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Table of Content - Volume 6 Issue 2 - May 2017
Clinical profile and role of serum globulin in assessment of immunity in patients with HIV
Suresh I1, Sai Krishna Tulasi2*, M Swamy3
1Associate Professor, 2Sr. Resident, 3Professor and HOD, Department of General Medicine, Kamineni Academy of Medical Sciences and Research Centre, L. B. Nagar, Hyderabad, Telangana, INDIA. Email: drtsk86@gmail.com
Abstract Background: India has the third largest epidemic in the world with 2.1 million people living with HIV. Along with T helper cell dysfunction, there is documented evidence of B cell dysfunction. B cell dysfunction is associated with Objectives: This study was done to evaluate correlation between serum globulins and CD4 count, and role of serum globulins as a marker for immunity. Materials and Methods: This study was done in Kamineni academy of medical sciences and research centre, data was collected from 47 patients and analyzed. RESULTS AND DISCUSSION- most common presentation was anemia (29.7%), 25% had tuberculosis,17% had oral candidiasis, pneumonia and gastroenteritis. Serum globulins had negative correlation with CD4. Serum globulin >3.5 gm/dl had 65% sensitivity and 73% specificity, 72% positive predictive value in predicting CD4 count less than 200cells/cumm. CONCLUSION- Future studies to evaluate the potential use of calculated globulins as marker for immunity during follow up in patients being treated with ART are warranted. Key Words: HIV, Serum globulins, Immunity.
India has the third largest HIV epidemic in the world. In 2016, HIV prevalence in India was an estimated 0.3%1 This figure is small compared to most other middle-income countries but because of India's huge population (1.324 billion) this equates to 2.1 million people living with HIV.1 In the same year, an estimated 62,000 people died from AIDS-related illnesses.1 A number of mechanisms responsible for cellular depletion and/or immune dysfunction of CD4+ T cells have been demonstrated in vitro; these include direct infection and destruction of these cells by HIV, as well as indirect effects such as immune clearance of infected cells, cell death associated with aberrant immune activation, and immune exhaustion due to aberrant cellular activation and with resulting cellular dysfunction2. Effective evasion of immune system is achieved by establishment of a sustained level of replication associated with the generation of viral diversity via mutation and recombination. Because of mutation there is no effective antibody neutralization2. HIV employs at least three mechanisms to evade neutralizing responses: hypervariability in the primary sequence of the envelope, extensive glycosylation of the envelope, and conformational masking of neutralizing epitopes. Persistent viremia also results in exhaustion of B cells similar to the exhaustion reported for CD4+ T cells, adding to the defects in the humoral response to HIV2. The predominant defect in B cells from HIV-infected individuals is one of aberrant cellular activation, which is reflected by increased propensity to terminal differentiation and immunoglobulin secretion and increased expression of markers of activation and exhaustion2. The globulin fraction includes hundreds of serum proteins including carrier proteins, enzymes, complement, and immunoglobulins. Most of these are synthesized in the liver, although the immunoglobulins are synthesized by plasma cells. Globulins are divided into four groups by electrophoresis. The four fractions are and, depending on their migratory pattern between the anode and the cathode. Increases in the globulin fraction usually result from an increase in immunoglobulins3.
MATERIALS AND METHODS It’s a retrospective observational study done in Kamineni academy of medical sciences and research centre. Data were collected from patients admitted in Department of General Medicine. The patients of both sexes aged >18 years. Data was collected by detailed history, physical examination, radiological examination, and laboratory data. Serum samples were collected from patients after they were confirmed HIV positive according to NACO guidelines. All the samples were collected in plain bottle. Total serum protein was measured by biuret method. Albumin was measures using Bromo Cresol Green enzymatic method. Serum globulin was calculated by using formula- total serum protein-serum albumin. Inclusion Criteria
Exclusion Criteria
Data was statistically analysed using graphs, tables and correlation coefficient using SPSS software trail version
RESULTS Total 47 cases were collected and data was analyzed. 34 patients were males and 13 were females. Age group was wide spread from 15 years to 80 years with majority in 30-50 years age group (Graph-1), mean age was 44.6. Almost all the patients had multi system involvement. (Table-1) shows different opportunistic infections with which patients had presented. There was a negative correlation between CD4 count and Serum globulin (p=0.008). Serum globulin >3.5 gm/dl was compared with CD4 count <200/cells as alternate marker. It showed had 65% sensitivity and 73% specificity, 72% positive predictive value (Table-2).
Figure 1: Showing age distribution
Table 1: Showing Different Manifestations
Table 2: Showing Comparison Between Serum Globulin And Cd4 Count
DISCUSSION Total 47 cases were collected and data was analyzed. 34 patients were males and 13 were females. Age group was wide spread from 15 years to 80 years with majority in 30-50 years age group (Graph-1), mean age was 44.6. In the study of Lang et al the mean age was 47.5 years4, while in Tabarsi et al study the mean age for all 111 HIV patients was 38[5] Olawumi et al One hundred and eighty-five patients aged 37 years were recruited to this study6 and in the study of Koethe et al the mean age was 41.6 years7 Patients presented with wide spectrum of diseases, and each had more than one system involvement. Most common presentation was anemia (29.7%), followed by tuberculosis (25%). 17% had acute gastroenteritis and pneumonia, 17% oral and esophageal candidiasis (table-1). Anemia is the most common hematological abnormality in HIV patients and has been shown to be associated with disease progression8. It is usually normocytic and normochromic, with a low reticulocyte level[9]. Almost 95% of HIV patients present anemia during the course of the disease8. Furthermore, it has been demonstrated that anemia is associated with increased mortality, and that mortality decreases when anemia is resolved8,10. This characterizes hemoglobin concentration (Hb) as an independent mortality factor, regardless of the baseline CD4 count8. Lang et al found oral candidiasis in 38% and pulmonary tuberculosis in 17%. Tabarsi et al found in his study oral candiasis was seen in 59% and pulmonary tuberculosis in 12%. Average CD4 count was 266, Average serum Globulin was 4.2 mg/dl. Average serum albumin was 3.4 mg/dl. No statistical correlation was found between serum albumin and CD4 count (R=0.26, P=0.09). There was a negative correlation (R=-0.41, p=0.008) between CD4 count and serum globulin suggesting as CD4 count decreased globulin levels increased. This shows that as the CD4 count decreases B cell dysfunction also worsens leading to altered antibody secretion. Hyperglobuinemia in HIV was demonstrated by Slucher et al, Quensel A et al, Miguez-Burban et al and Moja P et al. Hyperglobulinemia seen in HIV patients may be due to increased levels of IgG and IgA in this disease11,12,13,14. Serum globulins above 3.5 gm/dl was taken as cut of value to predict the CD4 count below 200cells/cumm had 65% sensitivity and 73% specificity, 72% positive predictive value. In our study we could not obtain any correlation between CD4 count and White cell count (P=0.48). Yusuf moolla in his study in south Africa had show that Calculated serum globulin as a single marker had negative correlation with CD4 count with borderline statistical significance (p=0.05), When serum globulin and White cell count were combined and analyzed he found the sensitivity was 81% and specificity was 55%15. REFERENCES
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