Negative Antibody Test Research Articles

Abstract P225: Persistent Vascular Dysfunction and Blood Pressure Elevation Over 12 Months After COVID-19 Recovery in Non-Hypertensive Adults – LOCHINVAR Study

Background: The potential long-term vascular consequences of COVID-19, particularly in relation to future hypertension risk, remain poorly understood. This study aims to elucidate the longitudinal blood pressure trajectories in individuals who have recovered from COVID-19 but were not hypertensive prior to their infection, over a 12-month observational period. Methods: This study enrolled participants who had recovered from a hospital-admitted COVID-19 infection at least 12 weeks prior and had no history of hypertension. A control group was established from individuals with no prior SARS-CoV-2 infection, confirmed by a negative antibody test. All participants underwent ambulatory blood pressure monitoring (ABPM), flow-mediated dilation (FMD), and 6-minute walk test (6MWT) both at baseline and after 12 months. RAAS phenotyping was conducted at baseline. Paired t-tests and multivariable adjusted regression models were employed in the analyses of the full-dataset and per-protocol subset (because of variation in participant characteristics due to changing COVID-19 landscape during the recruitment period). Results: The full dataset had 97 participants (SARS-CoV-2 Negative:Positive 60:37) and per protocol data set had 66 participants (SARS-CoV-2 Negative:Positive 51:15). The median age was 50 (IQR:42-54) years with majority females. Per-protocol analysis revealed the positive group showed an increase in systolic and diastolic blood pressure (SBP/DBP) by 4.6/4.5 mmHg, a decrease in FMD by 3.2%, and an improvement in the 6MWT distance by 145.6 meters over 12 months, compared to the negative group (Figure 1). Baseline RAAS phenotyping showed no significant differences between groups. Conclusions: Our study demonstrates a significant increase in diastolic blood pressure 12 months following COVID-19 recovery in previously non-hypertensive individuals, accompanied by a decline in FMD. These findings suggest a possible vascular basis for the development of hypertension post-COVID-19 recovery.

Changes in bodyweight after initiating antiretroviral therapy close to HIV-1 seroconversion: an international cohort collaboration.

Understanding the reasons for and consequences of bodyweight change in people living with HIV initiating antiretroviral therapy (ART) is crucial to optimising long-term health and wellbeing. We aimed to examine bodyweight trends and associated factors among individuals with well estimated dates of HIV-1 seroconversion. In this cohort study, we pooled retrospective data from clinical records of participants in CASCADE aged 16 years and older recruited from clinics in France, Greece, the Netherlands, Spain, Sweden, the UK, and Canada. All participants had well estimated dates of HIV-1 seroconversion, seroconverted between Jan 1, 2007, and Dec 31, 2022 (HIV-1 positive antibody test within 12 months of an HIV-1 negative antibody test, or other laboratory evidence of seroconversion), initiated ART within 1 year of seroconversion, and were previously ART-naive. Participants were followed up to the time of data pooling (May 31, 2023). We modelled bodyweight changes after ART initiation by ART class, BMI categories, and other demographic characteristics using linear mixed models. Of 15 755 potentially eligible participants, 5698 met inclusion criteria. Of those, 5148 (90·3%) were assigned male at birth, 517 (9·1%) were assigned female at birth, and 33 (0·6%) had sex not known. 2778 (48·8%) participants initiated integrase strand transfer inhibitor (INSTI)-based ART regimens, 1809 (31·7%) initiated protease inhibitor-based regimens, and 1111 (19·5%) initiated non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. The majority of participants were men who have sex with men (MSM; 4519 [79·3%]). Median age at seroconversion was 33·7 years (IQR 26·9-43·2). Bodyweight changes differed significantly by ART class within all baseline BMI categories (BMI <18·5 kg/m2 p=0·026, BMI 18·5-24·9 kg/m2 p<0·0001, BMI 25·0-29·9 kg/m2 p=0·0021, and BMI ≥30·0 kg/m2 p=0·0033; ART class and BMI interaction p=0·011). Participants with BMI less than 30 kg/m2 on regimens including both INSTI and tenofovir alafenamide gained 4·76 kg (95% CI 4·05-5·46) or more at 3 years. Of those with baseline BMI 18·5-24·9 kg/m2, 31·3% (95% CI 29·5-33·1) on INSTI-based regimens, 25·3% (23·0-27·7) on protease inhibitor-based regimens, 20·4% (18·8-22·9) on NNRTI-based regimens, 37·4% (33·9-40·9) on tenofovir alafenamide-based regimens, and 38·4% (34·6-42·1) on tenofovir alafenamide and INSTI-based regimens had gained more than 10% of their baseline bodyweight at 3 years. The greatest 3-year bodyweight gains by individuals on INSTI-based regimens and with BMI 18·5-24·9 kg/m2 were in women (5·63 kg [95% CI 4·92-6·35]), and people originating from sub-Saharan African (5·76 kg [5·06-6·46]), compared with MSM (3·82 kg [3·50-4·13]). Our findings suggest a direct effect of INSTIs and tenofovir alafenamide on bodyweight gain, rather than a return to health effect. Given the known risk for cardiometabolic disease, bodyweight management needs to be part of the overall care of individuals prescribed these drugs. ViiV Healthcare UK, Janssen Pharmaceutica, and Merck Sharp & Dohme.

Racial and ethnic disparities in testing of Hepatitis C virus-exposed children across the United States.

Despite rising hepatitis C virus (HCV) prevalence among pregnant individuals in the United States, HCV testing among exposed infants remains low. Although recent guidelines recommend early RNA testing for HCV-exposed children to help improve testing rates, national studies describing factors associated with HCV testing and type of testing completed are lacking. In this retrospective national study, we characterized HCV testing and care among HCV-exposed infants born 2010-2020 captured in the electronic health record-based TriNetX Research Network. We analyzed factors associated with appropriate HCV testing completion (negative or positive HCV RNA testing or negative HCV antibody testing at any age through study end in 2022) and with RNA compared with antibody testing, using univariable and multivariable logistic regression with clustered standard errors by healthcare organization. Of 8,516 HCV-exposed children, 45.8% completed any HCV testing and 42.1% completed appropriate testing (25% of whom had RNA testing only). 182 (5.1% of appropriately tested children) had evidence of HCV infection. Of 104 treatment-eligible children, 14.4% were treated. Black (OR 0.38, 95% CI 0.26-0.55), Asian/Pacific Islander (OR 0.06, 95% CI 0.03-0.11), and Hispanic/Latinx children (OR 0.56, 95% CI 0.36-0.88) had lower odds of appropriate testing compared with White and non-Hispanic/Latinx children, respectively. Fewer than half of HCV-exposed children in this national sample were tested for HCV, with lower testing odds among Black, Asian/Pacific Islander, and Hispanic/Latinx children. Substantial work to increase testing and treatment and decrease disparities in testing among HCV-exposed children is needed to help reach US HCV elimination goals.

Outcomes of Primary Percutaneous Coronary Intervention in Post COVID-19 Patients Presenting with ST Segment Elevation Myocardial Infarction

Abstract Background Coronavirus disease-2019 (COVID-19) is thought to predispose patients to wide variety of thrombotic disease, including Acute Coronary Syndromes (ACS). While such fact is established in literature to occur during the acute infection, data regarding the long term thrombotic effects of COVID-19 are still unclear. Aim and Objectives To determine the special coronary angiographic findings, the procedural and clinical success of revascularization among post COVID-19 patients presenting with STEMI. Patients and Methods This study was performed on a 100 patients who presented to emergency departments of Ain shams university hospitals with ST Segment Elevation Myocardial Infarction and underwent primary PCI, during a period of 6 months: From January to June of 2022. The patients were randomized into two groups: Group (A) the Post COVID-19 group, comprising 50 patients who developed COVID-19 infection in the past 6 months, as diagnosed at the time by RT-PCR or a CT chest of CORADS-IV or more – and group (B) the Control group, comprising 50 patients who deny COVID-19 infection in the past 6 months, endorsed by a negative COVID-19 antibody test. A subgroup analysis was done where patients in group (A) were further divided into two subgroups: the Early Post-COVID subgroup, having developed STEMI within 8 weeks of infection and comprising 16 patients, and the Late Post-COVID subgroup, having developed STEMI &amp;gt;8-24 weeks post infection and comprising 34 patients. The groups were compared as regards clinical, angiographic, laboratory and echocardiographic outcomes of percutaneous intervention. Results Our study demonstrated that patients who developed STEMI within 8 weeks of a COVID-19 infection (the Early Post-COVID subgroup) showed a statistically significant high thrombus burden on angiography, at 81.3% versus 48% of the control group. A high thrombus burden was defined in our study as having a modified thrombus grade of 4 or more. This subsequently resulted in higher use of pre-dilatation (56.2% versus 24%) and thrombus aspiration (43.8% versus 4%) in the Early Post- COVID subgroup, both at a statistically significant level (P-values = 0.015 and 0.001 respectively). Coronary No-Reflow was a much more frequent complication following PCI in the Early post-COVID subgroup (62.5%) compared to the Control group (22%). These patients also suffered a lower Ejection Fraction on Echocardiography (Mean 36% versus 43.4%) and a larger LVIDs (Mean 47mm versus 43.9mm) as compared to the Control group. This data translated clinically into a higher MACE among the Early Post-COVID patients, at 31.3% versus 6% of the control group. Of note that these differences were not as evident upon comparing the whole post COVID group to the control group. Conclusion We concluded that the thrombogenic effect of COVID-19 on the outcomes of STEMI persists even after resolution of the infection but gradually declines overtime. It affects the angiographic, procedural and overall clinical success of revascularization during in-hospital stay. This effect is maximal during the first 8 weeks after infection, but declines thereafter.

AUTOIMMUNE ENCEPHALITIS: DIAGNOSTIC AND TREATMENT APPROACH

Autoimmune encephalitis is a type of brain inflammation induced by an inappropriate immune response to a neuronal antigen, resulting in the generation of autoantibodies. Autoimmunity as important cause of encephalitis in recent years has not been much reported in Indonesia. Increased familiarity with autoimmune encephalitis among physician, not only neurologist, is extremely important for early detection. Prompt diagnosis and early immunotherapy leads to better prognosis in this potentially treatable disease, despite a long disease course. Autoimmune encephalitis is characterized by acute-subacute progressive neuropsychiatric symptoms with associated cognitive dysfunction, encephalopathy, psychiatric disorders, movement disorders and seizures, with anti-N-methyl-D-aspartate (NMDA) receptors encephalitis as the most common type. In addition to clinical features, further diagnostic investigations needed are brain magnetic resonance imaging (MRI), electroencephalography (EEG), cerebrospinal fluid (CSF) analysis, and autoantibody testing. Challenges in establishing diagnosis include wide range of clinical symptoms, absence of abnormalities in brain MRI, unspecified EEG findings, negative antibody testing, and limited availability of antibody testing in Indonesia. This literature review discusses the recognition, diagnosis and principle of treatment of autoimmune encephalitis.

COVID-19 point-of-care tests can identify low-antibody individuals: In-depth immunoanalysis of boosting benefits in a healthy cohort.

The recommended COVID-19 booster vaccine uptake is low. At-home lateral flow assay (LFA) antigen tests are widely accepted for detecting infection during the pandemic. Here, we present the feasibility and potential benefits of using LFA-based antibody tests as a means for individuals to detect inadequate immunity and make informed decisions about COVID-19 booster immunization. In a health care provider cohort, we investigated the changes in the breadth and depth of humoral and T cell immune responses following mRNA vaccination and boosting in LFA-positive and LFA-negative antibody groups. We show that negative LFA antibody tests closely reflect the lack of functional humoral immunity observed in a battery of sophisticated immune assays, while positive results do not necessarily reflect adequate immunity. After booster vaccination, both groups gain depth and breadth of systemic antibodies against evolving SARS-CoV-2 and related viruses. Our findings show that LFA-based antibody tests can alert individuals about inadequate immunity against COVID-19, thereby increasing booster shots and promoting herd immunity.

The clinical, diagnostic and treatment spectrum of seropositive and seronegative autoimmune encephalitis: Single‐center cohort study of 51 cases and review of the literature

AbstractObjectiveAutoimmune encephalitis (AE) comprises a spectrum of inflammatory neurological syndromes characterized by immune responses to neuronal autoantigens, leading to diverse clinical manifestations, particularly behavioral and cognitive decline.MethodsThis single‐center retrospective study included 51 patients diagnosed with AE from 2013 to 2019 in a southeast Michigan tertiary care hospital. Patients were then divided into two groups, seropositive AE (AE+) and seronegative AE (AE−), based on antibody detection in the serum, cerebrospinal fluid or both when available. The study compares AE+ and AE− subtypes across clinical, diagnostic, and therapeutic parameters.ResultsA total of 34 patients were classified as AE+, and 17 as AE−. Demographic analysis showed no significant differences in age, sex or race between the two groups. Clinical presentations varied widely, encompassing psychiatric symptoms, movement disorders, seizures and confusion; 24% patients had a prior malignancy. Laboratory assessments found diverse autoantibodies in AE+ patients' serum. Radiological and electrophysiological assessments showed no significant differences between the groups. AE− patients had higher rates of confusion compared with AE+ patients (59% vs. 18%, P = 0.004).ConclusionsThis study focuses on the complexities associated with diagnosing AE, emphasizing the challenges posed by the heterogeneity of symptoms and often negative antibody test results. Rapid identification of AE, regardless of seropositivity or seronegativity, emerges as a critical factor for clinicians, facilitating the prompt initiation of immunotherapy and/or tumor removal if needed. These insights contribute to a better understanding of the landscape of this condition, offering clinicians the tools to refine their diagnostic and treatment strategies. Ultimately, the study aimed to enhance the management of AE, empowering healthcare professionals to make accurate and timely interventions for patients.

Prevalence of SARS-CoV-2 antibodies and associated factors in the adult population of Belgium: a general population cohort study between March 2021 and April 2022

BackgroundThis study assessed seroprevalence trends of SARS-CoV-2 antibodies in the Belgian adult population between March 2021 and April 2022, and explored factors associated with seropositivity and seroreversion among the vaccinated and unvaccinated population.MethodsA prospective longitudinal surveillance study was conducted within a random sample of the general population (18 + years) in Belgium, selected from the national register through a multistage sampling design. Participants provided a saliva sample and completed a survey questionnaire on three occasions: at baseline and in two follow-up waves. Outcome variables included (1) seropositivity, defined as the presence of SARS-CoV-2 antibodies, assessed with a semi-quantitative measure of anti-RBD (Receptor Binding Domain) IgG ELISA and (2) seroreversion, defined as passing from a positive to a negative antibody test between two measurements. Trends in SARS-CoV-2 antibody prevalence were assessed using binary logistic regression with contrasts applying post-stratification. Potential determinants of seropositivity were assessed through multilevel logistic regressions.ResultsIn total 6,178 valid observations were obtained from 2,768 individuals. SARS-CoV-2 antibody prevalence increased from 25.1% in the beginning of the study period to 92.3% at the end. Among the vaccinated population, factors significantly associated with higher seropositivity rates were being younger, having a bachelor diploma, living with others, having had a vaccine in the last 3 months and having received a nucleic-acid vaccine or a combination. Lower seropositivity rates were observed among vaccinated people with a neurological disease and transplant patients. Factors significantly associated with higher seropositivity rates among the unvaccinated population were having non-O blood type and being non-smoker. Among vaccinated people, the seroreversion rate was much lower (0.3%) in those who had received their latest vaccine in the last 3 months compared to those who had received their latest vaccine more than 3 months ago (2.7%) (OR 0.13; 95%CI 0.04–0.42).ConclusionsThe rapid increase in antibody seropositivity in the general adult population in Belgium during the study period was driven by the vaccination campaign which ran at full speed during this period. Among vaccinated people, seropositivity varied in function of the time since last vaccine, the type of vaccine, sociodemographic features and health status.

Clinical course, management and outcomes of COVID-19 in HIV-infected renal transplant recipients: A case series.

HIV-infected kidney transplant recipients with COVID-19 are at increased risk of acute illness and death owing to their underlying comorbidities and chronic immunosuppression. To describe the incidence, clinical presentation and course of COVID-19, vaccination status, and SARS-CoV-2 antibody positivity rate among HIV-infected-to-HIV-infected kidney transplant recipients in South Africa (SA). This retrospective study reports on rates of SARS-CoV-2 infection, COVID-19 and mortality among SA HIV-infected kidney transplant recipients who received organs from HIV-infected donors (HIV positive to HIV positive), before and after vaccination. Patient demographics, clinical presentation, course, management and disease outcomes were analysed. Antibody serology tests were performed between May and September 2022. Among 39 HIV-positive-to-HIV-positive transplant recipients, 11 cases of COVID-19 were diagnosed from March 2020 to September 2022. Six patients (55%) required hospitalisation, of whom 3 were admitted to a high-care unit or intensive care unit. Two patients required mechanical ventilation, and 2 received acute dialysis. One patient was declined access to intensive care. Four patients (10%) died of COVID-19 pneumonia. All the COVID-19-positive patients had at least one comorbidity. Vaccination data were available for 24 patients, of whom 5 had refused SARS-CoV-2 vaccination. SARS-CoV-2 antibody data were available for 20 patients; 4 vaccinated patients had a negative nucleocapsid protein antibody test and a positive spike protein antibody test, suggesting vaccination-acquired immunity. The remaining 16 patients demonstrated immunity that was probably due to COVID infection, and of these, 14 were also vaccinated. Of the 11 COVID-19 cases, only 1 was observed after vaccination. In our case series, ~10% of the HIV-positive-to-HIV-positive transplant recipients died of COVID-19 pneumonia. This mortality rate appears higher than figures reported in other transplant cohorts. However, it is likely that the actual number of cases of SARS-CoV-2 infection was much higher, as the study only included polymerase chain reaction-confirmed cases. It remains unclear whether HIV infection, transplant or the combination of the two drives poorer outcomes, and larger studies adjusting for important demographic and biological factors may isolate these effects.

Utility of testing for third-generation anticyclic citrullinated peptide (anti-CCP3) antibodies in individuals who present with new musculoskeletal symptoms but have a negative second-generation anticyclic citrullinated peptide (anti-CCP2) antibody test

ObjectivesTo investigate the role of third-generation anticyclic citrullinated peptide (anti-CCP3) antibodies in predicting progression to inflammatory arthritis (IA) in individuals with new musculoskeletal (MSK) symptoms and a negative second-generation anti-CCP...

The geographic limits and life history of the tropical brown dog tick, Rhipicephalus linnaei (Audouin, 1826), in Australia with notes on the spread of Ehrlichia canis

The tropical brown dog tick, Rhipicephalus linnaei, is a tick of much medical, veterinary, and zoonotic importance. This tick has a nearly world-wide distribution due to its ability to survive and propagate in kennels and houses. Rhipicephalus linnaei is the vector of Ehrlichia canis, the causative agent of canine monocytic ehrlichiosis, an often debilitating disease of canids and, occasionally, humans. To prevent incursion of E. canis into Australia, dogs entering Australia have been required to have a negative immunofluorescence antibody test for E. canis. In May 2020 however, E. canis was detected in Western Australia. The detection of E. canis in Australia prompted disease investigation and concerted surveillance for R. linnaei and E. canis in regions across Australia. These investigations revealed that R. linnaei was established far beyond the previously recognised geographic range limits of this tick. In the present paper, using records from various collections, published data, and data from our network of veterinarian collaborators and colleagues, we update the current geographic range of R. linnaei in Australia. Our analyses revealed that the geographic range of R. linnaei in Australia is much wider than was previously supposed, particularly in Western Australia, and in South Australia. We also map, for the first time, where E. canis has been detected in Australia. Last, we discuss the possible routes of incursion and subsequently the factors which may have aided the spread of E. canis in Australia which led to the establishment of this pathogen in Australia.

Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Serologic Testing.

The role of serologic testing for SARS-CoV-2 has evolved during the pandemic as seroprevalence in global populations has increased. The Infectious Diseases Society of America (IDSA) convened an expert panel to perform a systematic review of the coronavirus disease 2019 (COVID-19) serology literature and construct updated best practice guidance related to SARS-CoV-2 serologic testing. This guideline is an update to the fourth in a series of rapid, frequently updated COVID-19 guidelines developed by IDSA. To develop evidence-based recommendations and identify unmet research needs pertaining to the use of anti-SARS-CoV-2 antibody tests for diagnosis, decisions related to vaccination and administration of monoclonal antibodies or convalescent plasma in immunocompromised patients, and identification of a serologic correlate of immunity. A multidisciplinary panel of infectious diseases clinicians, clinical microbiologists and experts in systematic literature reviewed, identified, and prioritized clinical questions related to the use of SARS-CoV-2 serologic tests. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel recommends against serologic testing to diagnose SARS-CoV-2 infection in the first two weeks after symptom onset (strong recommendations, low certainty of evidence). Serologic testing should not be used to provide evidence of COVID-19 in symptomatic patients with a high clinical suspicion and repeatedly negative nucleic acid amplification test results (strong recommendation, very low certainty of evidence). Serologic testing may assist with the diagnosis of multisystem inflammatory syndrome in children (strong recommendation, very low certainty of evidence). To seek evidence for prior SARS-CoV-2 infection, the panel suggests testing for IgG, IgG/IgM, or total antibodies to nucleocapsid protein three to five weeks after symptom onset (conditional recommendation, low certainty of evidence). In individuals with previous SARS-CoV-2 infection or vaccination, we suggest against routine serologic testing given no demonstrated benefit to improving patient outcomes (conditional recommendation, very low certainty of evidence.) The panel acknowledges further that a negative spike antibody test may be a useful metric to identify immunocompromised patients who are candidates for immune therapy. The high seroprevalence of antibodies against SARS-CoV-2 worldwide limits the utility of detecting anti-SARS CoV-2 antibody. The certainty of available evidence supporting the use of serology for diagnosis was graded as very low to low. Future studies should use serologic assays calibrated to a common reference standard.

293 - False negative antibody testing in SRA-Positive Heparin-Induced thrombocytopenia

293 - False negative antibody testing in SRA-Positive Heparin-Induced thrombocytopenia

Granulomatosis with Polyangiitis Presented with Temporal Headache and Tenderness

Granulomatosis with polyangiitis is a necrotizing vasculitis affecting small blood vessels, primarily in the upper and lower respiratory tracts and kidneys. When limited to the upper respiratory tract or nervous system without kidney involvement, it's termed limited granulomatosis with polyangiitis. Diagnosing this variant can be challenging, particularly with negative antibody tests. We report a case of a patient experiencing temporal headaches and tenderness, raising suspicion for temporal arteritis or limited granulomatosis with polyangiitis.

Difficulties in identifying antibodies of high frequency antigens: A case report of anti-Holley antibody

Abstract Introduction/Objective The Dombrock blood group system consists of the Dombrock (Do), Gregory (Gya), Holley (Hy), and Joseph (Joa) antigens, of which, the Gya, Hy, and Joa represent high prevalence antigens. Anti-Hy antibodies have been implicated in hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. Methods/Case Report We report a 22-year-old black female who presented with extensive burns following trauma. At admission the patient typed O, D-positive with a negative indirect antibody test (IAT). After receiving multiple units of red cells, plasma, and platelet products (&amp;gt;100 units total) the patient’s IAT, direct antiglobulin test (DAT) polyclonal, DAT IgG, and DAT C3 became seropositive (day 15 of ongoing transfusions). Elution was negative at all tested phases. An antibody rule-out panel was performed with pan-reactivity at polyethylene glycol (PEG)- anti-human globulin (AHG) (2+), Low ionic strength saline (LISS)-AHG (weak +), Ficin-AHG (2+), and negative with dithiothreitol (DTT)-PEG-AHG. Common DTT sensitive antigens were ruled out. Antigen typing displayed mixed field reactions secondary to transfusions. Hy-Jo(a-) confirmed cells were non-reactive at immediate spin and PEG-AHG. The patient was Dob positive, ruling out a null phenotype. Molecular testing could not be confirmed with serologic testing due to the extensive number of transfusions. Subsequent crossmatching demonstrated 1+ reactivity. The patient clinically tolerated the incompatible units. Her IAT resolved on day 29 of ongoing transfusions and remained negative throughout subsequent testing and transfusion. Results (if a Case Study enter NA) NA Conclusion Identification of antibodies to high frequency antigens is challenging due to the limitation of antigen negative sera in the setting of pan-reactive cells. Furthermore, blood contaminated with donor product limits the ability to perform serologic testing in the setting of mixed field reactivity. This case highlights the difficulty in identifying antibodies to high frequency antigens as well as the limitations in patient testing after extensive transfusion.

Heterogeneous Genetic Landscape of Chronic Idiopathic Neutropenia Revealed By Whole Exome Sequencing

Background: Adultpatients with persistent, unexplained neutropenia who do not fulfill the diagnostic criteria of any underlying disease are characterized as chronic idiopathic neutropenia (CIN) cases.It is an exclusion diagnosis that can be established after a thorough clinical/laboratory investigation for any underlying causes, including negative anti-neutrophil antibody testing, inconclusive bone marrow (BM) aspiration/biopsy and normal cytogenetics. CIN patients regardless of their absolute neutrophil counts (ANC) usually display a benign and uncomplicated clinical course. Although the pathogenesis of CIN remains largely unknown, we hypothesize that a constitutional/congenital background might exist, at least in some cases, that have potentially escaped diagnosis during childhood. Aim of the study: To investigate the genetic landscape of neutropenia in CIN by conducting whole exome sequencing (WES) analysis in a number of adult CIN patients. Methods: We have performed WES in 16 adult (median age 59 years, range 30-72 years) patients (11 females and 5 males) with CIN according to previously published criteria (Fioredda F, et al Hemasphere. 2023). The patients had median ANC 1.2 x 10 9/L (range 0.4-1.6 x 10 9/L) for prolonged period and unknown neutropenia onset in most cases. Genomic DNA was extracted from peripheral blood samples, coding fragment libraries were prepared, sequencing performed on Illumina NovaSeq 6000 System, and data subjected to an in-house pipeline for bioinformatic analysis for variant calling and annotations. Singleton analyses were performed focusing on genes associated with congenital defects of phagocytes, BM failure (BMF) and immune deficiency and dysregulation. Mean depth of coverage was 70x and the mean number of variants/sample was 22553. Results: WES analysis identified 10 pathogenic/likely pathogenic (P/LP) variants in 10 patients. The variants consisted of 4 frameshift mutations, 3 nonsense mutations, 1 missense mutation, 1 splice-site mutation and 1 splice-region mutation. Pathogenic variants in congenital neutropenia (CN)-related genes included only a heterozygous mutation in G6PC3:c.511C&amp;gt;T,p.Gln171Ter (previously detected in one of our CN patients; Nikolouzakis TK et al, Ann Hematol. 2022). Pathogenic variants in genes associated with BMF were detected in two genes, namely FANCM:c.1492C&amp;gt;T, p.Gln498Ter and CTC1:c.3058C&amp;gt;T,p.Gln1020Ter, respectively. The majority of the pathogenic variants were found in genes associated with immune deficiency and dysregulation. These involved: (i) a heterozygous mutation in DCLRE1C:c.1784dup,p.Ile596fs (associated with immunodeficiencies affecting cellular and humoral immunity); (ii) a LP mutation in ORAI1:c.132_133del,p. Arg45fs and a pathogenic variant in SPINK5:c.1302+4A&amp;gt;T (related to combined immunodeficiencies with associated or syndromic features); (iii) a pathogenic variant in MEFV:c.2080A&amp;gt;G, p.Met694Val and a LP variant in PSMG2:c.703-2A&amp;gt;T (both genes associated with autoinflammatory disorders); (iv) a LP variant in IRF7:c.1089dup,p.Pro364Alafs (associated with defects in intrinsic and innate immunity); and (v) a LP variant in PEPD:c.738_739insGT,p.Ser247fs (associated with immune dysregulation). Regarding variants of undetermined significance (VUS) an average of 4.5 VUS variants per patient were detected in genes related to CN ( HAX1, VPS13B, LYST), BMF ( GATA2, SAMD9, CXCR4) or immunodeficiency ( TCF3). However, none of these patients display clinical symptoms typical of these conditions. Specifically, the majority of the patients presented with mild/moderate neutropenia and rarely with severe neutropenia, they have relatively normal BM biopsies and do not display major symptoms or signs related to severe immunodeficiency or immune dysregulation syndromes. Conclusions: This study is the first attempt of WES analysis in adult CIN patients and shows that there is a heterogeneous genetic landscape underlying the disease. More studies are required so that the detected P/LP variants and VUS can be associated with the clinical phenotypes to more accurately interpret their potential contribution to the neutropenia phenotype.

589. Clinical Utility and Patient Characteristics Associated with Positive Whole Blood PCR for Borrelia spp. in an Endemic Area Using Novel High-Definition PCRTM assay: A Case Series

Abstract Background Current guidelines recommend antibody testing to detect acute borreliosis. Detectable antibody response takes about 2-3 weeks limiting its usefulness in early infection. The ChromaCode High-Definition PCR (HDPCR)™ Tick-Borne Pathogen Panel (TBP) is a research use only qualitative, real-time PCR assay for detection and identification of tick-borne pathogens including Borrelia spp. from whole blood samples. Methods HDPCR™ TBP was put in clinical use after this was validated in the laboratory to identify Anaplasma phagocytophilum, Babesia microti, Ehrlichia spp, Borrelia spp. (B. burgdoferi B. mayonii, and B. miyamotoi). Chart review was performed on all (+)Borrelia spp. from 8/1/22 to 12/31/22. Descriptive analysis was performed on each case. All data was captured and stored using RedCap. Results Over a period of 5 months, 9 (0.5%) out of 1667 tested were (+) for B. burgdorferi; one (0.06%) was (+) for B. miyamotoi; out of these 6 cases had clinical information for review as described in Table 1. Mean age was 64 years; 4 were white and 2 were Hispanic. All 6 lived in western Massachusetts, and only 1 had a known history of tick bite. All had reported systemic symptoms at the time of testing. 3 had (+) B. burgdorferi IgM antibodies;1 case tested (+) PCR for B. miyamotoi but serology was not performed. 1 case was (+) for B. burgdorferi PCR 28 days after symptom onset and had babesiosis co-infection; 1 with B. burgdorferi mono-infection had a (+) PCR test on day 14 of symptoms. All 6 had symptom improvement after doxycycline treatment for 10-14 days. Case description Conclusion HDPCR™ TBP for Borrelia spp is a low yield test, even in an endemic region. All (+) cases were symptomatic and clinically improved following doxycycline treatment supporting the test’s validity. Two cases had negative IgM antibody testing and diagnosis would be likely missed without PCR testing. None were immunocompromised including 2 with prolonged PCR positivity with 1 case having babesiosis co-infection. Study was limited only to 6 cases excluding analysis of other tick-borne infections as part of syndromic testing. Clinical usefulness and timing of HDPCR™ TBP to diagnose borreliosis and other tickborne illnesses need further study. Disclosures All Authors: No reported disclosures

SAT084 Maternally Inherited Diabetes With Deafness: A Rare And Challenging Diagnosis Of Diabetes

Abstract Disclosure: K. Cuan: None. I.R. Bass: None. Introduction: Maternally inherited diabetes with deafness (MIDD) is a rare mitochondrial disease with variable phenotypic expression characterized by a defect in insulin secretion and sensorineural hearing loss. Other potential features of MIDD include proximal myopathy, macular retinal dystrophy, and renal focal segmental glomerulosclerosis. Mitochondrial diseases are difficult to recognize given their heterogeneous presentation, however accurate diagnosis of MIDD is important as there are implications for management. DESCRIPTION: A 38-year-old adopted woman with previously diagnosed type 1 diabetes (T1DM), congenital deafness, and chronic kidney disease presented to our endocrinology clinic with concerns for difficulty controlling her blood glucose levels. She was diagnosed with T1DM at age 21 based on age and normal body habitus and was started on insulin. Due to insurance issues, she discontinued insulin use for several years and her diabetes was poorly controlled during that time, however, she never experienced diabetic ketoacidosis (DKA). Upon resuming insulin, she experienced multiple unpredictable episodes of hypoglycemia and subsequently self-discontinued insulin and presented 8 months later for further care. Past history was notable for muscle weakness with walking upstairs and vision loss in her left eye, which led to a diagnosis of retinopathy in her early twenties. Her family history was unavailable as she was adopted. Her physical exam was significant for a normal body mass index of 24. Labs showed a hemoglobin A1C of 10.8% and detectable c-peptide, 2.7 ng/mL (1.1-4.4 ng/mL) with a glucose of 192mg/dL. Glutamic acid decarboxylase, zinc transporter 8, IA-2 and islet-cell antibodies were all negative. Her creatinine was 1.23 ng/dL with a severely increased microalbumin to creatinine ratio (638, 0-29 mg/g). In view of her congenital deafness, non-diabetic retinopathy, absence of DKA while off insulin, negative antibody testing, and chronic kidney disease, mitochondrial diabetes was considered. She was referred to a geneticist for mitochondrial genome sequencing, of which the results are pending. Dietary modification and oral agents were recommended for her diabetes management, rather than insulin therapy. DISCUSSION: MIDD can be challenging to diagnose and patients may be incorrectly labeled as having type 1 diabetes. The presence of maternal transmission can aid in the diagnosis of MIDD, however, our patient was adopted and this information is unavailable. Additionally, retinal and renal features of MIDD can be misconstrued as microvascular complications of diabetes. In patients with deafness and poorly controlled diabetes with negative antibody testing, MIDD should be considered as an alternative diagnosis. MIDD can be managed with dietary modification, oral agents, and insulin if appropriate. Presentation: Saturday, June 17, 2023

SAT580 Incidental Diagnosis Of Genetic Variant PTPN11 Noonan Syndrome With Multiple Lentigines, Sensorineural Hearing Loss And Rheumatoid Arthritis In Adult Female With Hashimoto’s Thyroiditis. Case Report

Abstract Disclosure: M.M. Eid: None. T. Zahra: None. J. Vargas-Jerez: None. Introduction: Hashimoto’s thyroiditis (HT, chronic lymphocytic thyroiditis, autoimmune thyroiditis) and Rheumatoid arthritis (RA) are autoimmune disorders, affect mainly females (1). Noonan syndrome with Multiple Lentigines (NSML, Leopard Syndrome) is a rare multigenetic autosomal dominant disorder. It includes cerebrovascular and cardiac anomalies, facial phenotype, hearing abnormality and developmental delay (2). Case: 41 yo, Female with history of HT since 2002 (high TSH, thyroid peroxidase antibody more than 1000 u/ml, low FT4 and FT3) on levothyroxine 150mcg/day. Recently moved to the USA from EL Salvador. Presented for initial evaluation. Denied smoking, alcohol, allergy. Maternal aunt with thyroid disease. Had menstrual irregularities, no previous attempt to conceive. Review of system: 5 months of pain, swelling and morning stiffness for 1 hour in hand joints, hearing difficulty for 2 years, painless brown skin spots for years, childhood learning difficulty and constipation. Physical examination body weight 139Ib, height 162cm, Stable vitals, diffuse lentigines. Head: board forehead, hypertelorism, high arched eye brows, micrognathia, low set ears. Heart: normal heart sounds, no murmur. No thyromegaly, nystagmus or vertigo. Hand: swelling of metacarpophalangeal and proximal interphalangeal joints. Laboratory work up TSH 8 normal 0.27 to 4.2 uIU/ml, FT4 0.8 normal 0.9-1.8 ng/dl, A1C 5.7, positive rheumatoid factor 199IU/ml, anti-CCP antibody &amp;gt; 250U, ANA 1/320, ESR 61ml/hr, negative anti-tissue transglutaminase antibody, normal liver and kidney function tests and complete blood count. Hand X-ray: decrease joint space and bone erosion. Thyroid US: normal size, vascularity, no nodule. Normal Echocardiogram, EKG and chest X ray. Internal auditory canal MRI: no masses or abnormal enhancement. DEXA Scan: osteopenia of femur and lumbar spine. She was diagnosed with seropositive RA, B/L sensorineural hearing loss (SNHL) more on right side. Genetic test revealed heterozygous pathogenic variant of PTPN11 gene consistent with NSML and negative for Neurofibromatosis type 1. Kept on prednisone and methotrexate, levothyroxine was increased 162mcg/day. Conclusion: Autoimmune disorders have a common pathogenesis including humoral and cell mediated immunity, autoimmune oxidative stress, UV radiation exposure, genetic linkage and biochemical changes. Diagnosis of one autoimmune disorder increases the possibility of other autoimmune disorders (1). NSML has a variable presentation. PTPN11-NSML is usually associated with SNHL and cardiac anomalies as pulmonary stenosis. It is infrequent to diagnose NSML with HT and structurally normal heart like our case(2).

THU668 Euthyroid Graves’ Ophthalmopathy: Case Series

Abstract Disclosure: S.S. Alfadl: None. A.A. Asiri: None. A.A. Jammah: None. O. Alsagheir: None. Introduction: Graves’ ophthalmopathy is an autoimmune disorder that affects the eyes, characterized by swelling, proptosis, lid lag, inflammation and eyelid retraction. A significant proportion of cases are associated with thyrotoxicosis and positive serum TSH receptor antibody tests. Case Description: We present a case series of euthyroid Graves’ ophthalmopathy in patients with a negative TSH receptor antibody. The first case is of a 37-year-old lady who was recently diagnosed with idiopathic intracranial hypertension due to history of recurrent headaches and was found on CT brain to have an incidental empty sella syndrome and findings highly suggestive of thyroid associated orbitopathy. A dedicated MRI orbit showed bilateral mild proptosis with bilateral medial and inferior recti thickening, sparing the tendinous insertion. The involved extraocular muscles show mild peripheral high T2 signals and minimal enhancement on post gadolinium images. The enlarged extraocular muscle demonstrates diffusion restriction with low Apparent Diffusion Coefficient (ADC) value. Clinically, the patient did not exhibit any symptoms of hyperthyroidism or hypothyroidism. She did not notice any changes in her eyes’ appearance, nor any changes in vision or double vision. On examination, she had mild proptosis, no restriction of extraocular movement or provoked double vision. Consequently, she was referred to Ophthalmology for further management. Investigations included a pituitary panel which did not reveal any abnormalities and a thyroid panel which revealed that she was biochemically euthyroid with a negative TSH receptor antibody test. The second case is of a 24-year-old male who is medically free and initially visited the ophthalmology clinic complaining of double vision, without any additional ophthalmic complaints. He was subsequently referred to our care to rule out thyroid eye disease. Clinically, the patient had no indications of thyroid dysfunction. Upon examination, he exhibited severe right eye proptosis with dystopia and early left eye proptosis. CT orbit showed swelling of the right-sided superior rectus, medial rectus, lateral rectus and left-sided superior rectus muscles. The left-sided superior rectus muscle was abutting the optic nerve. Nevertheless, all tendons were spared. Biochemically, he was euthyroid with unremarkable laboratory results. Conclusion: These findings provide insight into the clinical presentation of euthyroid Graves’ ophthalmopathy in patients without thyrotoxicosis or detectable circulating levels of TSH receptor antibodies. Thus, suggesting that thyroid ophthalmopathy might present earlier than Graves’ disease and even earlier than the presence of TSH receptor antibodies. We conclude that a high index of suspicion and proper follow up is recommended in similar patients for the development of Graves’s disease. Presentation: Thursday, June 15, 2023