Relative Lymphopenia Research Articles

Blood leukocytes in heart failure with preserved ejection fraction: Impact on prognosis

Heart failure (HF) with preserved ejection fraction (HFpEF) is an emerging problem of cardiovascular medicine with increasing prevalence and poor prognosis [1,2]. The pathophysiological mechanisms of HFpEF are still poorly understood. Leukocytes play important role in the pathogenesis and prognosis of HF with reduced ejection fraction (HFrEF) via their contribution to inflammation, extracellular matrix remodelling, and reparatory processes [3]. Relative lymphopenia is a strong predictor of mortality in severe HFrEF [4,5]. In contrast, neutrophils are often increased in HFrEF and pose an increased risk of all-cause and cardiovascular mortality [6]. However, only scarce data are available on the impact of leukocytes on pathophysiology and outcome in HFpEF. In this study we aimed to compare levels of neutrophiles, lymphocytes and monocytes between patients with HFrEF and HFpEF and to establish their impact on the mortality in HFpEF. The total number of 1019 HF patients referred the Cardiology Clinic of the Grodno Regional Clinical Hospital in 2008–2009 with either HFpEF (n=856, age 55[49–64], 81% males) or HFrEF (n=163, age 58[51–65], 56% males) were included into the study. The diagnosis of HFrEF or HFpEF was established according to the current ESC guidelines [7]. Patients with life expectancy b1 year due to noncardiac courses (e.g., cancer) and those with terminal HF (NYHA class IV) were not included. All subjects underwent transthoracic echocardiography with LVEF measured using the modified Simpson's biplane method and diastolic function assessed by evaluating E/A ratio. The leucocytes were measured using an automatic haematocytometer (Micros-60 Horiba, ABX Diagnostics, France). The patients were followed for at least 1 year with median (interquartile range) follow-up duration of 17[14–20]months with the end-point of any-cause death registered. The study was approved by the Institutional Research Board of the Grodno State Medical University. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8]. Most patients had mild HF (NYHA I–II class in 98% of HFpEF, 82% of HFrEF) predominantly of ischemic aetiology (74% of HFpEF, 73% of HFrEF). Patients with HFrEF had lower body mass index (p=0.017), and proportion of patients with history of hypertension (pb0.001), higher proportions of males (pb0.001), and subjects with history of previous myocardial infarction (p=0.002). PatientswithHFpEF as comparedwithHFrEF had significantly lower neutrophil count (4140[3498–5293] vs. 3933[3247–4760] per μl, p=0.004) and percentage (63[58–68]% vs. 65[59–69]%, p=0.018) and higher lymphocyte percentage (30[26–34]% vs. 29[24–33], p=0.004). On regression analysis, significant clinical predictors of reduced LVEF in the whole study population were advanced age, male sex, history of hypertension and atrial fibrillation (pb0.05). Among leukocytes, high neutrophil count and percentage and low lymphocyte percentage were associated with reduced LVEF and remained so after adjustment for the clinical predictors above (pb0.05). During the follow-up period, 41 deaths (4.02%) occurred (28 in HFpEF and 13 in HFrEF). Using logistic regression analysis, a history of hypertension was the only significant clinical predictor of death in HFpEF. Among leukocytes, high monocyte count was predictive of death in HFpEF before (p=0.01) and after (p=0.012) adjustment for age, LVEF, and hypertension (p=0.012) (Table 1). In HFpEF 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.12.049

Haemato-biochemical alterations induced by Diclofenac sodium toxicity in Swiss albino mice

Aim: An experiment was conducted to study the haemato-biochemical alterations induced by Diclofenac Sodium toxicity. Materials and Methods: 48 Swiss albino mice of either sex, divided uniformly into four different groups. The mice of group I received only deionised water as control while, group II, III and IV were given Diclofenac sodium @ 2.37 mg/kg B.W, 4.75 mg/kg B.W, 9.5 mg/kg B.W orally for 28 days. Results: In dose dependant significant reductions in TEC, Hb, PCV, MCV, MCHC were observed. No significant change was observed in total WBC count in both the sexes. However, relative values of leukocytes indicated relative neutrophilia and relative lymphopenia in higher group. Biochemically dose dependant significant changes were observed for AST, ALT, Total bilirubin, Total protein, Albumin, Globulin, Cholesterol, Urea, Creatinine and Uric acid in male and female animals. Conclusion: The present study indicates hepatobilliary, nephric and gastrointestinal toxicity in albino swiss mice due to Diclofenac Sodium Toxicity.

Low CD40L levels and relative lymphopenia in narcoleptic patients

Narcolepsy has been studied as a possible autoimmune disease for many years, and recent findings lend more credence to this belief. Although recent and important advances have been done, no study has analyzed the role of the CD40L in patients with narcolepsy. The purpose of this study was to assess CD40L levels, CD3, TCD4, TCD8, CD19, and CD56 lymphocytes, as well as levels of tumor necrosis factor–α and interleukin-6 in narcoleptic patients. We quantified the levels of CD40L, different types of lymphocytes, and levels of tumor necrosis factor–α and interleukin-6 in narcoleptic patients and control subjects. Narcoleptic patients had lower levels of CD40L. Total lymphocytes; CD3, and TCD4 were lower than in the control group. Our findings highlight the important role of CD40L in narcolepsy.

Severe swine influenza A (H1N1) versus severe human seasonal influenza A (H 3N 2): Clinical comparisons

At the beginning of the swine influenza (H1N1) pandemic in the spring of 2009, there were still stories of human seasonal influenza A circulating in the New York area. Adult patients admitted with influenza-like illnesses (ILIs) (fever > 102°F, dry cough, and myalgias) presented diagnostic problems. First, clinicians had to differentiate ILIs from influenza, and then differentiate human seasonal influenza A from H1N1 in hospitalized adults with ILIs and negative chest films (no focal segmental/lobar infiltrates). Human seasonal influenza A was diagnosed by rapid influenza diagnostic tests (RIDTs), but H1N1 was often RIDT negative. Reverse transcriptase-polymerase chain reaction for H1N1 was restricted or not available. The Winthrop-University Hospital Infectious Disease Division developed clinical diagnostic criteria (a diagnostic weighted point score system) to rapidly and clinically diagnose H1N1 in patients with negative RIDTs. The point score system was modified and shortened for ease of use, that is, the diagnostic H1N1 triad (any 3 of 4) (ILI, see above) plus thrombocytopenia, relative lymphopenia, elevated serum transaminases, or an elevated creatine phosphokinase. Our clinical experience during the pandemic allowed us to develop the swine diagnostic H1N1 triad. In the process, similarities and differences between human seasonal influenza A and H1N1 were noted. We present 2 illustrative cases of severe influenza, one due to human seasonal influenza A and one due to H1N1, for clinical consideration reflective of our experiences early in the H1N1 pandemic in 2009.

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) is a disorder of innate immunity and Th1 activation responsive to IL-1 blockade

The syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is the most common periodic fever disease in children. However, the pathogenesis is unknown. Using a systems biology approach we analyzed blood samples from PFAPA patients whose genetic testing excluded hereditary periodic fevers (HPFs), and from healthy children and pediatric HPF patients. Gene expression profiling could clearly distinguish PFAPA flares from asymptomatic intervals, HPF flares, and healthy controls. During PFAPA attacks, complement (C1QB, C2, SERPING1), IL-1-related (IL-1B, IL-1RN, CASP1, IL18RAP), and IFN-induced (AIM2, IP-10/CXCL10) genes were significantly overexpressed, but T cell-associated transcripts (CD3, CD8B) were down-regulated. On the protein level, PFAPA flares were accompanied by significantly increased serum levels of chemokines for activated T lymphocytes (IP-10/CXCL10, MIG/CXCL9), G-CSF, and proinflammatory cytokines (IL-18, IL-6). PFAPA flares also manifested a relative lymphopenia. Activated CD4(+)/CD25(+) T-lymphocyte counts correlated negatively with serum concentrations of IP-10/CXCL10, whereas CD4(+)/HLA-DR(+) T lymphocyte counts correlated positively with serum concentrations of the counterregulatory IL-1 receptor antagonist. Based on the evidence for IL-1β activation in PFAPA flares, we treated five PFAPA patients with a recombinant IL-1 receptor antagonist. All patients showed a prompt clinical and IP-10/CXCL10 response. Our data suggest an environmentally triggered activation of complement and IL-1β/-18 during PFAPA flares, with induction of Th1-chemokines and subsequent retention of activated T cells in peripheral tissues. IL-1 inhibition may thus be beneficial for treatment of PFAPA attacks, with IP-10/CXCL10 serving as a potential biomarker.

Systemic lupus erythematosus (SLE) pneumonitis mimicking swine influenza pneumonia during the swine influenza (H1N1) pandemic

Background We present a young woman with a negative medical history who presented with acute systemic lupus erythematosus (SLE) pneumonitis mimicking swine influenza (H1N1) pneumonia. Because this case occurred during the H1N1 pandemic, the initial diagnostic impression was of H1N1 pneumonia. Methods Although her clinical and laboratory findings were consistent with the diagnosis of H1N1 pneumonia, e.g., fever, sore throat, dry cough, arthralgias, myalgias, thrombocytopenia, relative lymphopenia, and elevated serum transaminases, some findings suggested an alternate diagnosis, e.g., leukopenia, a highly elevated erythrocyte sedimentation rate, highly elevated serum ferritin levels, elevated antinuclear antibody (ANA) levels, and double-stranded (DS) DNA titers. Her chest x-ray showed an accentuation of basilar lung markings, with a small pleural effusion similar to the chest x-ray findings of early H1N1 pneumonia. Initially, her headaches were thought to be related to central nervous system manifestations of H1N1. Results After laboratory test results demonstrated elevated ANA and anti-DS DNA titers, she was diagnosed with acute SLE pneumonitis. The take-home lesson for clinicians is that other infectious diseases, e.g., human parainfluenza virus or Legionnaires’ disease, can mimic H1N1 pneumonia during an influenza pandemic. Excluding asthma, congestive heart failure, exacerbations of acute bronchitis, chronic obstructive pulmonary disorder, and pulmonary interstitial disease, noninfectious mimics of H1N1 are extremely rare. Conclusion To the best of our knowledge, this is the first reported case of de novo SLE pneumonitis mimicking H1N1 pneumonia during the swine influenza pandemic.

Meningitis, cranial neuritis, and radiculoneuritis associated with Borrelia burgdorferi infection in a horse

A 12-year-old Thoroughbred was examined because of signs of depression, neck stiffness, and poor performance. Physical examination revealed that the horse was dull, appeared depressed, was reluctant to raise its neck and head above a horizontal plane, and had a temperature of 38.5°C (101.3°F). No radiographic or scintigraphic abnormalities of the neck were found; however, high plasma fibrinogen concentration and relative lymphopenia were identified and the horse was seropositive for antibodies against Borrelia burgdorferi. Analysis of CSF revealed neutrophilic inflammation, and results of a PCR assay of CSF for B burgdorferi DNA were positive. Immunologic testing revealed severe B-cell lymphopenia and a low serum IgM concentration consistent with common variable immunodeficiency. The horse responded well to do×ycycline treatment (10 mg/kg [4.5 mg/lb], PO, q 12 h for 60 days) and returned to normal exercise. However, 60 days after treatment was discontinued, the horse again developed a stiff neck and rapidly progressive neurologic deficits, including severe ataxia and vestibular deficits. The horse's condition deteriorated rapidly despite IV oxytetracycline treatment, and the horse was euthanatized. Postmortem examination revealed leptomeningitis, lymphohistiocytic leptomeningeal vasculitis, cranial neuritis, and peripheral radiculoneuritis with Wallerian degeneration; findings were consistent with a diagnosis of neuroborreliosis. Nervous system infection with B burgdorferi should be considered in horses with evidence of meningitis and high or equivocal serum anti-B burgdorferi antibody titers. Evaluation of immune function is recommended in adult horses evaluated because of primary bacterial meningitis.

Human parainfluenza virus type 3 (HPIV 3) viral community-acquired pneumonia (CAP) mimicking swine influenza (H1N1) during the swine flu pandemic

Background The swine influenza (H1N1) pandemic began in Mexico in 2009 and quickly spread worldwide. During the H1N1 pandemic, many patients were admitted to the Winthrop-University Hospital with influenza-like illnesses (ILIs). Many hospitalized adults had H1N1 pneumonia diagnosed by laboratory or clinical criteria. However, the laboratory diagnosis of H1N1 was problematic. The rapid influenza (QuickVue A/B [Quidel, San Diego, CA]) test frequently showed false-negative results. Reverse transcriptase-polymerase chain reaction (RT-PCR), the definitive test for H1N1, was restricted or unavailable, or results were reported after they were clinically relevant. Because of difficulties making a laboratory diagnosis of H1N1, Winthrop-University Hospital’s Infectious Disease Division developed clinical criteria to diagnose H1N1 when rapid influenza diagnostic test (RIDT) results were negative. It also became clear that some patients with negative RIDT and RT-PCR H1N1 clearly had H1N1 pneumonia on a clinical basis. There have been patients who died of H1N1 pneumonia with negative RIDT and RT-PCR H1N1 but had postmortem lung specimens positive for H1N1 by RT-PCR. Methods During the flu pandemic, the main diagnostic and infection control problems were to differentiate ILIs from H1N1. Unlike admitted adults hospitalized with ILIs, clinical H1N1 pneumonia patients with negative RIDT results but had dry cough, myalgias, temperatures greater than 102°F, and a negative chest x-ray without focal segmental/lobar infiltrates. With the use of the Winthrop-University Hospital’s Infectious Disease Division diagnostic H1N1 triad, patients with H1N1 had the above plus 3 of the following 4 laboratory abnormalities: relative lymphopenia, thrombocytopenia, elevated serum transaminases, or elevated creatine phosphokinase. It was important to rapidly and accurately diagnose H1N1 to place such patients on proper precautions and initiate oseltamivir therapy. Results As the H1N1 pandemic progressed, it became clear that there were some infectious diseases that mimicked H1N1 pneumonia (eg, Legionnaires’ disease). We describe the case of a 61-year-old man who presented with an ILI with dry cough, fever, myalgias, and shortness of breath. His rapid influenza A test result was negative, and specimens for RT-PCR for H1N1 were ordered. On admission, he had relative lymphopenia, thrombocytopenia, and an elevated creatine phosphokinase. His chest x-ray showed no focal segmental or lobar infiltrates. The patient was placed on influenza precautions and administered oseltamivir. During the patient’s hospital course, the RT-PCR for H1N1 was reported negative. His respiratory fluorescent antibody viral panel was negative for influenza A, influenza B, metapneumoviruses, respiratory syncytial virus, and adenoviruses but positive for human parainfluenza virus type 3 (HPIV 3). Conclusions Clinicians should be aware of other causes of community-acquired pneumonia that may mimic H1N1 pneumonia. In our experience, the most common mimics of H1N1 pneumonia are Legionnaires’ disease or HPIV 3 in adults, and metapneumovirus or respiratory syncytial virus in children. In adult patients who present with an ILI and negative RIDT results, we suggest that respiratory secretions specimens be obtained for respiratory fluorescent antibody viral testing pending RT-PCR for H1N1 results. HPIV 3, known to be an important community-acquired pneumonia pathogen in transplant recipients and immunosuppressed patients, is also an important pathogen in immunocompetent adults. In normal adult hosts, the clinical presentation of HPIV 3 pneumonia may clinically closely mimic H1N1 pneumonia.

Human parainfluenza virus type 3 (HPIV 3) community-acquired pneumonia (CAP) mimicking pertussis in an adult: The diagnostic importance of hoarseness and monocytosis

Background There are relatively few causes of acute community-acquired pneumonias (CAPs) in adults associated with prolonged cough. In adults the most common acute CAPs with a prominent and persistent nonproductive cough are due to Mycoplasma pneumoniae, Chlamydophilia (Chlamydia) pneumoniae, or Bordetella pertussis (pertussis). Pertussis is an underrecognized and underappreciated cause of CAP in adults. Different from classic pertussis in children, pertussis in adults presents with prolonged dry cough, that is, the “100-day cough.” In pertussis, the characteristic nonspecific laboratory findings are leukocytosis and relative lymphocytosis. Dry cough accompanied by hoarseness with CAP in an adult should suggest C. pneumoniae or a respiratory virus (eg, influenza, parainfluenza, respiratory syncytial virus). Methods We present the case of a young woman who presented with a prominent and persistent pertussis-like cough with hoarseness. She had no leukocytosis or relative lymphopenia, which argued against the diagnosis of pertussis. Notably, she had persistent monocytosis. Her protracted pertussis-like cough that persisted during her hospitalization was so impressive that the diagnostic impression was pertussis. Direct fluorescent antibody (FA) and throat cultures were negative for pertussis. Furthermore, her hoarseness suggested the possibility of C. pneumoniae, but her C. pneumoniae immunoglobulin-M titer was negative. Results Because C. pneumoniae was ruled out, her hoarseness suggested a respiratory viral cause. A respiratory FA viral panel and viral throat cultures were obtained. The respiratory FA viral panel was negative for influenza A/B, respiratory syncytial virus, metapneumovirus, adenovirus, cytomegalovirus, and parainfluenza viruses. However, her viral throat cultures grew parainfluenza virus type 3 (HPIV 3), confirming the diagnosis. Conclusion To the best of our knowledge, this is the first case of HPIV 3 CAP presenting with a prominent and persistent pertussoid cough in an adult mimicking pertussis with hoarseness and monocytosis.

Swine influenza (H1N1) and acute appendicitis

During the swine influenza (H1N1) pandemic that began in 2009, many hospitalized adults had gastrointestinal symptoms. The most common symptoms associated with swine influenza (H1N1) were nausea, vomiting, or diarrhea. In the experience of the authors, swine influenza was not complicated by abdominal pain. There are a wide variety of infectious and non-infectious disorders that may present with a pain in the right lower quadrant, mimicking appendicitis, ie, pseudoappendicitis. Influenza predisposes to some types of bacterial infection, eg, influenza pneumonia may be complicated by simultaneous Staphylococcus aureus community-acquired pneumonia or subsequent community-acquired pneumonia due to Haemophilus influenzae or Streptococcus pneumoniae. It remains unclear if there is direct involvement of the appendix, ie, pseudoappendicitis as occurs with measles or if influenza itself somehow predisposes to increased frequency/severity of bacterial appendicitis. German clinicians first noted an increased incidence of acute appendicitis in children/young adults with influenza. The American and British cases of influenza and acute appendicitis compared to age-matched controls with more severe and of delayed onset/complicated by appendicial perforation/abscess. These reports noted an increased incidence/severity of acute appendicitis during influenza. A 15-year-old girl presented to the hospital with an influenza-like illness and right lower quadrant abdominal pain. Acute appendicitis was diagnosed by a computed tomography scan and the patient underwent emergency appendectomy. Subsequently, it was noted that she did not have leukocytosis and, in fact, had borderline leukopenia. Her differential white blood cell count also revealed relative lymphopenia. Neither leukopenia nor relative lymphopenia are features of acute bacterial appendicitis. These two findings in the setting of an influenza-like illness indicate the underlying presence of influenza. Post-operatively, respiratory secretion samples were sent for swine influenza (H1N1) testing. Both her respiratory florescent antibody (FA viral panel) was positive for influenza A, as was her RT-PCR for swine influenza (H1N1). The authors believe that this is the first case of swine influenza (H1N1) and acute bacterial appendicitis. Direct involvement of the appendix by swine influenza (H1N1) virus could not be demonstrated. The authors conclude that during the swine influenza (H1N1) pandemic clinicians should be alert to the possibility of an increased incidence/severity of acute bacterial appendicitis in patients with swine influenza (H1N1) infection.

Rapid clinical diagnosis of Legionnaires' disease during the “herald wave” of the swine influenza (H1N1) pandemic: The Legionnaires' disease triad

BackgroundIn adults hospitalized with atypical community-acquired pneumonia (CAP), Legionnaires' disease is not uncommon. Legionnaire's disease can be differentiated from typical CAPs and from other atypical CAPs based on its characteristic pattern of extrapulmonary organ involvement. The first clinically useful diagnostic weighted point score system for the clinical diagnosis of Legionnaires' disease was developed by the Infectious Disease Division at Winthrop-University Hospital in the 1980s. It has proven to be diagnostically accurate and useful for more than two decades, but was time-consuming. Because Legionella spp. diagnostic tests are time-dependent and problematic, a need was perceived for a rapid, simple way to render a clinical, syndromic diagnosis of Legionnaires' disease pending Legionella test results. During the “herald wave” of the swine influenza (H1N1) pandemic in the New York area, our hospital, like others, was inundated with patients who presented to the Emergency Department with influenza-like illnesses (ILIs) for H1N1 testing/evaluation. Most patients with ILIs did not have swine influenza. Hospitalized patients with ILIs who tested positive with rapid influenza diagnostic tests (RIDTs) were placed on influenza precautions and treated with oseltamivir. Unfortunately, approximately 30% of adult patients admitted with an ILI had negative RIDTs. Because the definitive laboratory diagnosis of H1N1 pneumonia by reverse transcription-polymerase chain reaction(RT-PCR), testing was restricted by health departments, resulted in clinical and infection control dilemmas in determining which RIDT-negative patients did, in fact, have H1N1 pneumonia.ObjectiveAccordingly, a diagnostic weighted point score system was developed for H1N1 pneumonia patients, based on RT-PCR positivity by the Infectious Disease Division at Winthrop-University Hospital. This diagnostic point score system for hospitalized adults with negative RIDTs was time-consuming. As the pandemic progressed, a simplified diagnostic swine influenza (H1N1) triad was developed for the rapid clinical diagnosis of probable H1N1 pneumonia, which also differentiated it from its mimics as well as from bacterial pneumonia, eg, Legionnaires' disease. During the “herald wave” of the H1N1 pandemic, we noticed an unexplained increase in Legionnaires' disease CAPs. Because clinical resources were stressed to the maximum during the pandemic, it was critically important to rapidly identify patients rapidly with Legionnaire's disease who did not require influenza precautions or oseltamivir, but who did require anti-Legionella antimicrobial therapy.MethodsBased on the Winthrop-University Hospital Infectious Disease Division's diagnostic weighted point score system for Legionnaires' disease (modified), key indicators were identified and became the basis for the diagnostic Legionnaires' disease triad. The diagnostic Legionnaires' disease triad was used to make a clinical diagnosis of Legionnaires' disease until the results of Legionella diagnostic tests were reported. The diagnostic Legionnaires' disease triad diagnosed Legionnaires' disease in hospitalized adults with CAPs with extrapulmonary findings (atypical CAP) and relative bradycardia, accompanied by any three (ie, a triad) of the following: otherwise unexplained relative lymphopenia, early/mildly elevated serum transaminases (SGOT/SGPT), highly increased ferritin levels (≥2 × n), or hypophosphatemia. The diagnostic Legionnaires' disease triad provides clinicians with a rapid way to clinically diagnose Legionnaires' disease, pending Legionella test results.ResultsThe accuracy of the diagnostic Legionnaires' disease triad was confirmed in our 9 cases of Legionnaires' disease by subsequent Legionella diagnostic testing.ConclusionsThe diagnostic Legionnaires' disease triad is particularly useful in situations where a rapid clinical syndromic diagnosis is needed, ie, during an H1N1 pandemic.

Lymphocyte to monocyte ratio as a screening tool for influenza

In fall 2009 the emergency department of a clinic in Greece with increased patient visits due to influenza-like illness observed a particular pattern in the complete blood count (CBC) of these patients. In 90% of all patients with probable influenza, lymphopenia and/or monocytosis were present. Relative lymphopenia with or without monocytosis appears to be a laboratory marker for H1N1 virus infection, a finding that could play a major role in early identifying and treating patients with new influenza A. A ratio of lymphocytes to monocytes below 2 is proposed as a screening tool for influenza infection instead of rapid tests.

Autoreactive T Cells Escaping Thymic Deletion in REL-B Deficient Mice Depend on Dendritic Cell-encoded REL-B for Control of Autoimmunity

In humans and mice, autoimmunity is associated with mutations that attenuate T cell receptor (TCR) signaling capacity, which alter thymic selection, and signaling of the peripheral T cell repertoire. The RelB transcription factor controls maturation of antigen presenting cell function by dendritic cells (DCs). Similar to TCR signaling mutants, RelB-/- mice have severe T cell-dependent autoimmune disease and relative lymphopenia, but normal numbers of FoxP3+ regulatory T cells. By analysis of effector and regulatory T cell phenotype and function, distribution and function of antigen presenting cells (APCs) and DC transfer studies in RelB knockout and RelB-/- bone marrow chimeras, we addressed whether reduced capacity of thymic and peripheral APCs to signal T cells drives autoimmunity in RelB-/-mice. Th2-type RelB-/- CD44hi effector T cells, which escape thymic negative selection due to medullary atrophy and APC deficiency, are susceptible to RelB-/- Treg suppression only when signalled by wild type DCs, with enhanced costimulatory activity. Transfer of RelB-sufficient DCs, to RelB-/- mice reversed peripheral organ inflammatory disease, Th2 cytokine over-production, thymic atrophy and lymphopenia, and rendered effector T cells susceptible to suppression by Treg cells. Thus, similar to defects in TCR signaling, autoimmunity may also result from defects in APC function. In the absence of DC-encoded RelB, progressive T cell and myeloid cell-mediated inflammation, uncontrolled by Treg cells, destroys thymus and other organs. Genetic and environmental factors control the level of RelB expression, and reduced expression is predicted to exacerbate the effect of mutations, such as PTPN22R620W that attenuate TCR signaling capacity. Copyright © 2010 Published by Elsevier Inc.

Rapid clinical diagnosis in fatal swine influenza (H1N1) pneumonia in an adult with negative rapid influenza diagnostic tests (RIDTs): Diagnostic swine influenza triad

BackgroundThe “herald wave” of the H1N1 pandemic spread from Mexico to the United States in spring 2009. Initially, the epicenter of H1N1 in the United States was in the New York area. Our hospital, like others, was inundated with large numbers of patients who presented at the Emergency Department (ED) with influenza-like illnesses (ILIs) for swine influenza testing and evaluation.MethodsThe Winthrop-University Hospital ED used rapid influenza (QuickVue A/B) tests to screen for H1N1 infection. Patients who were rapid influenza A test-positive were also reverse transcription-polymerase chain reaction (RT-PCR) positive for H1N1. In our ED, 30% of patients with ILIs and possible H1N1 pneumonia had negative rapid influenza A screening tests. Because H1N1 RT-PCR testing was restricted, there was no laboratory test to confirm or rule out H1N1. Other rapid influenza diagnostic tests (RIDTs), e.g., the respiratory fluorescent antibody (FA) viral panel test, were used to identify H1N1 patients with negative RIDTs.ResultsUnfortunately, there was not a good correlation between RIDT results and RT-PCR results. There was a critical need to develop a clinical syndromic approach for diagnosing hospitalized adults with probable H1N1 pneumonia with negative RIDTs. Early in the pandemic, the Winthrop-University Hospital Infectious Disease Division developed a diagnostic weighted point score system to diagnose H1N1 pneumonia clinically in RIDT-negative adults. The point score system worked well, but was time-consuming. As the “herald wave” of the pandemic progressed, our ED staff needed a rapid, simplified method to diagnose probable H1N1 pneumonia in hospitalized adults with negative RIDTs. A rapid and simplified diagnosis was based on the diagnostic weighted point score system, which we simplified into a triad of key, nonspecific laboratory indicators. In adults hospitalized with an ILI, a fever >102°F with severe myalgias, and a chest x-ray without focal segmental/lobar infiltrates, the presence of three indicators, i.e., otherwise unexplained relative lymphopenia, elevated serum transaminases, and an elevated creatinine phosphokinase, constituted the diagnostic swine influenza triad. The Infectious Disease Division's diagnostic swine flu triad was used effectively as the pandemic progressed, and was not only useful in correctly diagnosing probable H1N1 pneumonia in hospitalized adults with negative RIDTs, but was also in ruling out mimics of swine influenza, e.g., exacerbations of chronic bronchitis, asthma, or congestive heart failure, as well as bacterial community-acquired pneumonias (CAPs), e.g., legionnaire's disease.ConclusionClinicians can use the Winthrop-University Hospital Infectious Disease Division's Diagnostic swine influenza triad to make a rapid clinical diagnosis of probable H1N1 pneumonia in hospitalized adult patients with negative RIDTs.

Blood profile holds clues to role of infection in a premonitory state for idiopathic parkinsonism and of gastrointestinal infection in established disease

The two-stage neuroinflammatory process, containment and progression, proposed to underlie neurodegeneration may predicate on systemic inflammation arising from the gastrointestinal tract. Helicobacter infection has been described as one switch in the pathogenic-circuitry of idiopathic parkinsonism (IP): eradication modifies disease progression and marked deterioration accompanies eradication-failure. Moreover, serum Helicobacter-antibody-profile predicts presence, severity and progression of IP. Slow gastrointestinal-transit precedes IP-diagnosis and becomes increasingly-apparent after, predisposing to small-intestinal bacterial-overgrowth (SIBO). Although IP is well-described as a systemic illness with a long prodrome, there has been no comprehensive overview of the blood profile. Here, it is examined in relation to Helicobacter status and lactulose-hydrogen-breath-testing for SIBO.A robust finding of reduced lymphocyte count in 126 IP-probands and 79 spouses (without clinically-definite IP), compared with that in 381 controls (p < 0.001 in each case), was not explained by Helicobacter-status or breath-hydrogen. This complements a previous report that spouses were 'down-the-pathway' to 'clinically-definite' disease. In 205 other controls without clinically-definite IP, there were strong associations between sporadic cardinal features and immunoglobulin class concentration, not explained by Helicobacter-status. Premonitory states for idiopathic parkinsonism associated with relative lymphopenia, higher serum immunoglobulin concentrations and evidence of enteric-nervous-system damage may prove viral in origin.Although only 8% of the above 79 spouses were urea-breath-test-positive for Helicobacter, all 8 spouses with clinically-definite IP were (p < 0.0001). Transmission of a 'primer' to a Helicobacter-colonised recipient might result in progression to the diagnostic threshold.Twenty-five percent of the 126 probands were seropositive for anti-nuclear autoantibody. In 20 probands, monitored before and serially after anti-Helicobacter therapy, seropositivity marked a severe hypokinetic response (p = 0.03). It may alert to continuing infection, even at low-density. Hyperhomocysteinemia is a risk factor for dementia and depression. Serum homocysteine exceeded the target in 43% of the 126 IP-probands. It was partially explained by serum B12 (12% variance, p < 0.001), but not by Helicobacter-status (gastric-atrophy uncommon in IP) or levodopa treatment. Immune-inflammatory activation increases homocysteine production. Since an estimated 60% of probands are hydrogen-breath-test positive, SIBO, with its increased bacterial utilisation of B12, is a likely cause. Thus, two prognostic indicators in established IP fit with involvement of Helicobacter and SIBO.

Escalated lymphodepletion Followed by Donor Lymphocyte Infusion (DLI) can Induce a Graft-Versus-Host Response without Overwhelming Toxicity.

Abstract 3033Poster Board II-1009▪▪This icon denotes an abstract that is clinically relevant.Donor lymphocyte infusion (DLI) approach alone for treatment of relapse has led to significant response in CML. For non CML diseases however, DLI remains relatively disappointing. Lymphodepletion may enhance anti-tumor effects of transferred T cells in vivo through several mechanisms including the elimination of suppressive CD4+CD25+ T-regulatory cells, NKT cells, with creation of an immunologic “space” with recruitment of homeostatic proliferative cytokines such as IL-7 and IL-15. DLI efficacy might be improved through manipulation of the recipient immune environment to allow for in vivo expansion of donor T cells. We postulated that induction of a relative lymphopenia in a graduated fashion may reduce toxicities and be sufficient to upregulate in vivo homeostatic cytokines to the benefit of transferred T cells. Therefore, we designed a dose-escalation study of DLI preceded by lymphodepletion with fludarabine (Flu) and cyclophosphamide (Cy). Lymphodepletion was proposed to avoid an overwhelming toxicity due to severe GVHD. We treated 17 patients (median age at transplant : 46 y (18 - 67) for relapse of various hematologic malignancies (6 AML/MDS, 4 ALL, 3 Hodgkin's disease, 2 T-NHL, 2 multiple myeloma) following allogeneic transplantation (5 myeloablative conditioning, 12 RIC; donors: 10 siblings, 7 MUD). To avoid overwhelming toxicity due to severe GVHD, we proceeded by sequentially escalating both LD and T cell doses infused with the DLI. Lymphodepletion consisted in Flu 25 mg/m2/d for 3 days followed by infusion of 1×107 CD3+ cells/Kg. If no GVHD developed and disease persisted or progressed, the same LD was followed by a second DLI at 5×107 CD3+ cells/Kg. At the next step, LD combined both Cy 600 mg/m2 for one day and Flu 25 mg/m2/d for 3 days followed by DLI at 5×107 CD3+ cells/Kg. Twenty-five LD-DLI were performed. Prior LD-DLI, eight patients received DLI not preceded by LD. Ten, six and one patient(s) received respectively one, two or three LD-DLIs. The first LD-DLI was given at a median of 234 days (range 62 days – 14 y 11 m) following allogeneic transplantation. Median follow-up after the first LD-DLI was 153 days (54-538). The cumulative incidence of grade II-IV acute GVHD was 36 %. The median onset of acute grade II-IV GVHD following the last LD-DLI was 31 days (range 15-59) not significantly different from a control group of 64 patients receiving DLI without lymphodepletion (34 days, range 12-120). Tumor response to LD-DLI was observed in 7 patients, 3 achieved CR, 4 achieved PR. At last follow-up, 7 pts died: 6 due to relapse (3 AML/MDS, 2 ALL, 1 T-NHL) and 1 from lung carcinoma. No patient died due to GVHD. Overall survival from LD-DLI was 55 % at one year. Although, there is some risk associated with lymphopenia in patients receiving multiple cycles of fludarabine therapy in this post-transplantation context, we did not observed significant infection. Study of the immunomodulatory effects of LD in these patients (pre- and post-LD-DLI T cells including Treg and cytokine secretion) are currently being further characterized. We conclude that LD-DLI has an acceptable toxicity if used in a stepwise manner or adapted to the severity of the disease. DisclosuresNo relevant conflicts of interest to declare.

Diagnostic Importance of Relative Lymphopenia as a Marker of Swine Influenza (H1N1) in Adults

Diagnostic Importance of Relative Lymphopenia as a Marker of Swine Influenza (H1N1) in Adults

Fever of unknown origin (FUO) due to a solitary cavitary lung lesion: The deadly ferritin-laced doughnut

Fever of unknown origin (FUO) is the clinical designation for patients who have fevers >101F that have persisted for >3 weeks that remain undiagnosed, after an intensive ambulatory/in-hospital workup. Fevers of unknown origin may be due to wide variety of infectious, neoplastic, or rheumatic/inflammatory disorders. The most common causes of FUOs in elderly patients are infectious and neoplastic diseases. With FUOs, the clinical presentation and routine laboratory tests are usually sufficient to narrow differential diagnostic possibilities. We present a case of an elderly Italian woman who presented with an FUO and a solitary, thick-walled cavitary lesion on chest x-ray (CXR). The infectious disease differential diagnosis of her FUO included lung abscess, M. tuberculosis (TB), systemic mycoses, and echinococcal-cyst (or hydatid-cyst) disease. The malignancy and neoplastic differential diagnosis included bronchogenic carcinoma, lymphoma, and metastatic carcinoma. Her nonspecific laboratory tests indicated a highly elevated erythrocyte sedimentation rate (ESR) >100 mm/hour, chronic thrombocytosis, relative lymphopenia, and highly elevated serum ferritin levels. Excluding highly elevated serum ferritin levels, the differential diagnosis of her FUO with a solitary, thick-walled cavitary lesion was lung abscess vs tuberculosis. However, her highly elevated serum ferritin levels proved to be the critical diagnostic clue in predicting the diagnosis of squamous-cell carcinoma. We conclude that serum ferritin levels are an important part of the laboratory workup. As with other nonspecific laboratory tests, the diagnostic significance of highly elevated ferritin levels depends associated clinical features in the clinical presentation.

Leukocyte Redistribution: Effects of Beta Blockers in Patients with Chronic Heart Failure

BackgroundOverproduction of pro-inflammatory cytokines is a well established factor in the progression of chronic heart failure (CHF). Changes in cellular immunity have not been widely studied, and the impact of standard medication is uncertain. Here we investigate whether a leukocyte redistribution occurs in CHF and whether this effect is influenced by beta-blocker therapy.MethodologyWe prospectively studied 75 patients with systolic CHF (age: 68±11 years, left ventricular ejection fraction 32±11%, New York Heart Association class 2.5±0.7) and 20 age-matched healthy control subjects (age: 63±10 years). We measured the response of cells to endotoxin exposure in vitro, analysed subsets of lymphocytes using flow cytometry, and assessed plasma levels of the pro-inflammatory markers interleukin 1, 6, tumor necrosis factor-α, and soluble tumor necrosis factor receptors 1 and 2.Principal findingsWhile no differences in the number of leukocytes were noted between patients with CHF and healthy controls, we detected relative lymphopenia in patients with CHF (p<0.001 vs. control), mostly driven by reductions in T helper cells and B cells (both p<0.05). The number of neutrophils was increased (p<0.01). These effects were pronounced in patients who were beta-blocker naïve (32% of all patients with CHF). Increased plasma levels of soluble tumor necrosis receptor-1 correlated with the relative number of lymphocyte subsets.ConclusionsIn patients with CHF, we detected a redistribution of leukocyte subsets, i.e. an increase in neutrophils with relative lymphopenia. These effects were pronounced in patients who were beta-blocker naïve. The underlying mechanism remains to be elucidated.

Relative CD4 lymphopenia and a skewed memory phenotype are the main immunologic abnormalities in a child with Omenn syndrome due to homozygous RAG1-C2633T hypomorphic mutation

We report a child with Omenn syndrome (OS) due to homozygous RAG1-C2633T mutations who had an unusual clinical and immunological presentation. She had delayed onset of OS-associated clinical features, had cleared a number of potentially fatal pathogens including respiratory syncytial virus, parainfluenza-3 virus and rotavirus, and was thriving at diagnosis. Laboratory assessment showed normal T and B lymphocyte number and function. T-cell-receptor repertoire in the blood was relatively diverse and her primary immunologic abnormality was skewing of circulating T-cells to the memory phenotype. A compelling explanation for the perplexing combination in OS of atopic/autoimmune and immunologic features has proven elusive. Homozygous RAG1-C2633T hypomorphic mutation may lead to significant residual immunity and a skewed memory phenotype. Our findings suggest that, in addition to host-genetic factors, environment, and/or pathogens, hypomorphic RAG mutations may differentially impact on V(D)J recombination activity and hence lead to a variable ability to sustain T and B cell lymphopoiesis. Importantly, this case emphasizes that such hypomorphic mutations may promote an attenuated phenotype, complicating the diagnosis of primary immunodeficiency (PID).