|Year : 2013 | Volume
| Issue : 3 | Page : 298-302
Zero CD4 count: A case of discordant CD4 response in a patient with well suppressed viral load
K Raja, C Chandrasekar, OR Krishnarajasekhar, G Manoharan
Government Hospital of Thoracic Medicine, Center of excellence, HIV care and support, Tambaram Sanatorium, Chennai, Tamil Nadu, India
|Date of Submission||24-Oct-2012|
|Date of Acceptance||30-Apr-2013|
|Date of Web Publication||25-Jul-2013|
Government Hospital of Thoracic Medicine, Center of excellence, HIV care and support, Tambaram Sanatorium, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Human immunodeficiency virus (HIV) positive patients continue to have raise in CD4 cell for several years after initiation of anti-retroviral therapy (ART). The discordant response of static or fall in CD4 cells in presence of well-suppressed viral load is an unusual finding. In this communication, we present a case report of an HIV patient in whom the repeated CD4 enumerations consistently showed zero/nil CD4 counts before and after the start of ART in spite of maximum viral suppression.
Keywords: Immunological and virological discordance, lip ulcer, World Health Organization′s immunological criteria, zero CD4
|How to cite this article:|
Raja K, Chandrasekar C, Krishnarajasekhar O R, Manoharan G. Zero CD4 count: A case of discordant CD4 response in a patient with well suppressed viral load. Indian J Med Microbiol 2013;31:298-302
|How to cite this URL:|
Raja K, Chandrasekar C, Krishnarajasekhar O R, Manoharan G. Zero CD4 count: A case of discordant CD4 response in a patient with well suppressed viral load. Indian J Med Microbiol [serial online] 2013 [cited 2020 Jan 26];31:298-302. Available from: http://www.ijmm.org/text.asp?2013/31/3/298/115658
| ~ Introduction|| |
Human immunodeficiency virus (HIV) patients after anti-retroviral therapy (ART) initiation in a resource limited settings in India were followed by CD4 count every 6 months. The treatment failure can be diagnosed by clinical, immunological and virological failure. Virologcal failure is the earliest and most sensitive marker for treatment failure, but very costly in a resource limited setting. Clinical failure (occurrence of new stage III or stage IV illness as per World Health Organization (WHO) clinical staging for HIV while on ART) occurs late and so treatment failure suspected on clinical failure may be late. In India to identify treatment failure immunological failure as per WHO's immunological criteria namely (a) CD4 Fall to pre-therapy baseline (or below), (b) CD4 persistently below 100 and (c) CD4 50% fall from the on-treatment peak value (if known). It is intermediate while comparing clinical and virological failure. If any one of criteria is present viral load test with more than 5000 copies is used to diagnose the treatment failure as per National HIV treatment guidelines. In this case report, a patient with "nil" CD4 cell count (with immunological failure and clinical failure with stage IV extra-pulmonary tuberculosis) without any identifiable cause, from the start and up to 3 years of continuous ART, but with well-suppressed viral load is presented because of its rarity.
| ~ Case Report|| |
A 49-year-male, South Indian farmer on ART, was hospitalized on 24 th March 2011 for a non-healing ulcer in the right side of the lower lip with a zero CD4 cell count.
The patient was tested HIV positive in November 2006 (HIV 1 positive); and was put on siddha (alternate Indian medicine system) medications and Cotrimoxazole (CTZ) prophylaxis since July 2007.
ART was initiated (Zidovudine [AZT] + Lamivudine [3TC] + Nevirapine [NVP]) on February 2008 with a baseline CD4 count of zero. The previous CD4 counts were not available. The siddha medications were stopped and CTZ prophylaxis was continued. The sputum was negative for Acid Fast Bacilli (AFB) during February 2008 and again on March 2008.
Ulcerated lesion on the right side of the lower lip with smooth margin, ulcerated base and serous exudation was first documented in May 2009 [Figure 1]. There was no improvement with a course of acyclovir and subsequent antibiotics. It was biopsied in December 2009 and it showed granulomatous tissue with predominant lymphocytes and epithelioid cells; the smear for AFB was negative; aerobic bacterial culture of the specimen did not grow any organisms.
|Figure 1: The lower lip ulcer: Earlier picture, at the time of first presentation|
Click here to view
Patient was started on category-I anti tuberculosis therapy under Revised National Tuberculosis Control Program with Rifampicin, Isoniazid, Ethambutol and Pyrizinamide thrice weekly directly observed treatment - short course Lesion regressed within a week, but then remain at the same size (2 cm × 1 cm) thereafter. Patient was adherent to ART with greater than 95% adherence levels and was regular to ART outpatient department for scheduled visits.
In the present admission, the patient was conscious and oriented; afebrile; his weight was 59 Kg and his body mass index was 21.7 kg/m 2 . On examination, a single ulcer of 2 cm × 1 cm size, over right side oflower lip, without tenderness, with irregular margins and the base was indurated with little amount of crusting [Figure 2]. Systemic examination and genital examination were normal. Patient is non-alcoholic, non-smoker. No history of chewing of tobacco or other tobacco related products. History of trauma to lip was ruled out. The current medications are three drugs ART with AZT, 3TC and efavirenz (EFV) and anti-tuberculosis therapy and CTZ prophylaxis.
|Figure 2: The lower lip ulcer: Later picture, (after the tuberculosis treatment and antibiotics)|
Click here to view
[Table 1] and [Table 2] shows CD4 counts and white blood cells (WBC) and lymphocyte counts.
November 2010: Peripheral Smear: Red blood cells were macrocytic, hypochromic; WBC were normal in count; platelets were adequate and no blood parasites seen.
December 2010: Three rapid HIV tests were repeated for HIV 1 and HIV 2 antibodies and the result showed HIV 1 positive and HIV 2 negative. National Aids Control Organization's guidelines were used with three rapid tests for confirmation. 
Haematology, blood sugar, urea and serum creatinine, bilirubin, serum glutamate oxaloacetate transaminase, serum glutamate pyruvate transaminase, serum proteins, serum albumin and globulin and Venereal Disease Research Laboratory test were normal during the period from 2008 to until the present admission. Chest X-ray was also normal.
February 2011: HIV 1 viral load was carried out and it was <50 copies/ml with COBAS TaqMan 48 real-time polymerase chain reaction analyses (Roche Diagnostics) using the COBAS TaqMan HIV 1 test kit, version 2.0 (Roche Diagnostics).
Bacterial culture from the lesion: Staphylococcus aureus sensitive to Vancomycin was isolated and it was sensitive (intermediate) to Ofloxacin also.
CD4 was tested using BD FACS CALIBUR, Beckton Dickinson sciences USA make, with BD calibur 3 beads, BD tritest antibodies, BD FACS lysing solution and BD trucount tubes. The serial CD4 values with month and year are given in [Table 2].
Treatment failure in this case is considered because (1) clinical failure-the non-healing lower lip ulcer, an extra-pulmonary tuberculosis, a stage IV illness of WHO clinical staging. for HIV And (2) immunological failure-the repeated "nil CD4 counts" in spite of continuous ART with more than 95% adherence and more than 6 months of continuous anti-retro viral therapy.
The lower lip lesion was first documented in May 2009. The initial working diagnosis was herpes simplex lesion. So, a course of Acyclovir was given, but the lesion did not respond. Aphthous ulcers, Sutton's ulcer, squamous cell carcinoma, primary syphilitic ulcer, leishmaniasis, other fungal infections and tuberculous ulcer were considered after failure of acyclovir treatment. After baseline and specific investigations a biopsy was carried out, which showed pattern consistent with granulomatous changes, with no evidence of malignancy. The granulomatous lesion leads to the diagnosis of tuberculous ulcer. Though the occurrence of tuberculous lesions involving oral cavity is rare,  the diagnosis was made because unusual manifestation of a common infection in a setting of HIV/acquired immunodeficiency syndrome (AIDS). Occult or latent systemic involvement of Tuberculosis was still considered - though clinical, laboratory, radiological investigations revealed nothing suggestive of underlying tuberculous source. Dixit et al.,  has reported a similar case of tuberculosis of lip ulcer, which was painful and patient had a long history of tobacco chewing. The authors of this case report have recommended that primary site of tuberculosis can be skin even in the absence of any clinical signs and symptoms of tuberculosis in any other systems of the body. Sporadic painless ulcers,  with similar clinical history were reported elsewhere, but the both the cases reported had enlargement of regional lymph nodes, which was not seen in this patient. The patient was started on anti-tuberculosis drugs after a second tissue biopsy report had corroborated with the granulomatous pattern with epitheloid cells. The lesions responded initially with regression visible in initial first 2-3 months [Figure 2]. As per WHO criteria of treatment failure in resource limited setting clinical treatment failure can be suspected by occurrence of stage IV illness, which in this case is extra-pulmonary tuberculosis.
The second focus of this case report is on immunological failure with "nil CD4 counts" after 6 months of continuous ART and 95% adherence with stage IV clinical illness. It indicates poor primary immunological response to first line ART. The patient was on AZT + 3TC + NVP since February 2008. NVP was substituted with EFV after starting of anti tuberculous therapy. As the CD4 count was "nil" in spite of being on triple drug ART as per the national guideline, patient was sent for State AIDS Clinical Expert Panel review. HIV 1 Viral load was carried out at this point of care and report showed well-suppressed viral load with <50 viral copies/ml.
Persistent zero CD4 count with well-suppressed viral load is rare. The zero CD4 count cannot be named as suboptimal treatment response because the viral load is suppressed well and remained less than 50 copies. Virological and immunological discordance can be considered but CD4 count remaining persistently at zero is very unusual.
The conditions that can lead to poor immunologic response despite adequate virologic suppression such as (a) bone marrow suppression by the use of AZT, (b) history of use of systemic corticosteroids or chemotherapeutic agents, (c) co-infections other than tuberculosis, which included hepatitis C co-infection, (d) sjogren's syndrome, (e) sarcoidosis, cotrimoxazole and (f) technical error. The investigations ruled out the above conditions.
The technical error can be two (i) Viral load of less than 50 copies can be due to the presence of infection due to HIV-1 non-M group, non-B subtypes, which may not be amplified or detected with latest available diagnostic tools and (HIV 2 can be detected by special techniques and protocols, ,,] and was negative by rapid test screening) (ii) the error in CD4 count machine.
The CD4 count machine used in this case is state approved and accredited as per National guidelines and carried out in one of the state level reference laboratory. The counts were repeated on two different machines; one using dual platform technique and the other single platform, both are based on flow cytometry (FACS count, BD) technique. Flow cytometry is considered as gold standard for detection of CD4. Both two CD4 enumeration machines utilizing gold standard concept has given consistent results of "nil CD4 counts". The findings have not been confirmed further with any other CD4 count machines which use different methods such as Guava Easy CD, Partec Cyflow and POINTCARE (point of care) CD4 machine because the patient was unable to pay for the tests and the program settings, in which the patient treated does not allow to use other than the labs designated and quality assured by national program. This tertiary care hospital's lab is one among them recognized for its quality for CD4 counts by national program managers. The external quality control by a lab in Canada has shown zero difference for CD4 count for the last 8 years.
Viral load is more sensitive in predicting disease progression and response to highly active antiretroviral therapy (HAART). In resource limited setting in India, routine viral load monitoring is not possible. So, WHO suggested CD4 counts for follow-up of the diseases progression, response to HAART and chances of getting opportunistic infections.
If CD4 counts not available, the WHO suggested that total lymphocyte count (TLC) in combination with clinical staging can be utilized as useful marker for initiation of ART and follow-up of patients on ART.  TLC <1200 cells/cubic cm is a sensitive marker, when used as a surrogate for CD4 <200 cells/cubic cm. Sreenivasan and Dasegowda,  in a study carried out in Indian patients has concluded that TLC <1200 cells/mm 3 had a 63.41% positive predictive value, 69.57% negative predictive value and 88. 14% sensitive and 34.78% specific for a CD4 count <200 cells/mm 3 . They also have commented that the decrease in CD4 cannot be predicted by fall in lymphocyte count. Even in Indian HIV program TLC was used in earlier days, but now with CD4 counters linkages available to all centres, TLC was dropped as a surrogate CD4 marker.
In this case, the TLC was carried out regularly and the value ranged from was 1000 cells/cubic.mm to 2700 cells/cubic.mm. On 8 occasions the count was equal to or less than 1200 cells/cubic.mm. The zero CD4 and TLC in this case did not matched well as predicted in previous studies.
The role of immune mechanisms cannot be ruled out in this scenario. Decreased production of IL-2, IL-2 receptor defects can lead to poor immune response.  Role of IL-2 is well-established in two large clinical trials Evaluation of Subcutaneous Proleukin in a Randomized International Trial and Study of interleukin-2 in people with low CD4+ T-cell counts on active anti-HIV therapy (SILCAAT) studies where in patients receiving the IL-2 had increase in CD4 function and number though the clinical benefits could not be well-established in these studies.
Role of lipopolysaccharide, lipopolysaccharide binding proteins (LPS, LBP) may to some extent explain the nil CD4 counts if we consider the CD4 cells to be depleted completely giving rise to undetectable or nil CD4 counts. Brenchley et al.,  found significantly higher levels of LPS, LBP and soluble CD14 in viraemic HIV 1-infected patients with CD4+ T cell depletion, compared with elite suppressors. Consideration of these mechanisms behind the nil CD4 counts in our case is still needs to be explored as the above finding of CD4 depletion occurs in presence of chronic viraemia.
The future plan for this patient is to counsel him on safe sexual practices. The well-suppressed viral load in blood may not clearly indicate the suppression in semen as established in one of the studies where 5% of men from sero-discordant heterosexual couples enrolled in an assisted reproduction program had detectable HIV in their semen despite a blood plasma viral load of lesser than 50 copies/ml.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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