Jomotsangkha patient tests negative but leaves behind a mystery

On 8th May the Health Minister Dechen Wangmo in a press conference said that the Jomotsangkha case had tested positive six times for Immunoglobulin M (IgM) antibodies on the Rapid Test Kit (RDT) which either means an early infection or an early path to recovery.

She at the time explained that the body in reaction to the COVID-19 virus first develops the IgM antibodies for around the first three weeks and then the Immunoglobulin G (IgG) antibodies only come into play later and stays for a lifetime.

Lyonpo said he had tested negative two times on the RT-PCR indicating that while he had been exposed to the virus it is not present in his throat or nose and so he could not infect others.

She at the time also said that since he claimed he did not have a travel history he must have got exposed to the virus from within the community and since they don’t know who in the community gave it to him the whole community was locked down.

The minister also said that while there are chances of cross reactivity with other types of coronaviruses the IgM test is specific to COVID-19 and she said while cross reactivity can happen but ‘probably not for IgM.’

The minister had also said that there is no testing kit in the world that is 100 percent and she said that same kit is used by 30 other countries and that the MoH is in touch with the makers of the test kit.

She said the IgM test was repeated six times to rule out human error.

After the press conference the MoH in its official Facebook page on 8th May announced that the third RT-PCR test again tested negative and so with the confirmatory test coming out negative, the lockdown in Jomotsangkha would be lifted by the morning of 9th May.

The MoH release said that as per existing protocol of the ministry, the primary suspect will be kept under quarantine for an additional seven days.

This means that the patient as per the MoH should have been released by 15th May.

However, he was kept in quarantine till 20th May and was tested on 21st May for antibodies. A MoH official said he was kept on a 21-day quarantine and was not released after seven days as announced earlier.

Puzzlingly the test result came negative not only for IgM but also for IgG now.

The reporter took up this new development with the Health Minister asking on why the patient did not develop the longer term IgG antibodies after testing positive for IgM antibodies earlier.

The minister said, “It is not necessary that patients develop IgGs as in COVID-19 you really don’t know. Generally, you will have it and it will taper off but in our patients who are discharged they don’t even develop IgGs. There is no scientific literature at this point that this (IgG) will continue for sure. So IgG is not a pre-requisite.”

Lyonpo was then asked that a lot of international literature showed the developed of IgM followed by IgG antibodies.

Here Lyonpo said that they too looked at the international literature and the literature is not conclusive on IgG being developed after recovery from COVID-19 in all cases. “It may not follow the same trend,” said Lyonpo.

Lyonpo said, “For us the objective to put him to be in quarantine was to observe to see that he is not shedding. So that is the main reason.  So now we are quite confident with his IgM negative and IgG negative which means he is okay.”

Lyonpo said that again to say he does not have to have IgG, one really does not know as it is a new virus.

When asked if the person cured himself as he tested IgM positive six times at one point Lyonpo said, “We don’t know as he probably has to be studied as a separate case and then we can see.”

Lyonpo said, “It is a new virus, you don’t know its response. If we have a clear virus that we are dealing with say like the HIV Virus, then we know how HIV virus is going to behave, we know for definite what the incubation period is, we know definitely when it will shed and when IgM will develop and when IgG will develop. In this virus have to go by its pre-successors as MERs and SARs and how the virus will behave and we really don’t know if it will behave in the same way.”

The Jomotsangkha may not be the first anomaly when it comes to COVID-19 because in Bhutan’s second COVID-19 case in the form of the partner of the US tourist she tested positive only 28 days after her first contact with the index patient, 19 days after the patient came to Bhutan with her and showed clear symptoms and only on the 14th day of the quarantine. She had tested negative three times in quarantine before that.

The common international wisdom until then was that an infected patient would show symptoms or the virus within 14 days or less.

It was due to her case and certain international outlier cases that led to the government to finally extend the quarantine period from 14 days to 21 days.

Though Bhutan has only had 27 imported cases testing positive so far, the relatively unknown nature of the virus and its behavior means that the country has to be on its toes and be prepared for all kinds of anomalies.

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