Assay Sheet
Test ID
3500 JCV Real-time qPCR
CPT Code
87799
Clinical Utility
JCV is the etiologic agent of progressive multifocal leukoencephalopathy (PML) which is mainly seen in HIV patients, organ transplant patients, and other immunodeficient syndromes. In addition to PML, JCV also causes nephropathy in the renal transplant setting, although with considerably less frequency than BKV. JCV should always be considered in an immunocompromised patient with progressively deteriorating CNS function. Quantitative JCV DNA PCR can be used to detect JCV in CSF in the setting of CNS disease, and blood and urine in the setting of renal dysfunction. Quantitative DNA PCR can be used to track the course of infection as well as monitor response to treatment.
Procedure
Extraction of JCV DNA from plasma, CSF, urine, other biological fluids, or tissues followed by amplification and detection using real-time, quantitative PCR. An internal control is added to ensure the extraction was performed correctly and the PCR reaction was not inhibited.
Specimens
Whole Blood: 3-5 ml submitted in an EDTA tube; ship ambient.
CSF: 1 ml fluid frozen; submitted in a sterile, leakproof tube; ship on dry ice.
Urine: 5 ml submitted in a sterile urinalysis container; ship ambient.
Other: Please inquire.
Specificity
The primers and probes used in this assay are specific for all known JCV strains based on similarity search algorithms. Additionally, no cross reactivity was detected when tested against adenoviruses, BKV, CMV, EBV, HSV-1, HSV-2, HHV-6 variant A, HHV-6 variant B, HHV-7, HHV-8, parvo B19, SV-40, and VZV.
JC Virus Assay Range
100 copies/ml to 1 x 1010 copies/ml
Turnaround Time
Within 24 hours of receiving specimen
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PCR tests are performed pursuant to a license agreement with Roche Molecular Systems, Inc.
This assay was developed and the performance characteristics were determined at ViraCor Laboratories. This test is performed in a CLIA certified laboratory. FDA approval is not required for the performance of this test.
AS10-0108
Pathogen Overview
ABOUT THE JC VIRUS
The JC virus (JCV) is a member of the Polyomaviridae family, which consists of small, nonenveloped viruses with a closed, circular double-stranded DNA genome. Polyomaviruses are ubiquitous in nature and can be isolated from a number of species. The human polyomaviruses were first isolated in 1971 and named JC and BK after the initials of the patients in which they were first discovered. JCV was isolated from the brain tissue of a patient with progressive multifocal leukoencephalopathy (PML). BKV and JCV share 75% homology at the nucleotide sequence level. JCV is the etiologic agent of PML, which only occurs in immunocompromised hosts.
JC VIRUS CLINICAL MANIFESTATIONS
An estimated 60-80% of adults in Europe and the United States have antibodies to JCV. JCV and BKV are believed to circulate independently. JCV appears to be acquired later in childhood than BKV, at 10-14 years versus 3-4 years, respectively. Evidence is unclear regarding the transmission of JCV and the course of events during primary infection. Currently, there is not an acute disease associated with JCV primary infection. It is proposed that JCV establishes a latent infection in the kidney following a primary infection, similar to BKV. Some evidence indicates latency also develops in the central nervous system. In-situ DNA hybridization has demonstrated JCV in B lymphocytes, bone marrow, lung, spleen, lymph node tissue and tonsillar tissue.
Progressive multifocal leukoencephalopathy (PML) is a rapidly progressing, extremely debilitating demyelination disease caused by infection of the central nervous system with JCV. It usually occurs in patients with diminished T cell function. PML is characterized by neurological deficits that progress rapidly, including hemiparesis, cognitive disturbance, visual field deficits, ataxia, aphasia, cranial nerve deficits and sensory deficits. Patients who have PML typically deteriorate rapidly and death commonly occurs within 6 months of diagnosis, however, a subset of patients will experience fluctuating symptomology over a 2-3 year period.
PML is a rare disease that almost always occurs in the setting of significant immunosuppression, more specifically, in the setting of abnormalities of cell-mediated immunity. Prior to the AIDS epidemic, lymphoproliferative disorders were the most common predisposing illnesses accounting for described cases of PML. Only 230 cases were described between 1958 and 1984. The AIDS pandemic dramatically changed the demography of PML. Prior to the adoption of highly active antiretroviral therapy (HAART) in 1996, approximately 5% of all HIV infected patients developed PML. More recently, PML has been described in a few patients receiving certain monoclonal antibodies, natalizumab and rituximab, for the treatment of several auto-immune disorders and B-cell lymphomas, respectively. The virus’ exact mechanism of entry into the CNS is not understood at this time.
There are a few reported cases in the literature of JCV causing nephropathy in renal transplant patients, much like BKV. However, this appears to be unusual.
Several studies have demonstrated that the virus is often present in the urine of up to 70% of the subjects studied, but generally not found in blood, saliva, nasopharyngeal aspirates or throat washings of either healthy subjects or HIV patients. In the case of PML patients, the virus appears to be present in the blood in very low titers, but present in CSF in high titers.
JC VIRUS LABORATORY DIAGNOSIS
The presence of JCV is detectable using a sensitive and specific quantitative real-time PCR assay, which can be performed on a variety of specimen types, such as CSF, urine, blood and organ biopsies. However, it is important to ascertain if the molecular assay being used is specific to JCV or if it cross reacts with BKV. The two viruses share a high level of homology and many molecular assays are unable to differentiate between the two. The ViraCor JCV assay was carefully developed to be specific for JCV and not cross react with BKV.
JC VIRUS TREATMENT
Currently, there is not a specific antiviral therapy proven effective for JCV. Current treatment of immunocompromised patients consists of restoring cell-mediated immunity to the greatest extent possible. Cidofovir is currently being studied as a treatment option for transplant patients, and cytarabine can be used in the treatment of PML, although there is conflicting data regarding the efficacy of the latter.
Selected References
Berger J, Miller C, Mootoor Y, Avdiushko S, Kryscio R, Zhu H. JC virus detection in bodily fluids: clues to transmission. Clin Infect Dis. 2006;(43):e9-e12.
Berger JR, Natalizumab and progressive multifocal leucoencephalopathy. Ann Rheum Dis. 2006;65(Suppl III); iii48-iii53.
Demeter LM. JC, BK, and other polyomaviruses; progressive multifocal leukoencephalopathy. In: Mandell GL, Bennett JE, Dolin, eds. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. Vol 2. 4th ed. New York, NY: Churchill Livingstone; 1995:1400-1406.
deViedina DG, Infantes MD, Miralles P, Berenguer J, Marin M, et al. JC virus load in progressive multifocal leukoencephalopathy: analysis of the correlation between the viral burden in cerebrospinal fluid, patient survival, and the volume of neurological lesions. Clin Infect Dis. 2002;(34):1568-1575.
Knipe D, Howley P. Fields Virology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
Salmaggi A, Maccagnano E, Castagna A, Zeni S, Fantini F, et al. Reversal of CSF positivity for JC virus genome by cidofovir in a patient with systemic lupus erythromatosus and progressive multifocal leukoencephalopathy. Neurol Sci. 2001;(22):17-20.
PAO-11-0707 PCR tests are performed pursuant to a license agreement with Roche Molecular Systems, Inc.
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Abstracts & Publications
Berger JR, Miller CS, Mootoor Y, et al. JC virus detection in bodily fluids: clues to transmission. Clin Infect Dis. 2006;(43):9-12.
JC virus in saliva, oropharyngeal fluid, blood, and urine samples obtained from 58 human immunodeficiency virus-infected persons and 58 matched controls was investigated by performing quantitative polymerase chain reaction. JC virus was rarely present in oropharyngeal fluid and blood samples, even in those obtained from immunosuppressed individuals, but it was commonly detected in urine samples from both groups, suggesting that urine contributes to transmission.
Berger JR. Natalizumab and progressive multifocal leucoencephalopathy. Ann Rheum Dis. 2006;65(3):48-53.
Current data suggest that as many as 1 in 1000 treated individuals may develop progressive multifocal leucoencephalopathy (PML) in concert with the use of natalizumab. Natalizumab was withdrawn in early 2005. The present paper provides a comprehensive description of PML and reviews the role of natalizumab in the pathogenesis of PML. It is likely that use of drugs which cause specific perturbations of the immune system will be accompanied by similar rare infections. Thus researchers should be on the alert when using such agents in clinical trials.
deViedina DG, Infantes MD, Miralles P, et al. JC virus load in progressive multifocal leukoencephalopathy: analysis of the correlation between the viral burden in cerebrospinal fluid, patient survival, and the volume of neurological lesions. Clin Infect Dis. 2002;(34):1568-1575.
JC virus (JCV) is the causative agent of progressive multifocal leukoencephalopathy (PML), a demyelinating central nervous system infection that mainly affects patients with acquired immunodeficiency syndrome. The diagnostic value of the detection of JCV DNA in cerebrospinal fluid (CSF) has been proved. A correlation between the JCV burden in CSF and the PML prognosis has been proposed. To our knowledge, the present study is the first to examine JCV burden in CSF in relation to the magnitude of neurological damage. An in-house quantitative polymerase chain reaction assay was used for measurement of the JCV burden in CSF samples from 12 patients with PML. A wide variation in JCV load (6.4 log) was found among the patient CSF samples, a finding that makes JCV load measurements worthwhile. Virus load values of >4.68 log were associated with shorter patient survival time. No correlation was found between the virus load values and the global volume of brain tissue damaged. Our data suggests that factors other than the volume of neurological lesions influence the shedding of JCV ion the CSF.
Dörries K, Sbiera S, Drews K, et al. Association of human polyomavirus JC peripheral blood of immunoimpaired and healthy individuals. J Neurovirol. 2003;9(1):81-87.
JC virus (JCV) infection is regularly asymptomatic in healthy individuals. In contrast, in immunocompromised individuals, highly activated virus replication may lead to PML. Peripheral blood cells (PBCs) are found to habor JCV DNA in healthy and diseased individuals and it is discussed that they might be responsible for dissemination of the virus to the central nervous system (CNS) during persistence. To better understand the role of JCV DNA in PBCs for persistent infection and pathogenesis, the authors characterized the extent of JCV infection in Ficoll-gradient purified blood cells (peripheral blood mononuclear cells [PBMCs]) of healthy and human immunodeficiency virus type 1 (HIV-1)-infected individuals. Virus activation in PBMCs from healthy JCV-infected individuals was found at a rate of 0% to 38% at low polymerase chain reaction (PCR) sensitivity. In progressive multifocal leukoencephalopathy (PML) patients, a stronger signal was found, indicating increased virus activation. JCV DNA was regularly detected in T and B lymphocytes and in monocytes at low levels. However, granulocytes were shown to be the predominant reservoir of JCV DNA harboring high copy numbers. Although the overall distribution of viral genomes holds true for the population studied, in the individual, a markedly changed pattern of distribution can be found.
Harault de Ligny B, Etienne I, Francois A, et al. Polyomavirus-induced acute tubulo-interstitial nephritis in renal allograft recipients. Transplantation Proc. 2000;(32):2760-2761.
Polyomavirus infection is endemic throughout the world. Primary infection occurs in childhood via oral or respiratory routes and is usually asymptomatic. Transmission occurs a little earlier for BK virus than for JC virus (100% anti-BK antibodies and 50% anti-JC antibodies at the age of 10 years). The virus remains latent in
B-lymphocytes and resides in a latent state in the kidney. Spontaneous reactivation is rare without immunosuppression. Polyomaviruses were until recently rarely responsible for clinical signs in renal transplant recipients. They have become more and more frequent ever since the prescription of new immunosuppressive agents (tacrolimus, mycophenolate mofetil). We report 10 cases of polyomavirus-induced acute tubulo-interstitial nephritis (PV-ATN).
Kleinschmidt-DeMasters BK, Tyler KL. Progressive multifocal leukoencephalopathy complicating treatment with natalizumab and interferon Beta-1A for multiple sclerosis. N Engl J Med. 2005;(353):1-6.
A 46-year-old woman with relapsing–remitting multiple sclerosis died from progressive multifocal leukoencephalopathy (PML) after having received 37 doses of natalizumab
(300 mg every four weeks) as part of a clinical trial of natalizumab and interferon beta-1a. PML was diagnosed on the basis of the finding of JC viral DNA in cerebrospinal
fluid on polymerase-chain-reaction assay and was confirmed at autopsy. Nearly every tissue section from bilateral cerebral hemispheres contained either macroscopic or microscopic PML lesions. There was extensive tissue destruction and cavitation in the left frontoparietal area, large numbers of bizarre astrocytes, and inclusion-bearing oligodendrocytes, which were positive for JC virus DNA on in situ hybridization.
Kwak EJ, Vilchez RA, Randhawa P, et al. Pathogenesis and management of polyomavirus infection in transplant recipients. Clin Infect Dis. 2002;(35):1081-1087.
Polyomavirus (JC virus[JCV], BK virus [BKV], and simian virus 40 [SV40]) establish subclinical and persistent infections and share the capacity for reactivation from latency in their host under immunosuppression. JCV establishes latency mainly in the kidney, and its reactivation results in the development of progressive multifocal leukoencephalopathy. BKV causes infection in the kidney and the urinary tract, and its activation causes a number of disorders, including nephropathy and hemorrhagic cystitis. Recent studies have reported SV40 in the allografts of children who received renal transplants and in the urine, blood, and kidneys of adults with focal segmental glomerulosclerosis, which is a cause of end-stage renal disease and an indication for kidney transplantation. Clinical syndromes related to polyomavirus infection are summarized in the present review, and strategies for the management of patients who receive transplants are discussed.
Langer-Gould A, Atlas SW, Bollen AW, Pelletier D. Progressive multifocal leukoencephalopathy in a patient treated with natalizumab. N Engl J Med. 2005;(353):1-7.
We describe the clinical course of a patient with multiple sclerosis in whom progressive multifocal leukoencephalopathy (PML), an opportunistic viral infection of the central nervous system, developed during treatment with interferon beta-1a and a selective adhesion-molecule blocker, natalizumab. The first PML lesion apparent on magnetic resonance imaging was indistinguishable from a multiple sclerosis lesion. Despite treatment with corticosteroids, cidofovir, and intravenous immune globulin, PML progressed rapidly, rendering the patient quadriparetic, globally aphasic, and minimally responsive. Three months after natalizumab therapy was discontinued, changes consistent with an immune-reconstitution inflammatory syndrome developed. The patient was treated with systemic cytarabine, and two months later, his condition had improved.
Manna P, Scantlebury V, Bryan K, Vats A. JC viral disease in renal transplantation. Poster presented at: American Transplant Congress; May 16, 2004. Click here to view poster.
Randhawa P, Baksh F, Aoki N, Tschirhart D, Finkelstein S. JC Virus infection in allograft kidneys. Transplantation. 2003;(71):1300-1303.
BACKGROUND: Polyoma virus nephropathy after transplantation is believed to be primarily due to the BK virus. We hypothesized that some cases may be associated with the JC polyoma virus (JCV), which is also known to be latent in the kidney.
METHODS: We sought polymerase chain reaction evidence of JCV infection in needle biopsy specimens with and without viral nephropathy. Cases positive by polymerase chain reaction were studied by immunohistochemistry for VP-1 antigen expression.
RESULTS: JCV DNA was found in 7 (36.8%) of 19 allograft kidney biopsy specimens with viral nephropathy and 0 (0%) of 19 native or allograft biopsy specimens without viral nephropathy. Immunohistochemistry localized JCV to the nuclei of tubular epithelial cells in one case.
CONCLUSIONS: JCV is detectable in a subset of renal allograft kidneys with polyoma virus nephropathy. The tubular epithelium is identified as a site capable of supporting JCV viral capsid protein VP-1 expression, and hence viral replication.
Salmaggi A, Maccagnano E, Castagna A, et al. Reversal of CSF positivity for JC virus genome by cidofovir in a patient with systemic lupus erythromatosus and progressive multifocal leukoencephalopathy. Neurol Sci. 2001;(22):17-20.
We report the case of a 36-year-old woman affected by systemic lupus erythematosus who developed rapidly progressive multifocal leukoencephalopathy. Cidofovir therapy induced disappearance of JC virus genome from the cerebrospinal fluid and stabilization of the MRI picture. Despite the fatal outcome after a few months of disease, cidofovir treatment deserves further testing as a single antiviral therapy in HIV-negative PML patients.
Stolt A, Sasnauskas K, Koskela P, et al. Seroepidemiology of the human polyomaviruses. J Gen Virol. 2003;(84):1499-1504.
To assess the stability of polyomavirus antibodies in serial samples over time and the incidence and age-specific prevalence of polyomavirus infections, we established enzyme immunoassays (EIAs) using purified yeast-expressed virus-like particles (VLPs) containing the VP1 major capsid proteins of JC virus (JCV) and the AS and SB strains of BK virus (BKV). A random subsample of 150 Finnish women who had serum samples taken during the first trimester of pregnancy and had a second pregnancy during a 5 year follow-up period was selected, grouped by age of first pregnancy. The polyomavirus antibody levels were similar in samples taken during the first and second pregnancies (correlation coefficient 0?93 for BKV SB and 0?94 for JCV). Analysis of serum samples from 290 Swedish children aged 1–13 years, grouped by age in 2 year intervals, demonstrated that BKV seropositivity increased rapidly with increasing age of the children, reaching 98% seroprevalence at 7–9 years of age, followed by a minor decrease. JCV seroprevalence increased only slowly with increasing age and reaching 72% positivity among mothers>25 years of age. The age-specific seroprevalence of the human polyomaviruses measured using this VLPbased EIA was similar to previous serosurveys by other methods. The stability of the antibodies over time indicates that polyomavirus seropositivity is a valid marker of cumulative virus exposure, and polyoma VLP-based EIAs may therefore be useful for epidemiological studies of these viruses.
Van Assche G, Van Ranst M, Sciot R, et al. Progressive multifocal leukoencephalopathy after natalizumab therapy for Crohn’s disease. N Engl J Med. 2005;(353):1-7.
The prior diagnosis of fatal astrocytoma in a 60-year-old man with Crohn's disease treated with natalizumab, a monoclonal antibody against alpha4 integrins, was reclassified as JC virus-related progressive multifocal leukoencephalopathy (PML). Analysis of frozen serum samples showed that JC virus DNA had appeared in the serum three months after the initiation of open-label natalizumab monotherapy and two months before the appearance of symptomatic PML. There was staining of the brain lesion for polyomavirus. This case report, along with two others, suggests that anti-alpha4-integrin therapy can result in JC virus-induced PML. Copyright 2005 Massachusetts Medical Society.
Yousry TA, Habil M, Major EO, et al. Evaluation of patients treated with natalizumab for progressive multifocal leukoencephalopathy. N Engl J Med. 2006;(354):924-933.
BACKGROUND: Progressive multifocal leukoencephalopathy (PML) was reported to have developed in three patients treated with natalizumab. We conducted an evaluation to determine whether PML had developed in any other treated patients.
METHODS: We invited patients who had participated in clinical trials in which they received recent or long-term treatment with natalizumab for multiple sclerosis, Crohn's disease, or rheumatoid arthritis to participate. The clinical history, physical examination, brain magnetic resonance imaging (MRI), and testing of cerebrospinal fluid for JC virus DNA were used by an expert panel to evaluate patients for PML. We estimated the risk of PML in patients who completed at least a clinical examination for PML or had an MRI.
RESULTS: Of 3417 patients who had recently received natalizumab while participating in clinical trials, 3116 (91 percent) who were exposed to a mean of 17.9 monthly doses underwent evaluation for PML. Of these, 44 patients were referred to the expert panel because of clinical findings of possible PML, abnormalities on MRI, or a high plasma viral load of JC virus. No patient had detectable JC virus DNA in the cerebrospinal fluid. PML was ruled out in 43 of the 44 patients, but it could not be ruled out in one patient who had multiple sclerosis and progression of neurologic disease because data on cerebrospinal fluid testing and follow-up MRI were not available. Only the three previously reported cases of PML were confirmed (1.0 per 1000 treated patients; 95 percent confidence interval, 0.2 to 2.8 per 1000).
CONCLUSIONS: A detailed review of possible cases of PML in patients exposed to natalizumab found no new cases and suggested a risk of PML of roughly 1 in 1000 patients treated with natalizumab for a mean of 17.9 months. The risk associated with longer treatment is not known.
JCV is the etiologic agent of progressive multifocal leukoencephalopathy (PML), which is mainly seen in HIV patients, organ transplant patients, and other immunodeficient syndromes. In addition to PML, JCV also causes nephropathy in the renal transplant setting although with considerably less frequency than BK Virus. JCV should always be considered in an immunocompromised patient with progressively deteriorating CNS function. ViraCor’s quantitative JCV DNA PCR assay is used to detect JCV in CSF in the setting of CNS disease, and blood and urine in the setting of renal dysfunction. Quantitative DNA PCR can be used to track the course of infection as well as monitor response to treatment.