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CD4 Drop in Virally Suppressed Patients

  • 1.  CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 04:07
    I had TWO patients yesterday whose CD4 dropped from 1400 to 320 and from 700 to 320.   They are both also undetectable viral load.  Does any have any explanations for this?

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    Samuel Samalin
    Los Angeles CA
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  • 2.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 15:27

    Sometimes this happens, typically though the ratio of CD4/CD8 cells doesn't change from when the CD4 was higher






  • 3.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 16:05
    Did they have a recent immunization? What is their CD4 percentage?

    --
    Hermeyone Bell, APRN, BC, AAHIVS
    Nurse Practitioner
    Bell Primary Care, LLC
    P:404-337-7486
    F: 352-329-4338





  • 4.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 16:14
    I can't comment on these two patients, but I'll note that the DHHS guidelines do not recommend ordering CD4 counts in people with undetectable viral loads and high CD4 counts, since you'd rarely do anything with the information.

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    Joel Gallant, MD, MPH
    San Francisco, CA

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  • 5.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 16:16
    I think I want to answer your question with more questions! Ha! First thing I want to know is what is their CD4 percent on their last draw and the most recent? Next question is around their total WBCs from last labs to recent? Lastly (well so many other questions but last here) were they recently sick with an acute infection OR got a vaccine recently? Answers to these could give a reason for the absolute drop

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    Angela Kapalko
    Physician Assistant Chairperson for AAHIVM
    Philadelphia FIGHT CommunityHealth Centers
    Philadelphia PA
    akapalko@fight.org
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  • 6.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 17:06
    Did they recently have COVID?  Or COVID immunization?  There has been some data showing drops in CD4 with COVID infection.  Just being curious, but what med are they on?  Any concern for adherence, even though undetectable, as some of the meds can have sustained suppression.

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    John Phoenix
    Las Vegas NV
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  • 7.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-20-2021 21:40
    If it happens thus I usually check for administrative error .
    Regards
    J

    Sent from my iPad




  • 8.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-21-2021 02:57
    I have had this happen as well - what I look at when this happens are the following:
    1.  where is the percent?  stable?
    2.  Lab issue?
    3  what is going on with the pts' white count?
    4.  are they sick/covid/something else going on?
    5.  Then I do repeat the cd4s in 3-4 weeks and see what happens.

    I always ask the pts if they are taking some new medication/otc meds/supplements.

    I hope this helps.

    Sara Back FNP

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    Sara Back
    North Central Bronx Hospital
    New York NY
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  • 9.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-22-2021 13:07
    Last summer I had a patient hospitalized with what turned out to be pneumocystis pneumonia. He had been stable for years with suppressed HIV RNA on treatment, and CD4 several years ago was in the 300s before we stopped tracking it. During hospitalization his CD4 was ~80 and HIV RNA still undetectable. 
    He is in his 70s, smoker, alcoholic, COPD, frailty.
    After discharge I changed nothing except to add SXT prophylaxis. Oh and he had lost 20 lb with his illness so started on HGH which has been helpful.
    CD4 is back up into the 300s. I don't know why his CD4 dropped and precipitated an OI but it was a bit of a sobering experience.

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    Peter Shalit
    Dr. Shalit's Office
    Seattle WA
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  • 10.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-22-2021 13:23
    The DHHS recommendation to stop checking CD4 counts only applies to people with undetectable viral loads and CD4 counts above 500.

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    Joel Gallant, MD, MPH
    San Francisco, CA
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  • 11.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-22-2021 20:00
    Other guidelines differ. BHIVA recommends stopping CD4 monitoring in pts with suppressed virus and CD4>350.

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    Peter Shalit
    Dr. Shalit's Office
    Seattle WA
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  • 12.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-22-2021 23:11

    Did he fall out of care? 

    I am a helicopter mom. I check all of my patients' CD4 counts regardless and pay close attention to that percentage. I had a weird situation a couple of years ago with CD4 count in the low 400's and this patient who had a strange rash on his leg. Beneath that rash low and behold was Kaposi's sarcoma. The dermatologist did a bunch of biopsies and found it intermixed with another underlying skin condition. His CD4 percentage was 10.  That was pretty fascinating. I seemed to be the only one who took notice to his CD4 percentage.  



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    Amber Siegel DNP AAHIVS
    Crew Healthcare
    Orlando, Florida
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  • 13.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-23-2021 12:21
    Hi
     
    I suspect the patient getting PCP with undetectable HIV viral load is more complex than described but of course do not know. Frequently, and often inappropriately, patients with COPD are placed on steroids chronically with inhaled steroids and often systemically for a flare of bronchitis. These would influenced greatly PCP pathogenesis.
     
    We should always remember that CD4 depletion is an expected consequence of systemic inflammation. As captains of the immune system CD4 cells move into tissues to try and address potential insults - and as others have indicated - their presence in the vasculature is reduced without representing an actual decline in their total population. Hence, I would expect with any form of pneumonia that the patient in question would have significantly depleted their already low serum CD4 population without that representing the temporal precipitant to the pneumonia process.
     
    It is very important to remember that immunity to most diseases involves multiple parts of the immune system. While PCP was quite prevalent in the pre-HAART era it was by no means universal despite near universal exposure. Someday in the not too distant future I suspect that the medical care system will regard the intricacies and individuality of each of our immune systems as being as equally unique as our fingerprints. That is to say that what happens in a single individual should not be applied to a large population. To me, COVID related disease is now the poster child for this phenomenon.
     
    I did have a patient with 'idiopathic' CD4 depletion while having a suppressed or nearly suppressed HIV viral load. There is a small literature on this topic. I did not allow this individual's unfortunate experience to influence my management of the remainder of my HIV population without any observable additional case. The patient getting PCP does not appear to have this condition as it appears his CD4 count returned to its pre pneumonia state.
     
    I wish to encourage all to avoid applying single cases to the general population. We all have two eyes two arms two kidneys – sic - and our own unique immune system.
     
     
    David M. Bebinger, MD
     
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  • 14.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-23-2021 22:11
    What was their percentage? Did the percentage stay the same?

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    Amber Siegel DNP AAHIVS
    Crew Healthcare
    Orlando, Florida
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  • 15.  RE: CD4 Drop in Virally Suppressed Patients

    Posted 04-26-2021 12:19
    Have they recently received the COVID vaccination around the time their blood was drawn?

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    Bridgette Flowers
    Ypsilanti MI
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