Low Total Lymphocyte Count Research Articles

Interruption of anti-thymocyte globuline treatment in solid organ transplantation is effectively monitored through a low total lymphocyte count.

Anti-Thymocyte Globulin (ATG) is a cornerstone in immune suppression for solid organ transplantation. The treatment is a delicate balance between complications arising from over-immunosuppression such as infections and cancer versus rejection stemming from under-immunosuppression. CD3+ T-lymphocyte measurements are frequently employed for treatment monitoring. However, this analysis is costly and not always accessible. The aim of this study was to investigate whether the total count of lymphocytes could replace CD3+ T-lymphocyte measurements based on data from our transplantation center combined with a review of the literature. The hypothesis was that the total lymphocyte count could serve as a diagnostic surrogate marker for CD3+ T-lymphocytes. A retrospective cohort study was conducted, including patients who underwent kidney and/or a pancreas transplantation and received ATG as induction therapy or for rejection treatment. The inclusion criterium was that the total lymphocyte count and CD3+ T-lymphocyte measurements were measured simultaneously on the same day. Additionally, PubMed and Embase were searched up to 18/10/2023 for published studies on solid organ transplantation, ATG, T-lymphocytes, lymphocyte count, and monitoring. In the retrospective cohort study, a total of 91 patients transplanted between 2016 and 2023, with 487 samples, were included. Total lymphocyte counts below 0.3 x 109/L had a high sensitivity (86%) as a surrogate marker of CD3+ T-lymphocytes below 0.05 x 109/L, but the specificity was low (52%) for total lymphocyte counts above 0.3 x 109/L as a surrogate marker for CD3+ T-lymphocytes above 0.05 x 109/L. A review of the literature identified seven studies comparing total lymphocyte counts and CD3+ T-lymphocytes in ATG monitoring. These studies supported the use of a low total lymphocyte count as a surrogate marker for CD3+ T-lymphocytes and an indicator to omit ATG treatment. However, there was no consensus regarding high total lymphocyte counts as an indicator for continued treatment. Results supports that the total lymphocyte count can be used to omit ATG treatment when below 0.3 x 109/L whereas the CD3+ T-lymphocyte analysis should be reserved for higher total lymphocyte counts to avoid ATG overtreatment.

Low Plasma Lipids Are Associated with Relapsing and Lethal Visceral Leishmaniasis in HIV-Infected Patients.

Visceral leishmaniasis (VL) results from protozoa Leishmania infantum and L. donovani infection. This study investigated whether host factors would explain the relapses. First, susceptibility to amphotericin B of L. infantum isolates was evaluated in vitro. Then, clinical data and the lipid profile of patients with relapsing and non-relapsing VL were assessed. Susceptibility to amphotericin B was similar between the isolates. CD4+ lymphocytes were reduced in both groups of patients in the first episode and with relapsing VL. Still, the strongest blood cell indicator associated with relapses was low total lymphocyte counts. Total plasma cholesterol, high-density lipoprotein, low-density lipoprotein, and, uniquely, triglycerides of the six individuals in the first episode and twenty-three with relapsing VL were lower in relapsing patients than those in the first episode. Deceased patients had extremely low low-density lipoprotein. After CD4+ decreases, lymphocyte CD8+ reduction is the final stage of immunological failure. The lower lipid concentrations appear to be secondary to the depletion of fat stores by inflammation-induced cachexia and fat exhaustion provoked by the co-occurrence of both diseases, which can finally lead to death.

Clinical Implications of Anemia Among Eastern Sudanese HIV Survivors.

Background In HIV patients, anemia is the most common hematopoietic consequence, and it has a major influence on life satisfaction, morbidity, and survival. The epidemiology of anemia in this cohort in Sudan, however, is poorly characterized. Aim This study aims to assess the prevalence of anemia and its implications among HIV-positive patients. Methods An observational case-control study was administered in 44 clinical HIV-positive cases at the Sudan National AIDS Program (SNAP), Red Sea State, Sudan, between January 2018 and December 2019. A total of 44 HIV-negative subjects as controls were enrolled. HIV-infected patients' demographic and clinical data, involving anemia and its outcome, were examined. WHO threshold was used to rank the clinical course of anemia in these patients. Results Of the 44 HIV patients examined, the mean age was 33.0 ± 11.2 years. Thirty (68.1%) were males, and 14 (29.8%) were females. The overall prevalence of anemia was 63.6% (95% CI 57.8-69.94%): mild grades of anemia at 25% (95% CI 14.4-34.4%), moderate grades of anemia at 36.4% (95% CI 28.7-43.2%), and severe anemia at 2.3% (95% CI 1.3-3.3%). In this study, 18 (64.3%) anemic patients showed normocytic thin smear pictures, among whom 44.3% were males and 20.5% were females. Microcytic anemia was seen in 17.8% of patients, while autoimmune hemolytic anemia was also detected in 17.8% of patients. The prevalence of anemia increased significantly with decreasing total lymphocyte count (TLC): 6.8% and 13.6% among patients with TLCs <1,000 and 1,000-4,800 cells/mm3, respectively (P = 0.016). Male sex was significantly associated with increased odds of anemia (OR 1.90, P = 0.049). Conclusion Anemia is a public comorbidity among HIV patients in the east of Sudan. Normocytosis is the most prominent form of anemia related to hypoproliferation in eastern Sudan, an event that can be triggered either by HIV chronicity or its combination with nutritional inadequacies. To prevent anemia progression and promote quality lifestyles, timely screening and appropriate therapy for anemia are critical, particularly for those with a low TLC.

T-Cell Immune Responses in Newborns and Long-Term Sequelae in Congenital Cytomegalovirus Infection (CYTRIC Study)

The objective of this study was to assess the role of T-lymphocyte immune responses in newborns with congenital cytomegalovirus (CMV) infection (cCMV) and their potential association with the development of long-term sequelae. A multicenter, prospective study from 2017 to 2022 was conducted across 8 hospitals in Spain. Blood samples were collected within the first month of life from neonates diagnosed with cCMV. Intracellular cytokine staining was employed to evaluate the presence of CMV-specific interferon-gamma (IFN-γ)-producing CD8+ and CD4+ T lymphocytes (CMV-IFN-γ-CD8+/CD4+) using flow cytometry. The development of sequelae, including hearing loss and neurologic impairment, was assessed during follow-up. In total, 64 newborns were included; 42 infants (65.6%) had symptomatic cCMV. The median age at the last follow-up visit was 25.3months (IQR 20.1-34.4). Eighteen infants had long-term sequelae (28.1%), predominantly hearing loss (20.3%) and neurologic disorders (15.6%). No relationship was observed between total count or percentage of CMV-specific IFN-γ-CD8+ or CD4+ lymphocytes and long-term sequelae. Multivariable analysis demonstrated an association between lower total lymphocyte count and long-term sequelae (aOR 0.549, 95% CI: 0.323-0.833), which requires further study. CMV-specific IFN-γ-CD4+ and CD8+ T-lymphocyte responses in neonates with cCMV were not predictive of long-term sequelae.

The need for paradigm shift: prognostic significance and implications of standard therapy-related systemic immunosuppression in glioblastoma for immunotherapy and oncolytic virotherapy.

Despite significant advances in our knowledge regarding the genetics and molecular biology of gliomas over the past two decades and hundreds of clinical trials, no effective therapeutic approach has been identified for adult patients with newly diagnosed glioblastoma, and overall survival remains dismal. Great hopes are now placed on combination immunotherapy. In clinical trials, immunotherapeutics are generally tested after standard therapy (radiation, temozolomide, and steroid dexamethasone) or concurrently with temozolomide and/or steroids. Only a minor subset of patients with progressive/recurrent glioblastoma have benefited from immunotherapies. In this review, we comprehensively discuss standard therapy-related systemic immunosuppression and lymphopenia, their prognostic significance, and the implications for immunotherapy/oncolytic virotherapy. The effectiveness of immunotherapy and oncolytic virotherapy (viro-immunotherapy) critically depends on the activity of the host immune cells. The absolute counts, ratios, and functional states of different circulating and tumor-infiltrating immune cell subsets determine the net immune fitness of patients with cancer and may have various effects on tumor progression, therapeutic response, and survival outcomes. Although different immunosuppressive mechanisms operate in patients with glioblastoma/gliomas at presentation, the immunological competence of patients may be significantly compromised by standard therapy, exacerbating tumor-related systemic immunosuppression. Standard therapy affects diverse immune cell subsets, including dendritic, CD4+, CD8+, natural killer (NK), NKT, macrophage, neutrophil, and myeloid-derived suppressor cell (MDSC). Systemic immunosuppression and lymphopenia limit the immune system's ability to target glioblastoma. Changes in the standard therapy are required to increase the success of immunotherapies. Steroid use, high neutrophil-to-lymphocyte ratio (NLR), and low post-treatment total lymphocyte count (TLC) are significant prognostic factors for shorter survival in patients with glioblastoma in retrospective studies; however, these clinically relevant variables are rarely reported and correlated with response and survival in immunotherapy studies (e.g., immune checkpoint inhibitors, vaccines, and oncolytic viruses). Our analysis should help in the development of a more rational clinical trial design and decision-making regarding the treatment to potentially improve the efficacy of immunotherapy or oncolytic virotherapy.

Vitamin D, Body Mass Index, and Total Lymphocyte Count in Drug-Sensitive and Drug-Resistant Tuberculosis Patients in Banjarmasin

Introduction: Tuberculosis (TB) remains a global health problem that causes high morbidity and mortality. Based on its classification, TB is divided into drug-sensitive (DS) and drug-resistant (DR). Several risk factors susceptible to TB are malnutrition with low body mass index (BMI), vitamin D deficiency (VDD), and low total lymphocyte count (TLC) related to low immune status. This study aimed to examine the relationship between vitamin D (VD), BMI, and TLC in the TB population in Banjarmasin. Methods: This was an analytic observational study with a cross-sectional design. The total study sample was 42 patients, confirmed by rapid molecular testing, who had not been treated for TB in Banjarmasin from January to May 2023 and met the inclusion and exclusion criteria. Chi-Square and Fisher's exact statistical tests were used to see the relationship between VD, BMI, and TLC in DS TB and DR TB. Results: The median age of DS TB was 38 (24-52) years old, and DR TB was 51 (37-58) years old. Most of the gender was male (24 patients/57.1%). There was a statistically significant difference between VD and BMI in DS TB and DR TB (p = 0.048; p = 0.019). There was a significant relationship between VD and TLC in DS TB and DR TB (p = 0.048). Conclusion: VD and BMI significantly differed in DS TB and DR TB. There was a significant correlation between VD and TLC in TB patients.

New insights on the mechanisms of myocardial injury in hypertensive patients with COVID-19

Abstract Introduction Cardiac comorbidities, particularly hypertension, are highly prevalent in patients hospitalized with COVID-19 and are related directly to the risk of clinical disease progression. Cardiac injury is the most frequently reported cardiac abnormality in these patients. Diverse forms and mechanisms of myocardial injury, including acute myocardial ischemia due to plaque rupture, oxygen supply/demand imbalance, non-ischemic injuries such as myocarditis, direct virus-mediated injury, and immune system dysregulation, have been described in patients with COVID-19. Purpose The mechanism of the association among hypertension, COVID-19 and cardiac injury and the reasons for worse clinical progression in these patients have not been elucidated clearly. Considering that myocardial injury due to direct SARS-CoV-2 infection is rare and that the immune system is often dysregulated in patients with COVID-19, and also that cytokine storm and lymphopenia are important immune markers of progression to severe disease, the present study aimed to investigate the immune profile of hypertensive patients with COVID-19 and myocardial injury to obtain a better understanding of the immune dysregulation and to provide new insights on the mechanism of myocardial injury in hypertensive patients with this disease. Methods All patients were selected prospectively from a multicenter registry of adults hospitalized with confirmed COVID-19. Cases had hypertension and myocardial injury, defined by troponin levels above the 99th percentile upper reference limit, and controls were hypertensive patients with no myocardial injury. Biomarkers and immune cell subsets were quantified and compared between the two groups. A multiple logistic regression model was used to analyze the associations of clinical and immune variables with myocardial injury. Results The sample comprised 193 patients divided into two groups: 47 cases and 146 controls. Relative to controls, cases had lower total lymphocyte count, percentage of T lymphocytes, CD8+CD38+ mean fluorescence intensity (MFI), and percentage of CD8+ human leukocyte antigen DR isotope (HLA-DR)+ CD38–cells and higher percentage of natural killer lymphocytes, natural killer group 2A (NKG2A)+ MFI, percentage of CD8+CD38+cells, CD8+HLA-DR+MFI, CD8+NKG2A+MFI, and percentage of CD8+HLA-DR–CD38+cells. On multivariate regression, the CD8+HLA-DR+MFI, CD8+CD38+MFI, and total lymphocyte count were associated significantly with myocardial injury. Conclusion Our findings suggest that lymphopenia, CD8+CD38+MFI, and CD8+HLA-DR+MFI are immune biomarkers of myocardial injury in hypertensive patients with COVID-19. The immune signature described here may aid in understanding the mechanisms underlying myocardial injury in these patients. The study data might open a new window for improvement in the treatment of hypertensive patients with COVID-19 and myocardial injury.

The Prognostic and Predictive Value of Pre-Treatment Total Lymphocyte Count in HPV+ Oropharyngeal Carcinoma Receiving Definitive (Chemo-) Radiation

Evidence of prognostic importance of pre-radiotherapy (RT) total lymphocyte counts (TLC) and interaction with addition of cisplatin (CRT) in HPV-positive oropharyngeal carcinoma (HPV+OPC) is conflicting. Recent data suggest patients with high TLC may not benefit from the addition of chemotherapy (Price et al, JCO 2022). We assess the prognostic and predictive value of TLC in a large single center HPV+OCP cohort. All HPV+OPC patients treated at a single academic center with definitive RT/CRT between 2005-2018 were included. Pre-treatment TLC up to 6 weeks prior to RT start were considered. Multivariable analysis (MVA) was applied to assess the prognostic importance of TLC (continuous variable), adjusted for age, gender, performance status, TNM-8 stage, and smoking status in the CRT and RT subgroups. The actuarial rates of locoregional control (LRC), distant control (DC), and overall survival (OS) were calculated using Kaplan-Meier and competing risk methods, stratified by low vs high TLC (determined using Contal and O'Quigley method for optimal cutoff). Among 1153 eligible patients, 707 (61%) were treated with CRT. Median age was 59.7 (range 22.7-92.2) years. 526 patients were (46%) TNM-8 stage I, 366 (32%) stage II and 261 (23%) stage III. Median TLC was 1.6 x 109/L (range 0.1-8.5). Median follow-up was 5.5 years. On MVA, TLC was prognostic for patients receiving CRT (OS [adjusted hazard ration (aHR) 0.55 (0.38-0.79), p = 0.002], DC [aHR 0.57 (0.37-0.88), p = 0.011], LRC [aHR 0.57 (0.36-0.89), p = 0.014]) but not RT (OS [aHR 1.04 (0.82-1.31), p = 0.74], LRC [aHR 1.26 (0.86-1.85), p = 0.23], DC [aHR 0.87 (0.64-1.19), p = 0.4)]. The optimal TLC cut-off for OS with CRT was 1.9 x 109/L. Low vs high TLC patients receiving CRT had significantly inferior 5-year DC (87% vs 93%, p = 0.017) and OS (84% vs 90%, p = 0.026). The benefit of higher TLC was most evident in stage II disease (table 1). CRT vs RT improved OS for stage II/III disease at high and low TLC. Pre-treatment TLC is prognostic in a large cohort of HPV+OPC patients receiving CRT but not RT alone. Further investigation of the interaction of cisplatin and immune response during RT is warranted. The omission of chemotherapy based on TLC is not supported.

Serum Interferon Gamma (IFN-ɣ) Levels and Hematological Indices in Patients with HIV-MTB Co-Infection in North-Eastern Nigeria

Introduction: The dual epidemic of human immunodeficiency virus (HIV) infection and Mycobacterium tuberculosis (MTB) poses significant health challenges, particularly in sub-Saharan Africa. Understanding the immune response and hematological changes in HIV-MTB co-infection is crucial for better management of affected individuals. Objectives: This study aimed to evaluate the serum levels of IFN-ɣ and hematological indices in patients with HIV-MTB co-infection in North-Eastern Nigeria, as well as explore any potential relationships between these factors. Methods: A total of 88 participants were enrolled in the study, including 44 antiretroviral therapy-naive patients with HIV-MTB co-infection (study group) and 44 HIV mono-infected individuals as controls. Data on personal biodata and clinical details were collected using an interviewer-administered questionnaire. Blood samples were obtained from each participant and analyzed for IFN-ɣ levels using ELISA and hematological indices using an automated hematology analyzer. Statistical analysis, including Mann-Whitney U test, independent samples t-test, and Pearson's correlation analysis, was conducted to compare the study and control groups and assess the relationship between IFN-ɣ levels and hematological parameters. Results: Serum IFN-ɣ was insignificantly increased in the study group compared to the control group (p=0.093). The WBC count was also significantly reduced in the study group compared to the control group (p=0.038). The HGB, HCT, MCV and MCH were significantly reduced in the study group compared to the control group (p=0.001, 0.001, 0.002 and 0.001) respectively. Participants with HIV-TB co-infection have insignificantly increased serum IFN-ɣ levels, low total WBC, lymphocyte and monocyte counts compared to those with HIV mono-infection. In conclusion, participants with HIV-TB co-infection have insignificant increased serum IFN-ɣ levels, low total WBC, and lymphocyte and monocyte counts compared to those with HIV mono-infection. There was no correlation of IFN-ɣ with any of the haematological indices.

Vitamin D status modulates innate immune responses and metabolomic profiles following acute prolonged cycling

PurposeThe influence of vitamin D status on exercise-induced immune dysfunction remains unclear. The aim of this study was to investigate the effects of vitamin D status (circulating 25(OH)D) on innate immune responses and metabolomic profiles to prolonged exercise.MethodsTwenty three healthy, recreationally active males (age 25 ± 7 years; maximal oxygen uptake [{dot{text{V}}text{O}}_{{2}}max] 56 ± 9 mL·kg−1·min−1), classified as being deficient (n = 7) or non-deficient n = 16) according to plasma concentrations of 25(OH)D, completed 2.5 h of cycling at 15% Δ (~ 55–60% {dot{text{V}}text{O}}_{{2}}max). Venous blood and unstimulated saliva samples were obtained before and after exercise.ResultsParticipants with deficient plasma 25(OH)D on average had lower total lymphocyte count (mean difference [95% confidence interval], 0.5 cells × 109 L [0.1, 0.9]), p = 0.013) and greater neutrophil:lymphocyte ratio (1.3 cells × 109 L, [0.1, 2.5], p = 0.033). The deficient group experienced reductions from pre-exercise to 1 h post-exercise (− 43% [− 70, − 15], p = 0.003) in bacterial stimulated elastase in blood neutrophils compared to non-deficient participants (1% [− 20, 21], p = 1.000) Multivariate analyses of plasma metabolomic profiles showed a clear separation of participants according to vitamin D status. Prominent sources of variation between groups were purine/pyrimidine catabolites, inflammatory markers (linoleic acid pathway), lactate and tyrosine/adrenaline.ConclusionThese findings provide evidence of the influence of vitamin D status on exercise-induced changes in parameters of innate immune defence and metabolomic signatures such as markers of inflammation and metabolic stress.

Correlation between branched-chain amino acids intake and total lymphocyte count in head and neck cancer patients: a cross-sectional study

BackgroundCellular immunity as reflected by total lymphocyte count (TLC) has been proven to be related to overall survival rate cancer patients. Lymphocyte proliferation is regulated, to some extent, by nutritional factor. Branched chain amino acid (BCAA) is documented as one of numerous nutrients that play important role in lymphocyte proliferation through its effect on protein synthesis and DNA replication. Many studies describe the correlation between BCAA and TLC in hepatic cancer patients. This study emphasized the observation of that links in head and neck cancer patients.MethodsEighty-five subjects were included in final analysis, aged 18–75, mostly male, with head and neck cancer who had not received treatment participated in this cross-sectional study at the Dr. Cipto Mangunkusumo General Hospital’s radiation and medical haematology oncology clinic. The BCAAs intake was assessed using a semi-quantitative food frequency questionnaire. Flow cytometry method was used to quantify TLC.ResultsOverall, the subjects’ nutritional status mostly was considered normal, with the median intake of 1505 (800–3040) kcal/day of energy and mean of 73.96 ± 23.39 g/day of protein. Moreover, subjects’ average BCAA intake was 10.92 ± 0.48 g/day. Meanwhile, 17.6% of subjects were found to have low TLC level. From thorough analysis, we did not find a strong correlation between BCAA level and TLC (r = 0.235, p = 0.056).ConclusionIn participants with head and neck cancer who had not received chemoradiotherapy, there is no correlation between BCAA intake and TLC. The contribution of non-BCAA amino acids from dietary sources to lymphocyte proliferation requires further investigation.Trial registrationRetrospectively registered, with clinical trial number NCT05226065 on February 7th 2022.

New Insights on the Mechanisms of Myocardial Injury in Hypertensive Patients With COVID-19.

Myocardial injury is common in hypertensive patients with 2019 coronavirus disease (COVID-19). Immune dysregulation could be associated to cardiac injury in these patients, but the underlying mechanism has not been fully elucidated. All patients were selected prospectively from a multicenter registry of adults hospitalized with confirmed COVID-19. Cases had hypertension and myocardial injury, defined by troponin levels above the 99th percentile upper reference limit, and controls were hypertensive patients with no myocardial injury. Biomarkers and immune cell subsets were quantified and compared between the two groups. A multiple logistic regression model was used to analyze the associations of clinical and immune variables with myocardial injury. The sample comprised 193 patients divided into two groups: 47 cases and 146 controls. Relative to controls, cases had lower total lymphocyte count, percentage of T lymphocytes, CD8+CD38+ mean fluorescence intensity (MFI), and percentage of CD8+ human leukocyte antigen DR isotope (HLA-DR)+ CD38-cells and higher percentage of natural killer lymphocytes, natural killer group 2A (NKG2A)+ MFI, percentage of CD8+CD38+cells, CD8+HLA-DR+MFI, CD8+NKG2A+MFI, and percentage of CD8+HLA-DR-CD38+cells. On multivariate regression, the CD8+HLA-DR+MFI, CD8+CD38+MFI, and total lymphocyte count were associated significantly with myocardial injury. Our findings suggest that lymphopenia, CD8+CD38+MFI, and CD8+HLA-DR+MFI are immune biomarkers of myocardial injury in hypertensive patients with COVID-19. The immune signature described here may aid in understanding the mechanisms underlying myocardial injury in these patients. The study data might open a new window for improvement in the treatment of hypertensive patients with COVID-19 and myocardial injury.

The Use of STRONGkids, Total Lymphocyte Count, and Serum Albumin to Identify the Risk of Hospital Malnutrition in Children

Highlights: Medium- and high-risk STRONGkids scores are related with low total lymphocyte count and serum albumin, which are related to hospital malnutrition, albeit indirectly. The use of STRONGkids with total lymphocyte count and serum albumin can detect the risk of hospital malnutrition in children. Abstract: Hospital malnutrition occurs in hospitalized patients who do not consume enough food while their nutritional requirements increase. It occurs particularly in children who have undergone gastrointestinal surgery. Despite the lack of a universal instrument for detecting hospital malnutrition, various parameters can be considered to assist in its identification. STRONGkids has demonstrated its efficiency in detecting malnutrition risk in children. Total lymphocyte count (TLC) and serum albumin are biochemical markers that are related to infection and protein leakage, which can worsen hospital malnutrition. The research objective was to analyze the correlation between STRONGkids and biochemical markers (TLC, serum albumin) to identify hospital malnutrition in children who underwent gastrointestinal surgery. This was a retrospective cross-sectional observational study utilizing medical records. The statistical analysis was conducted using SPSS 21. This study included 37 subjects, with a 24.32% hospital malnutrition incidence rate. The subjects were divided into two groups: hospital malnutrition (n=9) and non-hospital malnutrition (n=28). The STRONGkids of both groups at admission demonstrated a significant difference, while the albumin and TLC did not. The significantly different STRONGkids scores of both groups at admission correlated negatively with the length of hospital stay (LOS), body weight reduction, TLC, and albumin. Those parameters also did not correlate with hospital malnutrition. However, hospital malnutrition increased the risk of low albumin and TLC at discharge by 2.951 and 5.549 times, respectively. In conlusion, TLC and serum albumin cannot be used as independent markers for hospital malnutrition, but STRONGkids can be used in conjunction with TLC and serum albumin to identify hospital malnutrition risk.

Improvement of nutritional status after parathyroidectomy in patients receiving maintenance hemodialysis.

Parathyroidectomy is associated with improved survival in patients with end-stage kidney disease. Protein-energy wasting (PEW) is common in patients with kidney failure and predicts poor outcomes. Recent clinical trials have linked hyperparathyroidism to PEW. The present retrospective cohort study examined whether parathyroidectomy was associated with improvement in nutritional status in maintenance hemodialysis patients. One hundred twenty-nine maintenance hemodialysis patients who had successful parathyroidectomy during 2012-2018 were identified (PTX group) and matched 1:1 to 479 patients with parathyroid hormone (PTH) levels ≤1,000 pg./mL (non-PTX control group) and 187 patients with PTH levels >1,000 pg./mL (pre-PTX control group) by propensity score. The matchings yielded 120 matched pairs from PTX and non-PTX groups (cohort 1) and 76 matched pairs from PTX and pre-PTX groups (cohort 2). Baseline and follow-up nutritional parameters associated with PEW were compared over the 12-month study period. In cohort 1, substantially lower serum albumin and serum creatinine/body surface area (Cr/BSA) and higher proportions of patients with serum albumin ≤38 g/L (low albumin) and serum Cr/BSA ≤380 μmol/L/m2 (low Cr/BSA) were observed in the PTX group. These parameters improved significantly after parathyroidectomy. Total lymphocyte count (TLC) was comparable at baseline but the percentage of patients with TLC <800 cells/mm3 (low TLC) decreased substantially after parathyroidectomy. At follow-up, serum albumin, serum Cr/BSA and proportions of patients with low albumin and Cr/BSA became comparable with the non-PTX control group. The percentage of patients with low TLC became lower in the PTX group. Mixed-models analysis confirmed significant differences in the changes in serum albumin, serum Cr/BSA, and proportions of patients with low albumin and TLC between the two groups. In cohort 2, nutritional parameters were comparable at baseline. At follow-up, serum Cr/BSA was higher and proportions of patients with body mass index ≤18.5 kg/m2, low TLC and low Cr/BSA were lower in the PTX group. Weight gain was more frequent and of greater magnitude in the PTX group in both cohorts. A substantial reduction in blood pressure was also observed in the PTX group. Severe hyperparathyroidism was associated with nutritional impairment which improved considerably after parathyroidectomy.

Humoral immune response to an mRNA-1273 booster after chAdOx1-nCoV-19-priming among patients undergoing hemodialysis.

Patients who are undergoing dialysis due to end-stage kidney disease are susceptible to greater coronavirus disease 2019 (COVID-19) complications. While vaccination is seen as the most effective tactic against COVID-19, the dialysis population usually has impaired immune responses to vaccination. Owing to the global vaccine supply shortage in the early phase of the COVID-19 pandemic, hemodialysis patients in Taiwan were administered homologous ChAdOx1 nCoV-19/ChAdOx1 nCoV-19 at 12-week intervals, with a third booster shot of mRNA-1273 given 12 weeks after the second dose. We assessed the antibody responses of these patients to this extended-interval dosing protocol. A total of 168 hemodialysis patients (mean age: 67 ± 13 years) without prior COVID-19 infection were vaccinated between June 16, 2021, and January 5, 2022, and followed until February 10, 2022. The primary outcome was seroconversion with an antispike immunoglobulin G (IgG) antibody level ≥50 arbitrary units (AU)/mL at 4 weeks after the administration of an mRNA-1273 booster shot. The secondary outcome was the level of antispike IgG antibodies. Multivariable linear regression models were used to evaluate the associations between the baseline characteristics and the antispike IgG level. A total of 163 (97.0%) patients reached the primary endpoint, with antibody levels after the third booster dose of mRNA-1273 being significantly higher than those after the second dose of ChAdOx1 nCoV-19 (median IgG titer 12,007 [4394-23,860] vs. 846 [interquartile range 295-2114] AU/mL; P < 0.001). Patients who were male, older, had a higher body mass index, had a lower total lymphocyte count, and used immunosuppressants had lower antibody levels. A third booster dose of mRNA-1273 after two consecutive priming doses of ChAdOx1 nCoV-19 with extended intervals resulted in adequate humoral immune responses among hemodialysis patients.

Leukemia Cutis of the Scalp Masquerading as 'Kerion' in a Child.

Dear Editor, Dermatologic manifestations of leukemia can be both specific (leukemia cutis) and nonspecific (leukemids). Leukemia cutis (LC) is defined as neoplastic leukocyte (either lymphoid or myeloid lineage) infiltration into the epidermis, dermis, or subcutaneous tissues.[1] LC may have diverse presentation and may often be misdiagnosed clinically.[2] Histopathology and immunohistochemistry help to clinch the diagnosis of LC. Here, we describe a child who presented with a crusted lesion and patches of alopecia on the scalp mimicking kerion. A 8-year-old male child presented with crusted lesions over the vertex since 3 months. It started as a coin-shaped patch of alopecia, which was treated initially with topical indigenous plant extracts. This led to the formation of a blister, which progressed into a crusted plaque. At the same time, the child developed pain, intermittent fever, and swelling in the neck. A provisional diagnosis of kerion was made by family physician and the child was treated with a course of oral antibiotics and antifungals without any relief. Examination revealed yellowish crusted indurated plaque on the right side of the scalp measuring 8 × 6 cm [Figure 1]. There was another patch of alopecia measuring 3 × 4 cm on the left parietal region. Cervical lymph nodes (submandibular and occipital) were enlarged, tender, and hard in consistency. The child also had swelling of bilateral testicle. Hematological examination revealed anemia (Hb of 6.6g/dL), raised ESR (90 mm/hr), and low total lymphocyte count of 5730 per mL with 18% blast cells. Potassium hydroxide mount from skin scrapings and hair showed no fungal elements. Histopathological examination revealed ulcerated epidermis and dense infiltration with atypical lymphoid cells in the dermis, confirming the diagnosis of leukemia cutis [Figure 2]. Immunohistochemistry analysis of the lymph node biopsy showed that the atypical lymphoid cells were positive for CD45, PAX5, CD99, CD10, bcl6, bcl2, and c-myc and negative for CD 20, CD3, TdT, CD34, Cyclin D1, CD 138, CD 56, and CD117. Marrow aspiration studies revealed 67% blast cells and 20% lymphocytes. Flow cytometry of bone marrow aspirate reported positive B cell markers like CD10, CD19, and CD79a; and negative for CD20. Based on these findings, a diagnosis of Pre-B acute lymphocytic leukemia (ALL) was made.Figure 1: Crusted plaque with peripheral alopecia on the scalpFigure 2: (a) Diffuse infiltration by monotonous population of atypical lymphoid cells in the dermis with loss of skin adnexal structures. Acanthosis of epidermis could be appreciated (H and E, x100). (b) Monomorphic population of atypical lymphoid cells in the dermis showing blastoid morphology defined by high nuclear-cytoplasmic ratio, scant cytoplasm, and irregular clumped chromatin (H and E, x400)Leukemia is the most common malignancy in children; acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) are the the most common forms of childhood leukemias.[3] LC has been found to be more common in AML than ALL. The most common cutaneous features of LC are papules and nodules followed by plaques; different morphological patterns may coexist in a given patient. It may not be possible to predict the type of underlying malignancy based on the morphology of skin lesions. Two main sites of predilection for LC in children are head and lower extremity.[3] In majority of patients, LC is the initial presenting manifestation of systemic disease. It can also be the manifestation of disease relapse. Rarely, it may precede by several months before the detection of leukemic cells in the peripheral blood (i.e., aleukemic leukemia).[23] Our patient presented initially with alopecia, which gradually progressed to form crusted plaque. Though irritant reaction following the use of plant extract would have led to the formation of a plaque, histopathology did not show significant spongiotic changes. ALL presenting as alopecia is an exceptional phenomenon. Potential pathophysiological mechanisms comprise malignant infiltration of the hair follicle and fibro-collagenous response to infiltration as well as cytokine release.[4] It is very important to perform a thorough general physical examination in a child presenting with alopecia; our case had scrotal swelling and cervical lymphadenopathy, which were hard in consistency. These features prompted us to suspect LC in this case. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Associations between nutritional and immune status and clinicopathologic factors in patients with tuberculosis: A comprehensive analysis.

This study was designed to assess and analyze nutritional status (NS) and immune status in patients with tuberculosis. A retrospective analysis was conducted on 93 TB patients hospitalized in the tuberculosis ward of the West China Hospital of Sichuan University. Subgroup comparisons were made according to age (<65 years and ≥65 years), nutritional risk score 2002 (NRS 2002 <3 and ≥3), tuberculosis location [pulmonary tuberculosis and extrapulmonary tuberculosis (including pulmonary tuberculosis complicated with extrapulmonary tuberculosis)], and prognostic nutrition index (PNI) (<45 vs ≥45). Significantly increased weight loss was associated with extrapulmonary tuberculosis (P =0.0010). Serum albumin (P =0.0214), total lymphocyte count (P = 0.0009) and PNI (P = 0.0033) were significantly decreased in older patients. Neutrophils/lymphocytes (NLR) (P =0.0002), monocytes/lymphocytes (MLR) (P < 0.0001), and platelets/lymphocytes (PLR) (P =0.0107) were higher. According to NRS 2002, higher nutritional risk was associated with lower body weight and body mass index (BMI) (P < 0.0001), higher weight loss (P = 0.0012), longer duration of hospitalization (P =0.0100), lower serum albumin level and hemoglobin concentration (P <0.01), lower creatinine level, and lower PNI (P < 0.01). 0.0001), lower total lymphocyte count (P = 0.0004), higher neutrophil and monocyte counts (P <0.05), and higher NLR (P = 0.0002), MLR (P = 0.0006), and PLR (P = 0.0156). Lower PNI was associated with lower body weight (P = 0.0001) and BMI (P =0.0074), lower total protein, albumin, and hemoglobin concentrations (P < 0.0001), and lower total lymphocyte count (P < 0.0001) and creatinine levels (P = 0.0336), higher age (P =0.0002) and NRS 2002 score, P < 0.0001), longer hos-pital stay (P = 0.0003), higher neutrophil count (P = 0.0042), and NLR, MLR, and PLR (P <0.0001) were significantly correlated. In multivariate logistic regression analysis, weight loss (OR: 0.209, 95% CI: 0.060-0.722; p =0.013) was significantly associated with higher nutritional risk (NRS 2002≥3). In multiple linear regression analysis, the NRS 2002 score was higher (B=2.018; p =0.023), and extrapulmonary tuberculosis (B=-6.205; p =0.007) was linked with a longer duration of hos-pitalization. Older tuberculosis patients are at nutritional risk, and older patients (≥65 years old) need to pay attention to nutritional monitoring and intervention. Older TB patients and those at risk of malnutrition have increased immune ratio and impaired immune function. Management of TB patients using basic diagnostic tools to assess nutritional and immune status and calculate PNI and immunological indexes (NLR, MLR, PLR) to improve treatment outcomes.

Malnutrition in Children with Uncomplicated Versus Complicated Appendicitis

Background : Acute appendicitis is one of the commonest surgical emergencies in children and malnutrition is prevalent in the country. This study was designed to compare if complicated appendicitis occurs more in malnourished children.&#x0D; Materials and methods: This cross-sectional study was conducted in Department of Paediatric Surgery, Chittagong Medical College Hospital from March 2017 to December 2019 with 155 children. Anthropometric measurements (Height, weight, Mid Upper Arm Circumference (MUAC) Triceps Skin Fold Thickness (TSFT) were recorded and biochemical assessment (Haemoglobin, albumin and total lymphocyte count) were done before surgery. Patients were grouped into two groups: Group A (Acute uncomplicated appendicitis; n=65) and Group B (Acute complicated appendicitis, n=90). Anthropometric and biochemical indices were compared between these two groups. &#x0D; Results: Age ranged from 2 -12 years (Mean 9.2 ±2.5 years) (Male: female- 1.35:1). Among the five anthropometric indices abnormal measurements in Group A vs Group B were respectively. Abnormal TSFT (73.8% vs 80%, p=0.4) wasting (38.5% vs 44.4%, p=0.4) low MUAC for age (13.8% vs 17.8%, p=0.8) low weight for age (30.8% vs 36.7%, p=0.5) and low height for age (21.5% vs 24.4%, p=0.7) low albumin (52.3% vs 83.3%, p&lt;0,001); low haemoglobin (61.5% vs 60.0%, p=0.6)) and low total lymphocyte count (39.5% vs 44.8%, p=0.7).&#x0D; Conclusions: Malnutrition was widely prevalent in both groups. Although the proportion of malnutrition was more with acute complicated appendicitis, it was not statistically significant. The lower serum albumin level in these patients might be due to the consequence of the disease rather than prevailing malnutrition.&#x0D; JCMCTA 2022 ; 33 (1) : 66-70

Comparison of Surgical Outcomes and Predictors in Patients with Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria.

Background: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus, Aeromonas hydrophila, and Aeromonas sobria are often associated with high mortality rates. The purpose of this study was to compare the independent predictors related to outcomes between Vibrio vulnificus and Aeromonas species necrotizing fasciitis. Patients and Methods: Monomicrobial necrotizing fasciitis caused by Vibrio vulnificus (60 patients) and Aeromonas species (31 patients) over an 11-year period were reviewed retrospectively. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the Vibrio vulnificus and Aeromonas species groups, and between the death and the survival subgroups of patients with Aeromonas species. Results: Six patients in the Vibrio vulnificus group (10%) and 11 in the Aeromonas species group (32.3%) died. Fifty-nine patents had bacteremia and 16 patients died (27.1%). Patients who had Vibrio vulnificus had a higher incidence of bacteremia. The patients who had Aeromonas species presenting with bacteremia were significantly associated with death. The death subgroup of patients with Aeromonas necrotizing fasciitis had a higher incidence of bacteremia, higher counts of banded leukocytes, lower platelet counts, lower total lymphocyte counts, and lower serum albumin level than the survival subgroup. Conclusions: Monomicrobial necrotizing fasciitis caused by Aeromonas species was characterized by more fulminating and higher mortality than that of Vibrio vulnificus, even after early fasciotomy and third-generation cephalosporin antibiotic therapy. Those risk factors, such as bacteremia, shock, lower platelet counts, lower albumin levels, and antibiotic resistance were associated with mortality, which should alert clinicians to pay more attention to and aggressively treat those patients with Aeromonas and Vibrio necrotizing fasciitis.

Malnutrition Contributes to Low Lymphocyte Count in Early-Stage Coronavirus Disease-2019.

Background and Aim: Lymphocytes play an important role in fighting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Low total lymphocyte count (TLC), which contributes to poor clinical outcomes, is common in persons with coronavirus disease 2019 (COVID-19). The current explanation for the cause of low TLC is that it is directly related to the invasiveness of SARS-CoV-2, which attacks lymphocytes. We hypothesized that malnutrition contributes to the development of low TLC in early-stage COVID-19.Methods: We prospectively enrolled 101 patients with confirmed COVID-19. On their first day of hospitalization, we collected baseline and laboratory data, including clinical symptoms; the Sequential Organ Failure Assessment, Nutrition Risk Screening 2002 and Subjective Global Assessment were used to assess the malnutrition status of the patients. Multivariable logistic regression was used to identify independent risk factors for low TLC and severe COVID-19.Results: Malnutrition was associated with lower TLC in COVID-19. Fifty-nine (58.4%) of the patients showed low TLC, 41 (40.6%) were at risk for malnutrition, and 18 of them were malnourished. Low TLC was an independent risk factor for severe COVID-19. Compared to patients with normal TLC, those with low TLC more often presented with anorexia, malnutrition, higher SOFA scores (P < 0.05) and comorbidities (diabetes and malignancies). Malnutrition (OR: 3.05, 95% CI: 1.5–6.19, P = 0.006) and SOFA scores (OR: 1.51, 95% CI: 1.04-2.43, P = 0.042) were identified as independent risk factors for low TLC.Conclusions: Malnutrition was common among our patients with early-stage COVID-19, and it contributed to the occurrence of low TLC.