIV-1 and HIV-2. , 2010, Journal of virological methods.

[13]  K. Dieckhaus,et al.  Clinical implications of elevated HIV-1 viral load results obtained from samples stored frozen in vacutainer plasma preparation tubes. , 2014, Journal of virological methods.

[14]  W. Preiser,et al.  Extraction buffer contaminated bacterially as a cause of invalid HIV-1 viral load results on the NucliSens EasyQ system. , 2008, Journal of virological methods.

[15]  R. Hayes,et al.  Low specificity of the Murex fourth‐generation HIV enzyme immunoassay in Tanzanian adolescents , 2007, Tropical medicine & international health : TM & IH.

[16]  S. Carmona,et al.  Separation of Plasma from Whole Blood by Use of the cobas Plasma Separation Card: a Compelling Alternative to Dried Blood Spots for Quantification of HIV-1 Viral Load , 2019, Journal of Clinical Microbiology.

[17]  P. Reiss,et al.  Acquisition of wild-type HIV-1 infection in a patient on pre-exposure prophylaxis with high intracellular concentrations of tenofovir diphosphate: a case report. , 2017, The lancet. HIV.

[18]  M. Markowitz,et al.  Newly Acquired Infection with Multi-Drug Resistant HIV-1 in a Patient Adherent to Pre-Exposure Prophylaxis. , 2017, Journal of acquired immune deficiency syndromes.

[19]  L. Morris,et al.  Rates of virological suppression and drug resistance in adult HIV-1-positive patients attending primary healthcare facilities in KwaZulu-Natal, South Africa. , 2017, The Journal of antimicrobial chemotherapy.

[20]  A. Rai,et al.  Positive or Not, That Is the Question: HIV Testing for Individuals on Pre-exposure Prophylaxis. , 2018, Journal of acquired immune deficiency syndromes.

[21]  Li-Na Jin,et al.  Interpretation of rubella serology in pregnancy—pitfalls and problems , 2002, BMJ : British Medical Journal.

[22]  R. Callard,et al.  Reactivity of routine HIV antibody tests in children who initiated antiretroviral therapy in early infancy as part of the Children with HIV Early Antiretroviral Therapy (CHER) trial: a retrospective analysis. , 2015, The Lancet. Infectious diseases.

[23]  S. Peel,et al.  Comparison of Detection Limits of Fourth- and Fifth-Generation Combination HIV Antigen-Antibody, p24 Antigen, and Viral Load Assays on Diverse HIV Isolates , 2018, Journal of Clinical Microbiology.

[24]  R. Kaiser,et al.  Detection of drug resistance mutations at low plasma HIV-1 RNA load in a European multicentre cohort study. , 2011, The Journal of antimicrobial chemotherapy.

[25]  G. Tipples Rubella diagnostic issues in Canada. , 2011, The Journal of infectious diseases.

[26]  M. Revello,et al.  Evaluation of fully automated assays for the detection of Rubella IgM and IgG antibodies by the Elecsys(®) immunoassay system. , 2014, Journal of virological methods.

[27]  Dan Turner,et al.  Comparison between Roche and Xpert in HIV-1 RNA quantitation: A high concordance between the two techniques except for a CRF02_AG subtype variant with high viral load titters detected by Roche but undetected by Xpert. , 2017, Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology.

[28]  Lai Wei,et al.  Performance Comparison of the Versant HCV Genotype 2.0 Assay (LiPA) and the Abbott Realtime HCV Genotype II Assay for Detecting Hepatitis C Virus Genotype 6 , 2014, Journal of Clinical Microbiology.

[29]  R Core Team,et al.  R: A language and environment for statistical computing. , 2014 .

[30]  E. Adams,et al.  Field accuracy of fourth-generation rapid diagnostic tests for acute HIV-1: a systematic review , 2015, AIDS.

[31]  M. Cotton,et al.  Interpretation of indeterminate HIV-1 PCR results are influenced by changing vertical transmission prevention regimens. , 2017, Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology.

[32]  R. Peeling,et al.  Systematic Review of the Use of Dried Blood Spots for Monitoring HIV Viral Load and for Early Infant Diagnosis , 2014, PloS one.

[33]  H. Fernandes,et al.  Coamplification of HIV-1 Proviral DNA and Viral RNA in Assays Used for Quantification of HIV-1 RNA , 2010, Journal of Clinical Microbiology.

[34]  M. Pentella,et al.  Laboratory testing for the diagnosis of HIV infection : updated recommendations , 2014 .

[35]  T. Ø. Jonassen,et al.  Overestimation of Human Immunodeficiency Virus Type 1 Load Caused by the Presence of Cells in Plasma from Plasma Preparation Tubes , 2009, Journal of Clinical Microbiology.

[36]  A. Puren,et al.  Young age at start of antiretroviral therapy and negative HIV antibody results in HIV-infected children when suppressed , 2015, AIDS.

[37]  Jerome H. Kim,et al.  Initiation of Antiretroviral Therapy During Acute HIV-1 Infection Leads to a High Rate of Nonreactive HIV Serology. , 2016, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[38]  W. Preiser,et al.  Pitfalls with rapid HIV antibody testing in HIV-infected children in the Western Cape, South Africa. , 2006, Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology.