Correspondence

Idiopathic CD4+ T-Lymphocytopenia

N Engl J Med 1993; 329:1045-1046September 30, 1993

Article

To the Editor:

Several articles and an editorial in the February 11 issue of the Journal draw the conclusion that idiopathic CD4+ T-lymphocytopenia is extremely rare1-5. However, transient CD4+ T-lymphocytopenia as a consequence of a low total white-cell count may be relatively common in some subgroups of the population. As part of a study of the heterosexual transmission of human immunodeficiency virus (HIV), we examined CD4 cells in a sample of 255 sexually active women without a history of intravenous drug use. The subjects were drawn from hospital clinics and from an area of New York (Kings County) with a high prevalence of HIV. T-cell counts were performed at a laboratory certified by the National Institute of Allergy and Infectious Diseases that had passed all proficiency tests. Seven women (2.7 percent) were positive for HIV type 1 (HIV-1) by enzyme-linked immunosorbent assay and Western blotting. Of the remaining 248 seronegative women, 6 (2.4 percent) had CD4 counts of less than 350 and 4 (1.6 percent) had counts of less than 300. Only one of the six women had a CD4 count that was less than 20 percent of the total white-cell count.

Several months later, five of the six women with low CD4 counts were retested by the same laboratory. All were still seronegative, and all had normal CD4 values. (The one woman with a low CD4 percentage was lost to follow-up.) All five of the women who returned had low total white-cell counts (less than 4.8 × 10⁶ initially, at follow-up, or both times. In a larger sample, of 633 women, whose white-cell counts were measured over time, a high percentage consistently had low total white-cell counts: 20 percent (n = 633) at enrollment, 26 percent (n = 378) after 6 months, and 21 percent (n = 176) after 12 months. Given the normal variability in the numbers of total lymphocytes and CD4 cells, we estimate that at any given time 0.4 to 4.1 percent (the binomial exact 95 percent confidence interval) of these women would have an absolute CD4 count of less than 300.

In the larger sample, 92 percent were black (38 percent African Americans and 54 percent Caribbean born), 6 percent were Hispanic, and 2 percent were Asian or white. Of the four patients who initially had CD4 counts of less than 300, two were Caribbean, one African American, and the other Hispanic. A relative high frequency of transient CD4+ T-lymphocytopenia appears to occur in some subgroups in which HIV-1 infection is very common. This emphasizes the importance of using HIV-antibody testing to diagnose HIV-1 infection rather than relying on T-cell counts as a surrogate, and reinforces the importance of using both absolute T-cell counts and CD4 percentages in assessing the progression of disease.

Jack A. DeHovitz, M.D., M.P.H.
Joseph Feldman, Dr.P.H.
Sheldon Landesman, M.D.
State University of New York Health Science Center at Brooklyn, Brooklyn, NY 11203

5 References

1. 1

   Smith DK, Neal JJ, Holmberg SD, Centers for Disease Control Idiopathic CD4+ T-Lymphocytopenia Task Force. Unexplained opportunistic infections and CD4+ T-lymphocytopenia without HIV infection -- an investigation of cases in the United States. N Engl J Med 1993;328:373-379
   Full Text | Web of Science | Medline

2. 2

   Ho DD, Cao Y, Zhu T, et al. Idiopathic CD4+ T-lymphocytopenia -- immunodeficiency without evidence of HIV infection. N Engl J Med 1993;328:380-385
   Full Text | Web of Science | Medline

3. 3

   Spira TJ, Jones BM, Nicholson JKA, et al. Idiopathic CD4+ T-lymphocytopenia -- an analysis of five patients with unexplained opportunistic infections. N Engl J Med 1993;328:386-392
   Full Text | Web of Science | Medline

4. 4

   Duncan RA, von Reyn CF, Alliegro GM, Toossi Z, Sugar AM, Levitz SM. Idiopathic CD4+ T-lymphocytopenia -- four patients with opportunistic infections and no evidence of HIV infection. N Engl J Med 1993;328:393-398
   Full Text | Web of Science | Medline

5. 5

   Fauci AS. CD4+ T-lymphocytopenia without HIV infection -- no lights, no camera, just facts. N Engl J Med 1993;328:429-431
   Full Text | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   T. Trojan, R. Collins, D. A. Khan. (2009) Safety and efficacy of treatment using interleukin-2 in a patient with idiopathic CD4 ⁺ lymphopenia and Mycobacterium avium-intracellulare. Clinical & Experimental Immunology 156:3, 440-445
   CrossRef

2. 2

   Ulrich A Walker, Klaus Warnatz. (2006) Idiopathic CD4 lymphocytopenia. Current Opinion in Rheumatology 18:4, 389-395
   CrossRef

3. 3

   D. J. Castelino, P. McNair, T. W. H. Kay. (1997) Lymphocytopenia in a hospital population - what does it signify?. Australian and New Zealand Journal of Medicine 27:2, 170-174
   CrossRef