Normal White Blood Cell Count Research Articles

The elevated admission white blood cell count relates to adverse surgical outcome of acute Stanford type a aortic dissection

BackgroundThe purpose of the study was to examine the association between white blood cell count (WBCc) on admission and early outcome in patients with the acute Stanford type A aortic dissection (TAAD).MethodsFrom January 2012 to December 2018, we retrospectively evaluated a series of 331 consecutive patients underwent surgery for TAAD in Tongji Hospital. The patients were divided into 2 groups based on the WBCc, i.e. the normal WBCc group (WBCc≤11 × 109/L) and leukocytosis group (WBCc> 11 × 109/L). The perioperative data were compared between the 2 groups. The in-hospital mortality and the compositive adverse event including multi-organ dysfunction syndrome, postoperative stroke, tracheotomy, and re-exploration for stopping bleeding were set as end points. Cox regression were used to assess the potential risk factors.ResultsThe in-hospital mortality was nearly 3 time higher in the leukocytosis group than in the normal WBCc group (20.9% vs.8.1%, P = 0.001), and 15.1% overall. For the circulatory arrest, there was significant higher mortality in patients with leukocytosis than normal WBCc group (26.1%vs.8.9%, P = 0.001). After adjustment for confounding factors, the leukocytosis was found to be a strong independent predictor of in-hospital mortality (odds ratio = 3.10; 95% confidence interval 1.38 to 6.97, P = 0.006). The leukocytosis was also a risk factor of adverse events (odds ratio = 1.80; 95% confidence interval 1.07 to 3.04, P = 0.027).ConclusionsThe WBCc within 24 h of admission for TAAD is a strong and independent predictor of in-hospital mortality as well as short-term clinical events. The results of this study have important clinical implications for risk-stratifying patients with TAAD.

Normal white blood cell counts predict long-term mortality of hemodialysis patients.

It is unclear whether normal white blood cell (WBC) counts are predictive of subsequent mortality in hemodialysis patients. All patients aged 17years or more, who initiated hemodialysis at a tertiary Hospital from January 2000 to August 2017 with a dialysis vintage of greater than 90days and normal median WBC count of their first dialysis year were included in the study. They were followed until they died, transferred to other dialysis facilities, switched to peritoneal dialysis, received a renal transplant or reached the end of the study (August 31, 2018). Cox regression was used to estimate hazard ratios for mortality of tertiles of WBC counts, adjusting for baseline demographic, clinical and laboratory variables. 611 patients [median (interquartile range) age 65.2 (53.3-72.6) years, 62.4% male] were studied. During a median follow-up of 3.9 (1.6-7.2) years, 270 participants died. Patients in the mid- (6.25-7.73 × 103/μL, n = 203) and top-tertile (7.73-10.50 × 103/μL, n = 203) of normal WBC counts had significantly higher mortality than patients in the bottom-tertile (3.50-6.25 × 103/μL, n = 205). The adjusted hazard ratio for mortality relative to the bottom-tertile was 1.54, 95% confidence interval (CI) 1.05-2.25 and 2.20, 95% CI 1.46-3.32, for the mid- and top-tertiles, respectively. In hemodialysis patients, higher WBC count within the normal range is associated with increased long-term mortality. This finding is described for the first time and provides further insight into the clinical significance of a "normal" WBC count result in dialysis patients.

Severe COVID-19 Pneumonia: Assessing Inflammation Burden with Volume-rendered Chest CT.

HomeRadiology: Cardiothoracic ImagingVol. 2, No. 2 PreviousNext Images in Cardiothoracic ImagingFree AccessPulmonary ImagingSevere COVID-19 Pneumonia: Assessing Inflammation Burden with Volume-rendered Chest CTLei Tang, Xiaoyong Zhang, Yvquan Wang, Xianchun Zeng Lei Tang, Xiaoyong Zhang, Yvquan Wang, Xianchun Zeng Author AffiliationsFrom the Department of Radiology, Guizhou Provincial People’s Hospital, Guiyang 550002, Guizhou Province, China.Address correspondence to X. Zeng (e-mail: [email protected]).Lei TangXiaoyong ZhangYvquan WangXianchun Zeng Published Online:Mar 6 2020https://doi.org/10.1148/ryct.2020200044MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In COVID-19 (formerly known as 2019 novel coronavirus [2019-nCoV]) broke out in December 2019, and it spread from Wuhan, Hubei Province, to all over China and many other countries in the world (1–4). A 54-year-old woman with a travel history to Wuhan was admitted to the hospital with a 7-day history of fever (38.5°C [101.3°F]), cough, fatigue, and chest congestion. Laboratory examinations showed normal white blood cell count and lymphocytopenia, increased C-reactive protein level and erythrocyte sedimentation rate, and decreased CD3+, CD4+, CD8+, and CD4/CD8. Unenhanced chest CT revealed patchy peripheral ground-glass opacities with upper lobe predominance (Fig 1). A three-dimensional volume-rendering technique (PULMO 3D software, VB20; Siemens Healthineers, Forchheim, Germany) highlighted the distribution of pulmonary opacities, which was useful to determine the extension of the disease (Fig 2, Movie [supplement]). Her nasopharyngeal swab was positive for COVID-19 with real-time fluorescence polymerase chain reaction test. The patient was diagnosed with severe COVID-19 pneumonia. When treated with oxygen inhalation, moxifloxacin, lopinavir/ritonavir, umifenovir, interferon, and thymosin, her body temperature returned to normal and the symptoms slightly improved. CT reexamination on the 5th day of hospitalization indicated increased lesions and mild absorption on the 9th day.Figure 1: CT images in a 54-year-old woman with severe COVID-19 pneumonia. Transverse and coronal images reveal patchy peripheral ground-glass opacities with upper lobe predominance.Figure 1:Download as PowerPointOpen in Image Viewer Figure 2: CT images in a 54-year-old woman with severe COVID-19 pneumonia. A, The color coronal image highlights the distribution of lung lesions (red areas) because software is used to automatically segment and render. B, On a three-dimensional volume-rendering image, trachea, bronchus, lung tissues, and lesions are differentiated by CT values and automatically segmented.Figure 2:Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie Three-dimensional volume-rendering movie in a 54-year-old woman with severe COVID-19 pneumonia. The images highlight the distribution of pulmonary lesions, which are useful to determine the extension of the inflammatory burden.Download Original Video (3.4 MB)Disclosures of Conflicts of Interest: L.T. disclosed no relevant relationships. X. Zhang disclosed no relevant relationships. Y.W. disclosed no relevant relationships. X. Zeng disclosed no relevant relationships.Keywords: CT, Computer Applications-3D, Infection, Lung Authors declared no funding for this work.

Clinical characteristics of COVID-19: an analysis of 11 cases

Objective To analyze the epidemiological features, clinical manifestations, laboratory test findings and radiologic features of COVID-19 patients. Methods Eleven patients positive for 2019-nCoV nucleic acid testing were collected from January 21 to February 4, 2020. Their epidemiological features, initial symptoms, white blood cell count, lymphocyte count, procalcitonin (PCT) level, serum amyloid A (SAA) level, C-reactive protein (CRP) level, radiographic features and treatment regimen were analyzed. All statistical analyses were performed using the SPSS 22.0 software. Results All patients were moderate cases, and the average time from the onset of the illness was (3.8 ±2.4) d. Eight patients had a history of travel to Hubei or exposure to people from Hubei province within 14 d before the onset. The initial symptoms were fever in 9 patients and pharyngalgia in 1 patient, and another patient had no clinical symptoms at all. All patients had normal white blood cell count, and 3 patients had a decreased lymphocyte count. Nine patients had an increased SAA level, and 6 patients had a mild increase in the CRP level. All of them showed a normal PCT level. Imaging mainly showed patchy and interstitial changes. All patients were treated with interferon-α and lopinavir/ritonavir tablets as the basic treatment plan. Three patients were given additional antibacterial treatment, and the disease was well controlled after treatment. Two patients had already been cured and discharged at the time of the manuscript submitted. Conclusions In this report, 11 COVID-19 patients were all imported moderate cases. There were no specific changes in laboratory findings, and the conditions were stable after treatment. Key words: Coronavirus infections; COVID-19; Epidemiology; Clinical features

Emerging 2019 Novel Coronavirus (2019-nCoV) Pneumonia.

BackgroundThe chest CT findings of patients with 2019 Novel Coronavirus (2019-nCoV) pneumonia have not previously been described in detail.PurposeTo investigate the clinical, laboratory, and imaging findings of emerging 2019-nCoV pneumonia in humans.Materials and MethodsFifty-one patients (25 men and 26 women; age range 16–76 years) with laboratory-confirmed 2019-nCoV infection by using real-time reverse transcription polymerase chain reaction underwent thin-section CT. The imaging findings, clinical data, and laboratory data were evaluated.ResultsFifty of 51 patients (98%) had a history of contact with individuals from the endemic center in Wuhan, China. Fever (49 of 51, 96%) and cough (24 of 51, 47%) were the most common symptoms. Most patients had a normal white blood cell count (37 of 51, 73%), neutrophil count (44 of 51, 86%), and either normal (17 of 51, 35%) or reduced (33 of 51, 65%) lymphocyte count. CT images showed pure ground-glass opacity (GGO) in 39 of 51 (77%) patients and GGO with reticular and/or interlobular septal thickening in 38 of 51 (75%) patients. GGO with consolidation was present in 30 of 51 (59%) patients, and pure consolidation was present in 28 of 51 (55%) patients. Forty-four of 51 (86%) patients had bilateral lung involvement, while 41 of 51 (80%) involved the posterior part of the lungs and 44 of 51 (86%) were peripheral. There were more consolidated lung lesions in patients 5 days or more from disease onset to CT scan versus 4 days or fewer (431 of 712 lesions vs 129 of 612 lesions; P < .001). Patients older than 50 years had more consolidated lung lesions than did those aged 50 years or younger (212 of 470 vs 198 of 854; P < .001). Follow-up CT in 13 patients showed improvement in seven (54%) patients and progression in four (31%) patients.ConclusionPatients with fever and/or cough and with conspicuous ground-glass opacity lesions in the peripheral and posterior lungs on CT images, combined with normal or decreased white blood cells and a history of epidemic exposure, are highly suspected of having 2019 Novel Coronavirus (2019-nCoV) pneumonia.© RSNA, 2020

Difficulties in indicating appendectomy; diagnosis of appendicitis in patients with normal white blood cell count

Objectives: Even after 130 years have passed since the first appendectomy, diagnosing acute appendicitis can still be challenging. The objective of this study was to investigate clinical, imaging and laboratory findings of patients diagnosed with acute appendicitis in order to determine whether white blood cell count is helpful in the diagnosis. &#x0D; Materials and Methods: Parameters of Alvarado score, patients’ complaints, physical examination and laboratory findings were recorded. Appendiceal diameters of patients detected with ultrasound (US) were also recorded. &#x0D; Results: Of the 98 patients, 89 patients (91%) had an appendiceal diameter wider than 8 mm and 9 patients (9%) had an appendiceal diameter of 8 mm and smaller in the preoperative US. Pathology was normal in 8 out of 9 patients (89%) with a diameter of 8 mm and below; and 9 out of 89 patients (9%) with a diameter above 8 mm (p

Cerebrospinal fluid pleocytosis as a predictive factor for CSF and plasma HIV RNA discordance and escape.

The aims of this study were to investigate the frequency of HIV-1 RNA level discordance between the cerebrospinal fluid (CSF) and plasma and of CSF viral escape (CVE) in patients with HIV-1 subtype C on antiretroviral therapy, and evaluate the CSF white blood cell (WBC) performance characteristics in predicting CSF discordance in HIV+ group and the frequency of cognitive impairment in individuals with CSF HIV discordance or escape. HIV-1 RNA levels were assessed in plasma and CSF samples from 68 HIV+ participants without opportunistic infection. CSF discordance was found in 7.4% and CVE in 10%, with comparable frequencies between HIV-1B and C. Twenty samples (29%) showed increased CSF WBC counts. This group had higher CSF and plasma HIV-1 RNA levels than the group with normal WBC counts (p < 0.0001 and 0.006, respectively). The odds of CSF discordance were 18 times higher for a person with CSF WBC count of > 5cells/mm3 than the group with normal CSF WBC count. CSF WBC counts (cut-off of 15cells/mm3) showed high-performance characteristics as a predictive biomarker of CSF discordance (AUC the ROC curve 0.98). The frequency of cognitive impairment for CSF escape or discordance was 83% and 80%. The odds of cognitive impairment in these groups were 19 and 15 times higher than those for an HIV(-) person. Viral discordance or escape in the CNS occurs at a comparable frequency for HIV-1C and HIV-1B. The CSF WBC count was effective as a predictive biomarker of CSF and plasma discordance.

An Unusual Finding During Endoscopic Ultrasound-Guided Gallbladder Drainage

Question: A 39-year-old man with stage III adenocarcinoma of the pancreas presented with right upper quadrant abdominal pain. Five months earlier, the patient was hospitalized for acute calculous cholecystitis complicated by gallbladder perforation, requiring antimicrobials and percutaneous drain placement, with eventual clinical resolution. Physical examination revealed right upper quadrant tenderness to palpation. Laboratory tests were notable for normal white blood cell count (4.9 × 103/μL) and normal total bilirubin (0.3 mg/dL).

CT Imaging Evolution of Novel Coronavirus Pneumonia during Hospitalization

Object: To evaluate CT Features on serial thin-section computed tomographic (CT) scans in patients with conventional Novel Coronavirus Pneumonia (COVID-19) for the period during which they remained hospitalized. Methods: In this Retrospective study, we collected clinical information including Laboratory investigations and more importantly we focused on collecting imaging data of these 15 selected patients (8 men and 7 women, 22 - 70 years old, average age (45 ± 15)) with COVID-19 disease. The mean time between the initial and repeat thin-section CT scans was 3.3 ± 2.1 days, 7.9 ± 2.1 days, 14.2 ± 1.3 days after onset of symptoms in these 15 patients. Three experienced Radiologists reviewed the CT images independently and also in collaboration with each other for complicated or unique cases, for the Imaging characteristics like number and site of lesions, distribution of lesions whether it is lobular, lobar, unilateral or bilateral, and comparing the severity of disease in relation to the CT findings. The CT features were compared using the χ2 test and Fisher’s exact probability. Results: All of 15 patients had a history of visit to the endemic center i.e. Wuhan city or came in direct contact with an infected individual. Fever (93.3%) was the most common symptom. Majority of patients had a normal white blood cell count, and normal lymphocyte count although there were patients with leucopenia and lymphocytopenia. CT images showed predominate Ground-Glass opacities in the initial and repeat CT scans with a percentage of 90.6%, 53.9%, 44.2% respectively during the three spaced CT examinations; most patients had bilateral lung involvement (60%, 93.3%, 93.3%), the lesions predominantly involved the posterior (87.5%, 71.9%, 76.6%) and peripheral (90.6%, 84.3%, 85.7%) part of the lungs. There were more consolidation and mixed patterns in repeat CT scan Versus initial CT scan, the difference was statistically significant (P-values were ± 2.1 days) 63 (7.9 ± 2.1 days), and 57 (14.2 ± 1.3 days) respectively. The median percentage of pneumonia lesions of the whole lung volume in three times CT scan was 1.69% (4.59), 3.47% (5.46), 2.33% (4.75) respectively. Besides, “Tree-in-bud” sign, lung cavitation, and lymphadenopathy were absent. Conclusion: The Thin-slice Section CT Imaging features show uniquely different characteristics, each time the scans are taken. The most common findings in our study were bilateral multiple peripheral and mostly posterior ground-glass opacities (GGO), however the CT scan images that were taken in a timely manner to follow up demonstrated some remarkable changes, which undoubtedly play an important role in the diagnosis and management of the patient with COVID-19 disease.

Efficacy of bilirubin values in diagnosing acute appendicitis in patients with normal white blood cell count and predicting complicated appendicitis.

Laboratory parameters have important diagnostic value in the evaluation of acute appendicitis. This study aimed to evaluate the efficacy of bilirubin values in predicting acute and complicated appendicitis in patients with leukocyte values in the normal reference range. This study included 200 patients aged 18 and over who underwent appendectomy with leukocyte values within the normal reference range. The demographic characteristics, total and direct bilirubin and C-reactive protein values of the patients were examined. According to the pathology results, the patients were divided into two groups as a normal appendix and acute appendicitis. Acute appendicitis was further classified as simple and complicated. Of the 200 patients included in this study, 110 (55%) were female and 90 (45%) were male, and the mean age was 37±16 years. The pathology results were reported as normal in 45 (22.5%) and acute appendicitis in the remainder of the sample. Of those diagnosed with acute appendicitis, 141 (91%) had simple appendicitis and 14 (9%) had complicated appendicitis. When the normal appendix and acute appendicitis groups were compared, the total and direct bilirubin levels were higher in the patients diagnosed with acute appendicitis. According to the receiver operator characteristic curve analysis, the area under the curve values of total bilirubin and direct bilirubin for the prediction of acute appendicitis were 0.597 and 0.625, respectively. In patients with normal leukocyte values, high bilirubin levels may be useful in predicting the diagnosis of acute appendicitis.

Pediatric COVID-19 Patients in Jeddah, Saudi Arabia: Clinical, Laboratory and Radiological Aspects

Objectives: The aim of this study is to describe the clinical manifestations along with the laboratory and radiographic findings in the local pediatric population in order to better understand the novel corona virus and its implications on the pediatric age group. Method: The Pediatric Coronavirus in Saudi Arabia (PERSONA) study, a retrospective cohort, was conducted at Dr. Soliman Fakeeh Hospital in Jeddah, Saudi Arabia to analyse the clinical, laboratory and radiological findings of pediatric patients confirmed to have the novel coronavirus through PCR for COVID-19 taken via nasopharyngeal swabs from March 1, 2020 to May 13, 2020. Result: Approximately 54% (13/24) were male and 46% (11/24) were female. Patients ages ranged from 13 days to 17 years with an average of about 8.4 years and a standard deviation of 5.87 years. Leucopoenia was present in 4/22 patients, while 75% had normal white blood cell counts. Neutropenia was evident in 25% (6/22) of patients while 83.3% (20/22) of patients exhibited normal lymphocyte counts. Eosinopenia was the striking finding in 75% (18/22) of those in the study while only four (16.7%) of the COVID-19 patients showed normal eosinophil counts. Conclusion: Eosinopenia may be a sign of less severe infection in children and therefore should be further studied. More research is needed in the region to better understand the implications of the novel corona virus and whether disease course and burden differs across nations and from adults to pediatrics. What’s Known on this Subject: The novel corona virus first emerged in Wuhan in December 2019. This virus is spread by respiratory droplets and initially infects the respiratory system. Most studies done to present day have been on the effect of the virus in adults. What this Study Adds: This study explores the effect of COVID-19 on children in Saudi Arabia and whether their clinical, laboratory and radiological features are similar to children in China. This study will help to better understand the disease course in this age group.

Co-infection with malaria and coronavirus disease-2019

Sir, Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), is an ongoing global pandemic. Among the plethora of knowledge being garnered about the virus, the occurrence of co-infections and superinfections is also being reported.[1] Although SARS-CoV-2 is the first culprit to be suspected in symptomatic cases, it is important not to lose sight of the burden India faces with other infectious diseases. We report a case of malaria and COVID-19 co-infection. A 67-year-old male, a known case of type 2 diabetes mellitus and heart disease, presented with complaints of fever and progressive exertional breathlessness for 4 days in the 1st week of May. He had no history of travel or contact with a COVID-19-confirmed case. On examination, his oxygen saturation was 96% on room air. Complete blood count revealed moderate thrombocytopenia of 71.0 × 109/L with normal hemoglobin and white blood cell counts. On peripheral blood examination, ring forms and trophozoites of Plasmodium vivax were seen, along with reactive lymphocytes [Figure 1]. Chest X-ray (anteroposterior view) showed haziness in both lung fields. The patient was started on intravenous injection artesunate, followed by artemether and lumefantrine, per oral. He responded well to the antimalarial treatment with symptomatic relief.Figure 1: Peripheral blood smear showing ring form (red arrow) and trophozoite (white arrow) of Plasmodium vivax. A reactive lymphocyte is also seen (black arrow) (Leishman stain, ×400)Although his first nasopharyngeal swab for SARS-CoV-2 real-time reverse transcription–polymerase chain reaction test indicated the absence of the virus, repeat swabs sent on day 3 revealed positivity for the same. In the coming week, his platelet counts improved to normal levels, and he became clinically asymptomatic and stable. Co-infections of COVID-19 are thought to be very common, as high as 80%, most commonly with seasonal respiratory pathogens.[1] With overlapping symptoms and travel history (significant for COVID-19 and malaria), co-infection diagnosis may be challenging. India witnesses a temporal rise in water-borne and water-related diseases, including malaria, in the monsoon season, annually. With the ongoing pandemic, one can expect an increase in the rate of co-infections with COVID-19. It is important to investigate thoroughly in order to correctly identify a treatable infection as well as the presence of co-infections. While many clinical trials are ongoing for COVID-19 with no approved treatment regimen yet, there are already established antimalarial, antiviral, and antibiotic schemes for known infections. At present, the entire population, globally, is at very high risk of COVID-19. In 2018, it was reported that nearly half of the world population was at risk of malaria.[2] A single case of COVID-19 can potentially be infective to 3.58 susceptible individuals.[3] Likewise, an untreated case of malaria can lead to community spread. Furthermore, due to lockdowns and restricted mobility, there have been interruptions to health-care access and national malarial control programs. The World Health Organization is urging countries to ensure the continuity of malaria services in the context of the COVID-19 pandemic.[4] It is advisable that health-care professionals screen for malaria while they test for COVID-19.[5] This would help in timely identification of two infectious diseases having significant global impacts and reduce unnecessary morbidity and mortality. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical presentations and management of COVID-19 infected children seen in a district health facility in Kambia, northern Sierra Leone

Studies reporting the clinical presentations of COVID-19 in children in sub-Saharan Africa are few, especially from resource-constrained countries. This case series reports the demographic and clinical characteristics and laboratory findings of confirmed cases of COVID-19 in children seen at a district hospital in Sierra Leone. This is a report of nine COVID-19 paediatric cases managed at a secondary level hospital in Kambia District, Northern Sierra Leone. Each child was detected by contact tracing after an infected adult was identified by the COVID-19 response team. The clinical symptoms at presentation, clinical courses, and treatments instituted and patient outcomes are discussed in the context of the facilities available at a typical West African district hospital. Nine out of 30 individuals with confirmed COVID-19 infection who presented to the hospital from 24 April to 20 September 2020 and who were admitted to the isolation center of the hospital were in the paediatric age group. The mean age (SD) and median (IQR) of the children were 69.0 ± 51.7months and 84.0 (10.5, 108.0) months, respectively; five (55.6%) were males. The children were asymptomatic or only had mild illnesses and none required intranasal oxygen or ventilatory support. In the five symptomatic children, the most common symptoms were fever (40%) and cough (40%). All children had normal haemoglobin, platelet and white blood cell (WBC) count. Four children had a positive malaria test and were treated with a complete course of anti-malaria medications. No child received steroid or had specific anti-COVID-19 treatment. All children stayed in the isolation center for 14 days and were re-tested for COVID-19 two weeks after initial diagnosis. No complications have been reported in any of them since discharge. The proportion of children among COVID-19 infected cases seen in a rural community in Sierra Leone was 30%. Fever was the most common symptom and malaria was confirmed in 40% of the infected children. This has significant implication on the diagnosis of COVID-19 in malaria-endemic settings and on how best to manage children who present with fever during the COVID-19 pandemic.

A Rare Hemoglobinopathy as a Cause of Erythrocytosis in a Patient with Suspected JAK2V617F Negative Polycythemia Vera: A Case Report

Introduction: Differential diagnosis of polyglobulia/erythrocytosis which is caused by deregulated erythropoiesis with an overproduction of red blood cells resulting in elevated hemoglobin and hematocrit levels is a diagnostic challenge. Case Report: A 31-year-old man was referred to us with a suspected diagnosis of polycythemia vera (a clonal myeloproliferative neoplasm) because of erythrocytosis. One year before, he suffered from an ischemic central retinal vein occlusion of unknown cause. Aspirin treatment was initiated. His mother was diagnosed with a JAK2V617F negative polycythemia vera years earlier and treated with phlebotomies as well as aspirin. Apart from erythrocytosis, laboratory analysis showed a normal white blood cell and platelet counts. The differential blood picture and lactate dehydrogenase were within the normal ranges. Molecular testing for BCR-ABL, JAK2V617F and Calreticulin gene mutations by PCR was negative. Bone marrow biopsy was normal without signs for a myeloproliferative neoplasm. As almost all patients with polycythemia vera carry the phenotype-driver mutation JAK2V617F, further genetic testing for congenital causes of erythrocytosis was conducted. Mutations in the EPO-receptor gene were not found, but a very rare heterozygous point mutation in the beta-globin-chain [exon 2 (c.119A>C) leading to a change in codon 40 (CAG>CCG)] was detected by next generation sequencing. This rare variant belongs to the high oxygen affinity hemoglobinopathies leading to a reduction of oxygen supply in tissues and an increase in red cell production. Conclusion: The diagnosis of a JAK2 mutation negative polycythemia vera must always be questioned and congenital causes of erythrocytosis excluded as the therapeutic and prognostic consequences are immense. Rare variants of hemoglobinopathies, particularly those with high oxygen affinity need to be excluded by molecular testing.

An Experience with 31 Cases of Neonatal Appendicitis: A Retrospective Study

Background: Neonatal appendicitis (NA) is rarely diagnosed due to lack of specific symptoms and signs. The aim of this study is to share our experience with NA.Methods: We performed a retrospective data review from electronic medical records of patients admitted at Children’s Hospital of Chongqing Medical University (CHCMU) with the clinical diagnosis of NA from October 2001 to July 2018.Results: Of 31 neonates, male neonates (n=20) accounted for 64.5%. Abdominal distension and anorexia were the most common clinical features (61.3%, n=19). Neonates with elevated C- reactive protein (CRP) accounted for 92.6% (n=25) where as 51.6% (n=16) had normal white blood cell count (WBC). Of 29 neonates who underwent surgery, 69% (n=20) had perforated appendicitis.Conclusion: Neonatal appendicitis lacks specific clinical features, and early diagnosis is difficult. Clinicians need to have high index of suspicion when attending neonates with features of abdominal sepsis.

The 31-nucleotide Y4-RNA fragment in plasma is a potential novel biomarker

The 31- and 32-nt 5′-fragment of Y4-RNA (Y4RNAfr) exists abundantly in human peripheral blood plasma. Although physiological roles of the plasma Y4RNAfr are not well established, its potential utility as a diagnostic/prognostic marker for acute coronary syndrome was suggested. In this paper, to establish a normal range of the Y4RNAfr level in plasma, we measured plasma Y4RNAfr levels of 40 healthy persons using the method we have developed, and compared them with other blood test data. From the obtained data, we tentatively regarded <0.1 fmol/ng as normal for the Y4RNAfr level in peripheral blood plasma. And the white blood cell count (WBC) and the C-reactive protein (CRP) level showed moderate positive correlations with the Y4RNAfr level, suggesting that Y4RNAfr could be a potential novel inflammatory marker. We also measured the Y4RNAfr level in peripheral blood plasma from four multiple myeloma patients. The plasma Y4RNAfr level was abnormal in all four myeloma patients, and the levels for two patients were far beyond the normal level. The WBC for each patient was normal and the CRP levels for two patients were normal. These observations together suggest that a high level of Y4RNAfr in peripheral blood plasma and a normal WBC could be indicative of multiple myeloma.

Determine White Blood Cell Count (WBCC) Limits and ABL Ct Cut-Off with ABL Copy Number (CN) Calibration for the Xpert® BCR-ABL Ultra Assay

Introduction Monitoring BCR-ABL transcript levels in peripheral blood of patients using real-time quantitative PCR is standard of care in the management of Chronic Myeloid Leukemia. Xpert BCR-ABL Ultra is an automated cartridge-based assay developed by Cepheid for sensitive assessment of BCR-ABL transcript levels. However, in clinical situations the total RNA isolated from white blood cell (WBC) in the patient's blood is insufficient to ensure assay LoD of 0.003% (IS)/MR4.52, or high WBCC in specimen can overload the Ultra cartridge, resulting in inaccurate test results. Therefore, it is necessary to determine proper WBCC input, to ensure accurate assay quantification results. Objectives The objective of this study was to determine the correlation between ABL copy number input and Ct value, determine lower and upper WBCC input limits for the Xpert BCR-ABL Ultra assay and establish the ABL Ct cut-offs. Methods To establish an upper ABL Ct limit that corresponds to a minimal ABL CN input of 32,000 for supporting LoD, a BCR-ABL plasmid DNA (pDNA, ERM-AD623) was serially diluted and tested in an EDTA whole blood background to make a calibration panel. A standard curve was generated against which the ABL Ct could be estimated as a function of ABL copy number. To estimate the lower WBCC limit, CML negative EDTA lysate with normal WBCC was serially diluted with WBC depleted EDTA lysate. To estimate the upper WBCC limit, EDTA lysate from a specimen with high WBCC (69.9×106cells/mL) was diluted with CML negative lysate with normal WBCC (3.5×106 cells/mL). To validate the WBCC limit, CML positive lysate with high WBCC (40×106cells/mL) was diluted with high WBCC (40×106cells/mL) CML negative lysate to produce five BCR-ABL levels within 0.03% (IS)/MR3.52 to 65% (IS)/MR0.19. Each level was further diluted with PBS lysate to achieve 8 levels of WBCC from 40×106 to 0.04×106 cells/mL. Results ABL Ct value of ~19 corresponding to a minimum ABL copy number input of 32,000 was established to support assay LoD of 0.003% (IS)/MR4.52 (Figure.1). To allow for a one Ct buffer, the upper ABL Ct cut-off was set at 18. The lower WBCC input limit, corresponding to the upper ABL Ct limit of ~18 with estimated ABL copy number greater than 64,000, was established to be 0.15×106 cells/mL (Figure.2) The upper WBCC input limit was established to be 30×106 cells/mL. This corresponds approximately to a Ct value of 10 (Figure.3). The Xpert BCR-ABL Ultra test monitors RNA expression levels of the BCR-ABL fusion transcript and the ABL transcript. Unlike a gene DNA marker, RNA expression levels are variable and can fluctuate. To accommodate for the variability in RNA expression levels and based on results from this study, the upper ABL Ct cut-off was lowered to 8. The lower and upper WBCC input limit, together with ABL Ct cut-off, were validated with CML patient specimens with WBCC input ranging from 0.04 to 40 × 106 /ml within IS% range of 0.03% to 65% (Table.1). The normal WBCC of 4 to 10 × 106/mL across all tested concentrations yielded ABL Ct range from 13.2 to 11.7 with estimated ABL copy number of 2.5×106 to 7.8×106. Conclusions A correlation between ABL copy number input and ABL Ct value was established with the standard curve generated from a pDNA calibration panel. The lower WBCC limit was set at 1.5×105 cells/mL and upper WBCC limit was set at 3.0×107 cells/mL, together with ABL Ct cut-offs of 18 and 8 and ABL copy number of 6.4×104 to 1.4×108, to support Xpert BCR-ABL Ultra assay performance. The normal WBCC of 4 to10×106/mL across all tested concentrations yielded an ABL Ct range from 13.2 to 11.7 with estimated ABL copy number of 2.5×106 to 7.8×106, indicating Xpert BCR-ABL Ultra assay normally provided more than 10 times the required minimum ABL Copy number to support the assay LoD claim at 0.003% (IS). *Product in development. Not for use in diagnostic procedures. Not reviewed by any regulatory body. Disclosures No relevant conflicts of interest to declare.

The clinical analysis of chronic obstructive pulmonary disease patients complicated with nontuberculous mycobacterial pulmonary disease

Objectives: Long-term use of inhaled corticosteroids (ICS) was reported as a risk factor for patients with chronic obstructive pulmonary disease (COPD) complicated with nontuberculous mycobacterial lung disease (NTM-LD). But it was not reported often in China. Methods: We conducted a retrospective analysis of patients who were diagnosed with COPD and NTM-LD in our department from January 1(st) 2017 to December 31(th) 2018. Results: This study consisted of 10 male and 5 female patients with a mean age of (66±7) years. The detailed clinical data and radiological images were reviewed systemically. There were 4 current smokers (26.7%) and 6 past smokers (40%). All cases were current ICS users, with a mean duration of (27.3±9.7) months, ranging from 3 months to 61 months. Among them, 8 cases (53.3%) used inhaled fluticasone and 7 cases (46.7%) used inhaled budesonide. Aggravated coughing (15 cases, 100%), expectoration (15 cases, 100%) and dyspnea (10 cases, 66.7%) were the common clinical manifestations, although fever was only reported in 4 cases (26.7%). All cases showed normal white blood cell count and lymphocyte count, and some of them (7 cases, 46.7%) showed elevated erythrocyte sedimentation rate and C-reactive protein. Most of them (14 cases, 93.3%) had normal TB-SPOT results. Multiple focal bronchiectasis (9 cases, 60%) and significant emphysema (12 cases, 80%) were the common manifestations of basic high-resolution CT (HRCT) prior NTM infection. The occurrence of bronchiectasis (15 cases, 100%), "tree in bud" sign (12 cases, 80%) and tiny cavities (8 cases, 53.3%) were the common HRCT abnormalities for the NTM-LD cases. According to the 2007's NTM-LD diagnosis criteria, most of them (13 cases, 86.7%) were diagnosed with positive sputum samples at least twice, and 2 cases were diagnosed with positive CT-directed bronchial alveolar lavage fluid. NTM-PCR analysis was performed routinely for the isolated NTM samples to identify the NTM species. Mycobacterium avium complex (MAC) was the most common NTM species (8 cases, 53.3%). After treatment with proposed anti-NTM strategies, most cases improved (9 cases, 60%), and some of them (4 cases, 26.7%) were cured and a few cases (2 cases, 13.3%) relapsed. Conclusions: When COPD patients treated with ICS showed aggravated cough, expectation and/or dyspnea, and new occurrence of bronchiectasis and/or "tree in bud" sign in the recent HRCT, the differential diagnosis of NTM-LD should be considered. Respiratory samples should be arranged for NTM cultures and PCR analysis as soon as possible. Earlier antimicrobial strategies according to the identified NTM species would improve the clinical outcomes.

377. Diagnostic Yield of Bone Marrow Aspiration and Biopsy in Human Immunodeficiency Virus Patients with Fever and/or Cytopenia

BackgroundHuman Immunodeficiency Virus (HIV) patients are at increased risk of opportunistic infections and malignancies. Evaluation for the etiology of fever and/or cytopenia with conventional means such as cultures and serology can remain negative. Bone marrow aspiration or biopsy (BMAB) has the advantage of diagnosing disseminated infections, hematological abnormalities and oncological malignancies in HIV patients.MethodsWe performed a retrospective descriptive study of HIV patients with fever and/ or cytopenia who underwent Bone marrow aspiration or biopsy (BMAB). Patients with a diagnosis of HIV, 18 years and older who underwent BMAB in University Health (UH) Hospital or in UH clinics from January 2012 to February 2018 were included.ResultsThere were a total of 42 patients who underwent Bone Marrow Aspiration or Biopsy. The median age was 41.5 years. Twenty-eight patients were Male and 14 were female. Preexisting Hematological malignancy was present in 10 patients at the time of BMAB. Average CD4 count at the time of BMAB was 92. 8 patients were compliant with ART and 12 patients were compliant with clinic appointments. White Blood Cell (WBC) count below 4.4 cells / L was present in 30 patients at the time of BMAB. Disseminated Mycobacterium Avium Complex infection (2 patients),Disseminated Histoplasmosis (2 patients), Disseminated Cryptococcus (1 patient) and Parvovirus B19 (based on Immunohistochemistry, 1 patient) were diagnosed from BMAB. CD4 count of these 6 patients range from 0 to 12 at the time of BMAB. All 6 patients presented to the hospital with fever for evaluation. Average WBC count, Hemoglobin and platelet count in these patients are 4.1 cells / liter, 8.7 g/dL and 74.8 k/micro liter, respectively. All 6 patients were non compliant to HIV medications and clinic appointments.ConclusionSince the advent of Anti Retroviral drugs with excellent efficacy and early diagnosis of HIV patients, incidence of disseminated fungal and mycobacterial infections have decreased in the United States. But patients with low CD4 count and cytopenias warrant a Bone Marrow aspiration or Biopsy to make a clear and early diagnosis.Disclosures All authors: No reported disclosures.

The clinical characteristics and prognosis of 20 patients with H7N9 avian influenza

Objective: To analyzed the clinical characteristics and prognosis of patients with H7N9 avian influenza. Methods: The baseline characteristics, clinical manifestations, treatments, laboratory and imaging findings were collected and analyzed for 20 patients with H7N9 avian influenza admitted to the First Affiliated Hospital of Nanchang University from December 2016 to March 2017. According to the final clinical outcome, the patients were divided into the death group and the survival group. Ten patients in the death group died, and 10 patients in the survival group were discharged. The data with normal distribution were analyzed by t test. The data with non-normal distribution were analyzed by Wilcoxon rank sum test. Results: Of the 20 patients, 13 were males and 7 were females, aging 40-82 years, with a mean age of (60±12) years. Twelve patients had a definite history of poultry exposure and 10 had chronic underlying diseases such as hypertension and diabetes. The clinical manifestations were mainly fever, cough, hemoptysis, respiratory distress, fatigue, etc. In the survival group, the platelet count was(167-315)×10(9)/L, while it was (78-152)×10(9)/L in the death group. The average white blood cell count was (7.78-11.52)×10(9)/L and (9.91-15.93)×10(9)/L in the survival and death groups respectively. The average value of lymphocyte count was (0.69-1.59)×10(9)/L and (0.58-0.86)×10(9)/L in the survival and death groups respectively. In the death group the glutamic-pyruvic transaminase (ALT) value was (14.0-352.0) U/L, the total bilirubin value was (6.9-34.5) μmol/L, the creatine kinase MB (CK-MB) was (16.0-162.0) U/L, the serum calcium value was (1.4-2.0) mmol/L, the C-reactive protein value was (33.1-414.0) mg/L, and the calcium reduction prime value was (0.6-100.0) μg/L. In the survival group,the ALT value was (25.0-181.0) U/L, the total bilirubin value was (4.8-25.9) μmol/L, the CK-MB value was (15.0-40.0) U/L, the serum calcium value was (1.9-2.4) mmol/L, the C-reaction protein value was (12.8-52.5) mg/L, and the procalcitonin value was (0.3-23.3) μg/L. Sixteen cases suffered severe pneumonia. Twelve patients received extracorporeal membrane oxygenation (ECMO), and 4 survived. The cause of death was mainly related to factors such as age, chronic underlying diseases and severity of illness. Conclusions: Human infection with H7N9 avian influenza virus was highly pathogenic, and prone to progress into severe pneumonia, with a high mortality. Decreased platelet count was associated with mortality (t=4.07, P=0.001), predictive of patient outcome.