Absolute CD4 Counts Research Articles

2272 A Case of Cryptococcal Hepatitis in HIV Patient With a Negative Serum Cryptococcal Antigen

INTRODUCTION: Infectious Cryptococcus neoformans occurs primarily in immunocompromised patients. The primary organ affected is the lungs, but CNS and skin involvement can also be seen. Disseminated Cryptococcosis can involve any organ in the body. However, hepatic involvement is rare. Here we offer a case of Cryptococcus hepatitis in a patient who presented with persistently elevated liver enzymes. CASE DESCRIPTION/METHODS: A 56-year-old Hispanic female with no known past medical history presented with fever, abdominal pain, nausea, unintentional weight loss, and diarrhea for two months. On physical examination, she was tachycardic with a heart rate of 110 bpm, and her abdomen was soft but tender to palpation in the right upper quadrant. Her liver function tests (LFTs) revealed elevated Aspartate Aminotransferase (AST) (415 U/L), elevated Alanine Aminotransferase (ALT) (201 U/L), elevated Alkaline Phosphatase (ALP) (763 U/L), normal total Bilirubin (0.9 mg/dl), and additional laboratory results in Table 1. Her HIV antigen screening was reactive, and absolute CD4 count was 22/ mcL. CT scan of the chest revealed two small calcified granulomas, for which she was started prophylactically on Azithromycin and TMP/SMZ. Over the course of her hospital stay, the patient's liver enzymes continued to trend upward while further workup ruled out hepatitis A, B, C, Wilson's disease, Hemochromatosis, AIH, PBC, PSC, other causes of viral hepatitis (CMV, EBV, HSV), with negative Histoplasma antibodies and negative serum Cryptococcal antigen titers. During the second week of hospitalization, her liver enzymes continued to rise with an ALP of 4046 U/L, AST of 407 U/L, and ALT of 276 U/L. With a persistent elevation of the liver enzymes without any definitive cause, an ultrasound-guided biopsy was warranted and performed. Pathology revealed Cryptococcal hepatitis (Figures 1 and 2), and the patient was started on a 15-day course of Amphotericin B with an 8-week course of Fluconazole 400 mg with LFTs nearly normalizing at 6 weeks. DISCUSSION: This case demonstrates an unusual manifestation of Cryptococcosis. Our patient did not present with the typical Cryptococcal pulmonary or central nervous system infection. As well, our patient's serum Cryptococcal antigen titers were negative, but biopsy results revealed Cryptococcal hepatitis, despite a very high sensitivity and specificity of the serum Cryptococcal antigen test. This case demonstrates the importance of maintaining a broad differential, specifically in immunocompromised patients.

P591Insights from Exercise Cardiac Magnetic Resonance Imaging (ExMR) With Cardiopulmonary Testing in HIV Patients

Abstract Background Cardiac magnetic resonance imaging in conjunction with exercise (exMR) and cardiopulmonary testing (CPET) to evaluate cardiopulmonary function has the potential of uncovering poorly understood mechanisms of dyspnea in patients that cannot be otherwise discerned with a single imaging modality. Purpose We prospectively evaluated the value of this technique in dyspneic patients with HIV without obvious cardiopulmonary etiologies to comprehensively assess mechanisms of dyspnea. Methods Thirty-six HIV patients with dyspnea without obvious cardiopulmonary causes [normal chest x-ray, normal resting LVEF and resting pulmonary artery (PA) pressures <40 mm Hg on echo] and exercise limitation [Modified Medical Research Council (MMRC) dyspnea scale >2] underwent testing using a novel combined exMR/CPET platform (Figure 1). Resting and exercise magnetic resonance imaging (MRI), including flow velocities across the pulmonary artery together with CPET was evaluated at pre and post peak stress. We analyzed the correlation between CPET and MRI pre and peak exercise variables. Results The mean age was 51 years; 60% were male; and mean absolute CD4 count was 718. Ventilator efficiency at peak exercise (Peak VO2) did not correlate with exMR parameters. Peak VE/VCO2 was negatively associated with peak LV and RV stroke volume (p values 0.002 & 0.005 respectively). There was a positive relationship between peak petCO2and LV cardiac output (p=0.02), peak exercise RV stroke volume (p=0.003), peak exercise LV stroke volume (p=0.02). Absolute CD4 count was positively correlated with post exercise pulmonary artery velocity (p=0.045). We found no correlation between absolute CD8 count and CMR and CPET exercise parameters. Figure 1. MRI-CPET setting Conclusion HIV patients appear to have an impairment of ventilatory efficiency, exemplified by the association of VE/VCO2and PetCO2 with exMR parameters in the context of normal RV/LV contractile reserve and no evidence of Pulmonary arterial hypertension. A combined CPET/exMRI platform may provide new insight into cardiopulmonary function and the factors influencing exercise tolerance in symptomatic HIV patients. Acknowledgement/Funding 7R01HL125060-03

1872 Mycobacterium Avium Complex Colitis in a Patient With AIDS

INTRODUCTION: Disseminated mycobacterium avium complex (MAC) is an uncommon diagnosis with the advent of highly active anti-retroviral therapy (HAART). The International Antiviral Society-USA Panel and the US Department of Health and Human services recently changed their guidelines recommending against routine MAC prophylaxis in patients on HAART. Gastrointestinal manifestations of MAC typically result in diarrhea, fever, weight loss, and abdominal pain. The diagnosis is clinically challenging as radiographic findings are non-specific and cultures can be negative for up to 2 weeks. Upper endoscopy with biopsy is required to make the diagnosis. We present a rare case of MAC colitis in a patient with AIDS with only focal subtle endoscopic changes. CASE DESCRIPTION/METHODS: A 31-year-old male was admitted for fevers, chills, diarrhea and rectal pain for 1 week. The patient was diagnosed with HIV 1 year prior and declined HAART. On admission, the patient had a benign abdominal exam with tender inguinal lymphadenopathy. Computed tomography (CT) of the abdomen/pelvis without contrast demonstrated subtle wall thickening in the rectosigmoid consistent with proctocolitis. His absolute CD4 count was 38 cells/uL, unfortunately an HIV viral load was not checked. Stool culture with shiga toxin, clostridioides difficile, coccidioides, stool giardia/ova and parasites/cryptosporidium were negative. Cytomegalovirus (CMV) serum PCR was positive at 15,400 IU/mL. Colonoscopy showed normal mucosa throughout the colon and terminal ileum, except for a single, subtle, erosion of the rectum 2 mm in length. Biopsies taken of the solitary erosion were notable for acid fast bacilli concerning for intestinal MAC, CMV was negative. An interferon gamma release study was indeterminate. The patient was discharged on therapy for CMV viremia. DISCUSSION: The incidence of disseminated mycobacterium avium infection has decreased to 2 cases per 1000 person-years with the use of HAART. However, the risk of infection increases with high HIV viral loads >1000 copies/mL, previous or concurrent opportunistic infections, and CD4 count <50 cells/uL. Gastrointestinal MAC is rare, and when identified is most commonly found in the small bowel. Endoscopically, this is associated with granular, erythematous mucosa with ulcerations. Identification of the pathogen can be difficult unless direct biopsies of suspicious lesions are obtained on endoscopy.

Reduced CD4+ terminally differentiated effector memory T cells in moderate-severe house dust mites sensitized allergic rhinitis patients.

Terminally differentiated effector memory (TEMRA) T cells exert potent effector function after activation. The proportions of CD4+ T cell subsets especially memory cells in allergic rhinitis (AR) patients sensitized to house dust mites (HDMs) have not been extensively studied. This study aimed to compare the mean percentages and absolute counts of CD4+ memory T cell subsets between: (i) non-allergic controls and AR patients; (ii) mild AR patients and moderate-severe AR patients. Sensitization to Dermatophagoides farinae and Dermatophagoides pteronyssinus were determined in 33 non -allergic controls, 28 mild AR and 29 moderate-severe AR patients. Flow cytometry was used to determine the percentage of CD4+ na?ve (TN; CD45RA+CCR7+), central memory (TCM; CD45RA-CCR7+), effector memory (TEM; CD45RA-CCR7-) and TEMRA (CD45RA+CCR7-) T cells from the peripheral blood. The absolute counts of CD4+ T cell subsets were obtained by dual platform method from flow cytometer and hematology analyzer. There were no significant differences in the mean percentages and absolute counts of CD4+ T cell subsets between non-allergic controls and AR patients sensitized to HDMs. However, there were significant reduction in the mean percentage (p=0.0307) and absolute count (p=0.0309) of CD4+ TEMRA cells in moderate-severe AR patients compared to mild AR patients sensitized to HDMs and 13/24 (54.2%) moderate-severe AR patients sensitized to HDMs had persistent symptoms. Reduction in the mean percentage and absolute count of CD4+CD45RA+CCR7- TEMRA cells were observed in moderate-severe AR patients compared to mild AR patients in our population of AR patients sensitized to HDMs.

CTLA-4 Expression Inversely Correlates with Kidney Function and Serum Immunoglobulin Concentration in Patients with Primary Glomerulonephritides

Major causes of chronic kidney disease are primary proliferative and nonproliferative glomerulonephritides (PGN and NPGN). However, the pathogenesis of PGN and NPGN is still not fully understood. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) is a T-cell membrane receptor that plays a key role in T-cell inhibition. Despite its role in autoimmunological diseases, little is known about the involvement of CTLA-4 in the pathogenesis of PGN and NPGN. The objective of this study was to determine the role of CTLA-4 in the pathogenesis of PGN and NPGN by evaluating the frequencies of T and B lymphocytes expressing CTLA-4 and the serum concentration of the sCTLA-4 isoform in patients with PGN and NPGN in relation to clinical parameters. The study included peripheral blood (PB) samples from 40 PGN and NPGN patients and 20 healthy age- and sex-matched volunteers (control group). The viable PB lymphocytes were labeled with fluorochrome-conjugated monoclonal anti-CTLA-4 antibodies and analyzed using flow cytometry. The serum concentration of sCTLA-4 was measured using ELISA. The frequencies and absolute counts of CD4+/CTLA-4+ T lymphocytes, CD8+/CTLA-4+ T lymphocytes and CD19+/CTLA-4+ B lymphocytes and the serum sCTLA-4 concentration were lower in PGN and NPGN patients that in the control group. Reduced sCTLA-4 expression was associated with a lower concentration of serum immunoglobulins. Our results indicate that deregulation of CTLA-4 expression may result in continuous activation of T cells and contribute to the pathogenesis of PGN and NPGN.

Value of absolute counts of lymphocyte subsets in the early prediction of refractory Mycoplasma pneumoniae pneumonia in children

To study the value of absolute counts of lymphocyte subsets in the early prediction of refractory Mycoplasma pneumoniae pneumonia (RMPP) in children. A retrospective analysis was performed for the clinical data of 244 children with Mycoplasma pneumoniae pneumonia (MPP). Among these children, 166 had MPP, and 58 had RMPP. The two groups were compared in terms of clinical features and laboratory markers such as lymphocyte subsets, lactate dehydrogenase, C-reactive protein, procalcitonin and immunoglobulin E (IgE). The receiver operating characteristic (ROC) curve was used to evaluate the specific indices for predicting RMMP. There were significant differences between the two groups in the absolute counts of CD3+, CD4+, CD19+, and CD56+ lymphocytes and the serum levels of lactate dehydrogenase, C-reactive protein, and IgE (P<0.05). The ROC curve analysis showed that the absolute counts of CD3+, CD4+ and CD19+ lymphocytes had an area under the ROC curve (AUC) of 0.866, 0.900 and 0.842 respectively in the differential diagnosis of RMPP and MPP, with a sensitivity of 86%, 90% and 82% respectively and a specificity of 75%, 70% and 80% respectively. The absolute counts of CD3+, CD4+ and CD19+ lymphocytes can be used to predict RMPP in children.

PS1187 ASSOCIATION OF CELLULAR IMMUNITY WITH MOLECULAR RESPONSE IN CHRONIC MYELOID LEUKEMIA PATIENTS ON TYROSINE KINASE INHIBITORS THERAPY

Background:Chronic myeloid leukemia (CML) is considered to be one of the cancers most sensitive to immunological manipulation. The most recent goal in CML treatment tyrosine kinase inhibitors (TKIs) is to induce a durable deep molecular response (DMR; BCR‐ABL1 ≤ 0.01%) as a prelude to successful treatment‐free remission. The lack of overt relapse in such pts has been attributed to immunological control of CML, although its precise mechanisms are as yet unclear.Aims:The aim of the study was to assess the relative (%) and absolute counts (AC) of major lymphocytic populations in correlation with the molecular response in a large series of patients with CML on TKI therapy.Methods:A total of 171 consecutive patients with CML treated with TKIs were enrolled in the study ‐ 91 men and 80 women. Immunophenotypic analysis of major T/B/NK cell populations was performed by flow cytometry at diagnosis and in the course of the disease in parallel with the monitoring of the molecular response (MR) by quantitative PCR analysis using GeneXpert fully automated platform (n = 523 tests).Results:At diagnosis, significant lymphocytosis was detected in all CML pts (mean 8.7 ± 4.4 x109/l), due to higher % and AC of T‐cells (mean 79.4% ± 11.6%; 7.1 ± 4.2 x109/l) with normal CD4:CD8 ratio (Th:Tc). The AC of NK and CD19+ B‐cells were within or close to the reference ranges. After therapy was given, all lymphocytic populations demonstrated a decrease of AC. However, significant differences in major lymphocytic populations were observed between pts with hematological response to TKIs who had never achieved MR compared to those with DMR in terms of higher mean values of WBC counts (p = 0.009); % and AC of CD3+ T‐cells (mean 68.4% ± 11.9% vs 67.3% ± 11.7%; mean 1.6 ± 8.3x109/l vs 1.4 ± 5.5 x109/l, p = 0.000); % and AC of CD8+ T‐cells (mean 24.8% ± 8.0% vs 22.1% ± 7.3%; mean 0.6 ± 0.4x109/l vs 0.4 ± 0.2x109/l, p = 0.000) resulting in lower Th:Tc. Further, within the group of MR4.5log/MR5log, pts with undetectable BCR‐ABL1 transcripts demonstrated lower % of CD8+ T‐cells compared to BCR‐ABL1 positive cases (mean 20.9% ± 6.7% vs 23.2 ± 7.4%, p = 0.011). Pts with optimal MR according to ELN criteria were characterized with lower % of CD8+ (mean 22.4% ± 7.2% vs 26.1 ± 9.2%, p = 0.000) and CD3+ (mean 72.1% ± 12.6% vs 76.4% ± 11.5%, p = 0.001) T‐cells; higher % of CD19+ B‐cells (mean 11.8 ± 6.1% vs 8.8 ± 4.8%, p = 0.000) and Th:Tc ratio (p = 0.006).Summary/Conclusion:Our data demonstrated dynamics in lymphocyte counts with treatment of CML patients as well as the differences in the lymphocytic populations, and clearly in the cytotoxic cells, depending on the depth of the therapeutic response achieved, thus supporting the idea that, in addition to the specific inhibition of the hybrid BCR‐ABL oncoprotein by TKIs in CML pts, the cellular immunity may further play role in disease control.

The relationship between zidovudine, lamivudine and nevirapine plasma drug levels and antiretroviral treatment outcomes in Nigeria children living with HIV

Plasma concentrations of antiretrovirals are significant and important determinants of treatment failure and toxicity. The relationship between antiretroviral pharmacokinetic exposures and immunovirological outcomes has not been extensively studied in our setting. The aim of this study was to investigate the relationship between antiretroviral plasma concentrations and virological and immunological treatment outcomes in children living with human immunodeficiency virus (HIV) A retrospective collection of demographic, clinical , laboratory data and a prospective determination of plasma drug concentrations in 120 children aged 2-14 years after two years of receiving fixed dose zidovudine, lamivudine and nevirapine tablets using a simple, rapid, sensitive and validated method of high performance liquid chromatography with UV detection for simultaneous quantification of zidovudine, lamivudine and nevirapine in human plasma. All analyses were performed using graph pad prism version 5.0. A perfect agreement (p 100 cells/mm3). At 2 years zidovudine, lamivudine and nevirapine therapeutic levels, zidovudine supra therapeutic levels ,and nevirapine subtherapeutic levels were respectively significantly associated with immunologic success (CD4%>15 %). Low nevirapine levels can be used to identify those that require adherence counseling. Despite good virological and immunological outcomes, plasma concentrations of zidovudine, lamivudine and nevirapine were not significantly associated with virological and immunological outcomes (Absolute CD4 counts) but was significantly associated with immunological outcomes (CD4%). Plasma drug levels may be good surrogates of adherence but not of treatment outcomes. Monitoring CD4% remains important to optimize paediatric HIV treatment.Keywords: Antiretroviral treatment, children, therapeutic drug monitoring, treatment outcomes, immune-virological outcomes, plasma concentrations, zidovudine, lamivudine and nevirapine

T memory stem cells after allogeneic haematopoietic cell transplantation: unique long‐term kinetics and influence of chronic graft‐versus‐host disease

T memory stem cells (TSCMs) are a subset of primitive T cells capable of both self-renewal and differentiation into all subsets of memory and effector T cells. Therefore, TSCMs may play a role in immune reconstitution and graft-versus-host disease (GVHD) in patients receiving allogeneic haematopoietic cell transplantation (HCT). We conducted a cross-sectional study to evaluate the proportions, absolute counts, phenotypes and functions of TSCMs in 152 adult patients without disease recurrence at least 12months after undergoing HCT. CD4+ TSCMs were negatively correlated with number of months after transplantation in HCT patients that received cord blood transplantation, but not in patients that received bone marrow transplantation or peripheral blood stem cell transplantation. The proportions and absolute counts of CD4+ TSCMs and expression levels of inducible co-stimulator (ICOS) in CD8+ TSCMs were significantly higher in patients with mild and moderate/severe cGVHD compared to patients without cGVHD. These data suggested that, more than 12months after allogeneic HCT, the kinetics of CD4+ TSCMs were dependent on the type of donor source, and further that CD4+ TSCMs and ICOS levels in CD8+ TSCMs were associated with cGVHD.

Modulating effect of a new ester, 28-O-phosphatidylbetulin (DAPB), obtained from hen egg yolk lecithin and betulin on lymphocyte subsets and humoral immune response in mice

Context: Leaf extracts of plants of the genus Betula have traditionally been used as diuretic, anti-rheumatic and diaphoretic preparations. One of the main active ingredients of Betula bark is betulin, lupane-type triterpene alcohol, with multiple biological activities.Objectives: The aim of this study was to investigate in vitro and in vivo immunomodulatory effects of a newly synthesized ester of betulin: 28-O-phosphatidylbetulin [28-O-(1,2-diacyl-sn-glycero-3-phospho)-betulin, DAPB] in comparison with betulin in mice.Materials and methods: Cytotoxic activity of DAPB or betulin was tested against non-cancer (D10.G4.1 and J774E.1) and cancer (GL-1; CL-1 and Jurkat) cell lines. The in vivo part assessed total lymphocyte count, weight ratio and subsets of lymphocytes in the lymphatic organs, and humoral immune response to sheep erythrocytes (SRBC).Results: In vitro assay showed that DAPB, contrary to betulin, had no antiproliferative activity. Exposure to four doses of DAPB increased the absolute count of immature CD4+CD8+ thymic cells as well as the percentage and absolute count of mature CD4+ and CD8+ thymocytes. DAPB enhanced the percentage or absolute count of CD3+ cells in spleen and lymph nodes with corresponding decrease in the percentage and/or absolute count of CD19+ cells. Both DAPB and betulin enhanced the percentage and absolute count of CD8+ lymphocytes in lymph nodes. In SRBC-immunized mice, betulin contrary to DAPB enhanced the number of splenocytes producing anti-SRBC antibodies (PFC). Both DAPB and betulin increased the level of total (IgM + IgG) and IgG titers.Conclusion: Despite the lack of cytotoxic activity, DAPB shows valuable immunomodulatory properties.

LIG4 syndrome: a report of four cases and literature review

Objective: To analyze clinical, immunological and genetic characteristics of 4 cases of LIG4 syndrome. Methods: We retrospectively analyzed the clinical data of 4 patients from 3 families with LIG4 syndrome who were admitted to Children's Hospital of the Capital Institute of Pediatrics from June 2017 to May 2018, and reviewed related articles, the clinical, immunological and genetic characteristics of LIG4 syndrome were summarized and analyzed. Results: Those 4 cases (P1 to P4), including 2 males and 2 females, had an average age of 1.5 years. All of them presented with special facial features, such as microcephaly, beak-like-nose, and receding forehead. Three of them presented with delayed physical development. P3 suffered from mental retardation and P4 had feeding difficulty. BCG scars were repeatedly ruptured in 3 cases, 4 cases had pneumonia, 1 case had EB virus infection, 2 cases had cytomegalovirus infection, 1 case had fungal infection, and 1 case had chronic diarrhea. Blood routine tests showed decreased neutrophil and lymphocyte counts. Immunoassay showed decreased absolute count of CD4(+)T lymphocyte and B lymphocyte, with normal CD8(+)T cells. P1, P2 presented with decreased immunoglobulin. All of those patients had LIG4 gene complex heterozygous mutations, of whom one had missense mutation had mild clinical phenotype and another three cases had frameshift mutation presented with severe clinical phenotype. One patient underwent hematopoietic stem cell transplantation, and has established normal immune function. He did not have recurrent infection during one year follow-up period. The other 3 patients had preventive anti-infection treatment and received regular human immunoglobulin infusion, but they still had recurrent infection. In literature review, 67 articles were retrieved, totally 37 case were reported, showing special faces and recurrent infection as characteristic presentation of this disease. Conclusions: The typical manifestations of LIG4 syndrome are microcephaly, special facial features and repeated infection. The average age at diagnosis of LIG4 syndrome was more than one year old. If a patient presented with microcephaly, BCG scar infection and leukopenia, LIG4 syndrome should be considered. Immunoglobulin is decreased at different degrees, and CD4(+) and CD19(+) lymphocyte counts always decrease, Naive T and B cells decrease more prominently, and CD8(+)T cells were normal in patients with typical LIG4 syndrome. It is effective to reconstruction of immune system with bone marrow transplantation in LIG4 syndrome patients.

Reduced Natural Killer Cell Subsets in Perinatally Acquired Long-Term Non-Progressor Human Immunodeficiency Virus-Infected Children.

Lymphocyte subsets of long-term non-progressor (LPNT) HIV-infected children is a less studied aspect of HIV infection. Evaluation of different lymphocyte subsets was done in HIV-infected children ≥8 years of age. Subjects were divided in two groups-group 1 (LTNP), treatment-naive with CD4 ≥ 500 cells/μL (n = 20); group 2, non-long-term non-progressor (nLTNPs) receiving antiretroviral therapy (ART) with CD4 count ≤500 on at least one occasion (n = 21). Group 3 comprised age-, sex-matched healthy controls (HCs, n = 20). Lymphocyte subsets were acquired with a flow cytometer (Navios; Beckman Coulter), and data were analyzed using Kaluza flow analysis software. The mean ages were 12.1 (±2.4 SD) and 12.5 (±2.7) years with mean duration of follow-up of 6.8 (±3.4) and 5.6 (±1.95) years in LTNP and nLTNP subjects, respectively. The mean duration of ART was 5.17 years for group 2. Absolute count and percentage of CD4+ T cells was lower in nLTNPs than in LTNPs. Cytotoxic T cells were high in both HIV-infected groups compared with HCs. Natural killer (NK) cells were found to be significantly lower in LTNP and nLTNP groups compared with HCs (p ≤ .000003 and p ≤ .00003, respectively). Naïve B cells were more in HIV-infected individuals than in HCs. NK cells were significantly lower in LTNP and nLTNP groups. Immune reconstitution was comparable in children initiated with ART early versus long-term HIV-infected children receiving no ART.

Safety and Efficacy of Donor Leukocyte Infusion for Single Unit Umbilical Cord Blood Transplantation to Accelerate Immune Reconstitution Prior to Thymopoiesis

Success of reduced intensity umbilical cord blood transplantation (UCBT) in chemotherapy naive patients is limited by an increased risk of mixed chimerism, infection, and delayed immune reconstitution (IR). In a prospective clinical trial, we utilized risk-adapted alemtuzumab dosing, tested the safety of donor leukocyte infusion (cDLI) from a fraction of the thawed graft and evaluated it's efficacy in impacting IR, viral infection, and/or donor chimerism. Patients with inborn errors of metabolism, immunity, or hematopoiesis underwent a single unit UCBT following a reduced-intensity conditioning regimen of alemtuzumab, hydroxyurea, fludarabine, melphalan, and thiotepa (ClinicalTrials.gov: NCT00744692). Up to 5% of the graft was re-cryopreserved for potential cDLI and administered in cases of declining donor Tcell chimerism, viral infection, or delayed IR. Alemtuzumab levels were obtained on the day of UCBT. Chimerism and IR were measured at standard time points. 33 patients had cDLI stored and 18 patients received cDLI at a median of 65 days post-UCBT. Indications included mixed whole blood or CD3 chimerism, viral infection, or delayed IR. All patients engrafted with neutrophils at a median of 15 days post-UCBT, however, one patient experienced secondary graft failure at day +38, despite cDLI 28 days post-UCBT. Improvement in chimerism was seen in 5 of 9 patients, viral load and/or symptoms of infection in 5 of 9 patients and absolute CD3 count in 5 of 5 patients. 15 patients developed acute grade I-III GVHD at a median of 69 days post-UCBT. In those who received cDLI, 8 developed grade I-II skin GVHD at a median of 19 days post-cDLI. 2 patients with a history of GVHD received subsequent cDLI without GVHD flare. No patients who received cDLI developed grade III or IV acute or extensive chronic GVHD, while 4 patients who did not receive cDLI developed grade III GVHD affecting skin and/or the gastrointestinal tract. There was no difference in the cumulative incidence of acute GVHD between those who received cDLI and those who did not (44% vs. 33%; p=0.81). The 3-year overall and event-free survival of all patients was 94% and 91% respectively, with treatment-related mortality (TRM) of 5% 1 year post-UCBT. We report outcomes on the largest prospective trial utilizing cord blood grafts for nonmalignant disease. cDLI is safe in patients undergoing single-unit UCBT as all engrafted. Greater than half of the patients had improvement in the primary indication for its use, without increased GVHD risk. Greatest benefit was seen in patients with delayed IR and TRM at 1 year was exceptionally low. In sum, cDLI may be a simple and effective way to address mixed chimerism, infection, and accelerate IR during the vulnerable time prior to the onset of thymopoiesis. Further characterization of the merits of cDLI should be explored in a larger clinical trial.

Delayed Immune Reconstitution and Increased Viral Infections Following Haploidentical BMT with Post-Transplant Cyclophosphamide for Sickle Cell Disease: Results of a Haploidentical Transplant Consortium for Hemoglobinopathies (ICHH)

Introduction Haploidentical bone marrow transplant (haplo-BMT) with post-transplant cyclophosphamide (PTCy) has increased curative options for patients with sickle cell disease (SCD), with near universal donor availability. However, this approach is associated with increased risk of graft failure, delayed engraftment, and early viral reactivation. Limited knowledge exists regarding immune reconstitution (IR) following haplo-BMT. We hypothesized that the immunomodulatory properties of the pre-transplant conditioning and PTCy contribute to increased early infectious risk and late effects. Objective To characterize IR and impact on infection and late effects post haplo-BMT for SCD. Methods We examined clinical outcomes and IR in 23 patients with severe SCD who received haplo-BMT in the context of a collaborative consortium involving three centers (France, London, U.S.). Common conditioning included fludarabine 150 mg/m2 total, cyclophosphamide 14.5 mg/kg x2, thiotepa 10 mg/kg x1, and thymoglobulin 4.5 mg/kg total, and total body irradiation 200 cGy x1. 18/23 received pre-conditioning with azathioprine 3 mg/kg/day, hydroxyurea 30 mg/kg/day, and hyper-transfusion. Graft source was bone marrow, and 20/23 donors were mobilized with filgrastim 10 mcg/kg/day x 5 days. PTCy (50 mg/kg/day x2), MMF, and sirolimus were given for GvHD prophylaxis. Cellular subsets analyzed included CD4, CD8, NK, and B cells. Patients deceased or without IR data were excluded. Results Table 1 shows patient and donor characteristics. Median total nucleated and CD34 cell doses were 4.9 × 10(9)/kg and 4.69 × 10(6)/kg, respectively. Among engrafted patients, those who received preconditioning had delayed platelet recovery (mean 35 days vs 27, p = 0.002), but higher median CD4 absolute cell count (cells/mL) at D+30 (43 vs 41), D+60 (190 vs 98), D+90 (229 vs 191), D+180 (304 vs 308), D+360 (1255 vs 394) compared to those without, respectively. While not statistically significant either, similar patterns were seen for CD8 and CD19 cells. Post-transplant infections were mostly viral, and occurred in the majority of patients 69.6% (16/23), Figure 2. Conclusion Delayed early IR and viral reactivation/infections were observed following haplo-BMT with PTCy for SCD. Further prospective studies are needed to better characterize IR following this approach to optimize immune-prophylaxis.

Correlation of Absolute Lymphocyte Count and CD4 Counts in HIV Infected Patients at a Tertiary Care Institute

Correlation of Absolute Lymphocyte Count and CD4 Counts in HIV Infected Patients at a Tertiary Care Institute

Sociodemographic Characteristics, Hematological Parameters and Absolute CD4 Counts of Healthy Blood Donors at Two Teaching Hospitals in Nigeria

Introduction: This observational study was undertaken to assess hematological parameters and the efficacy of screening methods in healthy subjects eligible for blood donation at the University of Abuja Teaching Hospital (UATH), Abuja Nigeria and Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria. Methods: Two hundred and twelve (212) healthy subjects from the two hospitals (NAUTH-104, UATH-108) were tested for hematological parameters and absolute CD4 cell count using Sysmex auto-hematology analyzer and Partec Cyflow counter respectively. Sociodemographic data were collected using a questionnaire and ABO blood group testing was performed. Descriptive and inferential statistics were used to analyze the data obtained. Results: The mean red blood cells, hematocrit, hemoglobin, white blood cells, CD4, and platelet count of the blood donor samples at UATH and NAUTH were within acceptable reference ranges except for hemoglobin values that showed a statistically significant decrease (p<0.05). Of 212 subjects tested, 40 (18.9%), 51 (24.1%), 24 (11.3%), 64 (30.2%), 16 (7.5%) and 22 (10.4%) had abnormally low values for red blood cells, white blood cells, hematocrit, hemoglobin, CD4 and platelets count respectively. Sociodemographic data showed that most blood donors were males, and belonged to O positive blood group, with a median age of 33 years old, and were students and traders. Conclusion: We found that hematocrit (HCT) alone as a screening value has clear limits. Moreover, our study demonstrated other blood cells were low in this healthy population. Therefore, routine screening of prospective blood donors should be expanded to other hematological parameters.

Donor Leukocyte Infusion for Single Unit Umbilical Cord Blood Transplantation: 5% of Thawed Single Cord Blood Unit Refrozen on Day of Transplant Is Safe with Signals of Efficacy in Improving Donor Derived Immunity

Introduction:Success of umbilical cord blood transplantation (UCBT) is limited by an increased risk of graft rejection, mixed chimerism, infection, and delayed immune reconstitution. Additionally, strategies such as donor lymphocyte infusion (DLI) to improve declining donor chimerism or augment immune reconstitution are extremely limited in UCBT. We hypothesized that removing and storing a portion of the thawed cord blood graft for future use as a cord DLI (cDLI) could be used to improve mixed chimerism or augment immunity without adverse impact on engraftment or graft versus host disease (GVHD).Methods:Patients with inborn errors of metabolism, immunity, or hematopoiesis underwent a single unit UCBT following a reduced-intensity conditioning regimen of alemtuzumab, hydroxyurea, fludarabine, melphalan, and thiotepa (ClinicalTrials.gov: NCT00744692) with a thaw and dilute (no wash) methodology. Up to 5% of the cord blood graft was removed from the thawed graft and re-cryopreserved for potential cDLI. The cDLI was infused at the discretion of the treating physician in discussion with the study PI (P.S.) in cases of mixed or declining donor chimerism, viral infection, or delayed immune reconstitution.Results:A total of 33 patients had cells cryopreserved prior to UCBT for potential cDLI. The characteristics of these patients are shown in Table 1. A total of 18 patients received cDLI at a median of 65 days (range 14-124) post-UCBT. The median cell dose of the cDLI was 8.46e+05 CD3/kg and 1.53e+04 CD34/kg. The indication for cDLI was mixed whole blood or CD3 chimerism (n=9), viral infection (n=9), and delayed immune reconstitution (n=5); 5 patients had more than one indication for cDLI, most commonly infection with delayed immune reconstitution (n=4).All patients engrafted with neutrophils at a median of 15 days post-transplant (range: 10-31 days); however, one patient experienced secondary graft failure at day 38 post-transplant despite cDLI at day 28 post-transplant. Improvement in chimerism was seen in 5 of 9 patients, viral load and/or clinical symptoms of viral infection in 5 of 9 patients (including gastroenteritis due to rotavirus (n=1) or adenovirus (n=1)), and absolute CD3 count in 5 of 5 patients (Figure).A total of 15 patients (45%) developed acute grade I-III GVHD at a median of 69 days (range: 13-95 days) post-UCBT. In the group of patients who received cDLI, 8 developed grade I-II skin GVHD at a median of 19 days (range 4-81 days) post-cDLI. In addition, 2 patients with a history of GVHD received subsequent cDLI without GVHD flare post-cDLI and were analyzed for progression post-cDLI. No patients who received cDLI developed grade III or IV acute GVHD or extensive chronic GVHD, while 4 patients who did not receive cDLI developed grade III GVHD affecting skin and/or the gastrointestinal tract. There was no difference in the cumulative incidence of acute GVHD between those who received cDLI and those who did not (44% and 33%, respectively; p=0.81; Figure). The 3-year overall and event-free survival of the entire group was 94% and 91% respectively (Figure), with treatment-related mortality of 6% at 1 year post-transplant.Conclusions:The use of cDLI is safe in patients undergoing single-unit UCBT. Despite the removal of a small portion of the cord blood graft for cDLI, all patients engrafted with neutrophils and no increased morbidity was seen. In addition, although the sample size is small, over half of the patients who received cDLI had improvement in the primary indication (chimerism, viral infection, or immune reconstitution) for cDLI, with the most benefit seen in patients receiving cDLI for delayed immune reconstitution, as evidenced by both clinical improvement in infectious symptoms and increases in absolute CD3 count. This suggests that cDLI may be an effective way to address mixed chimerism, infection, and particularly, delayed immune reconstitution and should be explored in a larger clinical trial. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

598. Choosing Wisely with CD4 Counts: When Less Is More

BackgroundThe HIVMA and Choosing Wisely campaign recommend using a simple lymphocyte panel for monitoring CD4 counts of patients with HIV. This panel shows CD4 absolute and percentage counts only. Complex lymphocyte panels, which are more comprehensive and expensive, often do not offer more clinically valuable information. Increasing the rate of simple panel utilization can significantly save costs for the healthcare system without compromising care.MethodsA before-and-after study was conducted in two community-based teaching hospitals with total capacity of 418 inpatient beds, and an outpatient HIV/AIDS center. All panels ordered from March 2016 to March 2018 were included in the study. Intervention started in November 2017. Simple panel was shown as the default test when CD4 test was ordered in the electronic health record while complex panels were eventually phased out. Panels ordered before and after the intervention were counted, and proportions compared. Costs were computed based on 2017 Medicare reimbursement rates.ResultsA total of 1,701 panels were done in the study period. 1,401 were ordered pre-intervention (20 months) while 300 were post-intervention (5 months). Complex panels represented 99% (n = 1,398) of tests ordered pre-intervention. The average cost of each test was $167.67. The healthcare system lost ~$183,051 due to added expense of complex panels during this period. In the post-intervention period, proportion of complex panels fell by 85% (95% CI 80.57–88.5, P < 0.0001). Average cost per test post-intervention lowered to $55.54. The mean difference was $112.13 and was statistically significant (95% CI 107.78–116.47; P < 0.0001). The percentage of simple panels consistently increased month-per-month post-intervention. In the last month of the study period, 100% of orders were simple panels (Figure 1). ConclusionUse of complex panels for monitoring CD4 count caused unnecessary expenses and resulted in significant losses for the healthcare system. An efficient and effective intervention to increase the use of simple panels was to implement an opt-out policy. Simple panels were set as the default test unless the provider specified otherwise. The intervention is projected to save ~$98,761 in 2018.Disclosures All authors: No reported disclosures.

Determination of CD4+ T- Lymphocytes in Healthy Children of Kathmandu

The cluster differentiation (CD) of T-cell is the good marker for the immunological competence study. Nepal does not have a reference value for CD4+ T cell count and percentage for children, which severely limits the prospect of pediatric prognosis. This cross-sectional study was conducted in Kathmandu valley where total 207 children of age 0-14 year age group were recruited in this study. We analyzed 50 cord blood and 157 peripheral blood samples in order to calculate the absolute count of CD4+ T lymphocyte using Fluorescence-activated cell sorting methodology. The reference range for absolute CD4+ T cell count was found to be 634-4040 cells/µL(mean1470; median: 1335 and 95% CI [1322-1617]) for male children and 491-2922 cells/µL (mean: 1443 median: 1326 and95% CI [1298-1588]) for the female children.We also observed elevated CD4 to the CD3 ratio in younger children (0.67 from cord blood Vs 0.53 from 10-14yr) compared to older ones. The observed CD4+ T cell counts among healthy children of Kathmandu highlights the gender differences skewed for male as well the need of defining specific reference values for other lymphocyte subsets as well in a country like Nepal which has a population with diverse genetic and socio-cultural parameters.

INTERFERON GAMMA RECEPTOR 1 DEFICIENCY (IFNGR1) WITH NEGATIVE QUANTIFERON GOLD AND ELEVATED C-REACTIVE PROTEIN

Introduction Defects in IFNGR1 leads to Mendelian Susceptibility to Mycobacterial Disease. The extent of reduction of IFNGR1 determines the phenotype of disease expression. Mutations occurring in Autosomal Dominant IFNGR1 deficiency lead to non-functional receptors on cell surfaces which fail to transduce IFNG signals. These patients are older than those with Autosomal Recessive complete IFGR1 deficiency, with later onset, less severe mycobacteria infections but high prevalence (79%) of non-tuberculous mycobacterial (NTM) osteomyelitis. Case Description A 30-year old male from United Arab Emirates presented with recurrent atypical mycobacteria infections for over 20 years, having multiple courses of anti-TB therapy. Therapy with IFNG from 2009 to 2011 was discontinued due to adverse effects. Gene sequencing identified a pathogenic variant in the IFNGR1 gene in a heterozygous state at c.819_822del p.(Asn274Hisfs*2) creating a shift in the reading frame starting at codon 274, with the new reading frame ending in a stop codon 2 position downstream causing autosomal dominant (AD) immunodeficiency type 27B mycobacteriosis. His QuantiFERON Gold test was negative despite the history of TB. C-reactive protein (CRP) was elevated at 74.6. His CD4, CD8 and CD3 absolute counts were normal. MRI scan of the thoracic spine showed multifocal areas of thoracic vertebral marrow infiltration. Discussion AD IFNGR1 deficiency leads often to NTM osteomyelitis as suspected in this case. Neither CRP elevation nor accuracy of the QuantiFERON Gold test have been reported in AD IFNGR1 deficiency patients. This case suggests QuantiFERON Gold test performance may be impaired in these patients.