CD4 Count

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Raymund Li

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Maryam Gbadamosi-Akindele

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4/4/2019 12:02:10 PM


CD4 count is a laboratory test that measures CD-4 T lymphocytes (T cells) via flow cytometry. This test is an important parameter in HIV management and is used to guide clinical treatment. The CD4 count is a reliable indicator of a patient’s immunologic status and is used to determine the necessity for initiation of prophylactic treatment against opportunistic infections.[1]

CD4 T cells are human helper T cells that express cluster determinant 4 (CD4) molecules. The CD4 molecule is a member of the immunoglobulin family and primarily mediates adhesion to major histocompatibility complex molecules. CD4 T cells are selectively targeted and infected by HIV. HIV proliferates rapidly during acute infection leading to high levels of viremia and rapid impairment and death of CD4 T cells.[2][3][4][5]

Specimen Collection

Flow cytometry usually determines the CD4 count. The specimen is collected through a standard blood draw and is processed within 18 hours of specimen collection.


Laboratory measurement of CD4 count through flow cytometry is reported as CD4 percentages. The absolute CD4 count is obtained by multiplying this percentage with the total measured white blood cell (WBC) count. The absolute CD4 count usually corresponds to the CD4 percentages. A CD4 percentage of greater than 29% corresponds to an absolute count of more than 500 cells/microliters, 14% to 28% corresponds to an absolute count between 200 and 500 cells/microliters, and less than 14% corresponds to an absolute count of fewer than 200 cells/microliters. It is, however, important to note that an increase in WBC will cause an increase in the absolute CD4 count while the CD4 percentage remains the same. CD4 count measurements may also have inter-assay or inter-laboratory variability.[6][7][8]


CD4 count monitoring is primarily used to assess when to initiate prophylaxis against several opportunistic infections. Although it is also obtained in monitoring response to ART, CD4 count is, by itself, insufficient in evaluating response to therapy. Viral load monitoring remains the most reliable indicator of treatment response. The CD4 count must be obtained at baseline 3 months after initiation of ART. It is subsequently monitored every 3 to 6 months during therapy. According to treatment guidelines, less frequent monitoring (every 12 months) may be done after 2 years of ART in patients who have a stable CD4 count of greater than 300 cells/microliters and consistently undetectable viral load.

Potential Diagnosis

CD4 count, although an essential part of HIV management, is not primarily used for the diagnosis of HIV infection. However, an absolute CD4 count less than 200 cells/microliter is one of the criteria utilized by the Center for Disease Control and Prevention (CDC) in the definition of AIDS, a clinical stage that indicates high susceptibility to opportunistic infections.

Normal and Critical Findings

The normal CD4 count range is between 500 and 1400 cells/microliters., taking into consideration laboratory variations.

Interfering Factors

There is significant intraindividual variability in CD4 count measurement. In a pre-ART (antiretroviral therapy) study, the intraindividual coefficient variation in 1020 untreated HIV patients was found to be at 25% on average. This variability was found even in healthy adult subjects. Several factors contribute to this variability. Any factors that lead to increase or decrease in WBC count may cause changes to the measured absolute CD4 count. These factors include infection, medications, or other chronic conditions. Leukocytosis may increase the absolute CD4 count while leukopenia may result in a decreased count. Patients with a history of splenectomy tend to have higher absolute CD4 cell counts, while patients with the advanced liver disease and splenomegaly tend to have lower counts which may be related to splenic sequestration. In these cases, the CD4 percentage usually has less variation. Therefore, any discordant changes between the absolute CD4 count and CD4 cell percentage should lead the clinician to investigate for possible factors that may be causing the changes, and caution should be used in CD4 count interpretation since it may not truly reflect the patient’s immunologic status.

Certain viral and bacterial infections have been associated with a mild decrease in CD4 cell count. These have been documented in viral infections such as Ebstein Barr Virus (EBV), cytomegalovirus (CMV), and HTLV-1 and bacterial infections such as tuberculosis. Patients with Hepatitis C virus (HCV) cirrhosis tend to have lower CD4 cell counts and HIV patients with HCV co-infection seem to have reduced immune recovery upon initiation of antiretroviral therapy.[9][10] Medications such as corticosteroids may also affect WBC counts which in turn lead to changes in CD4 cell counts.[11] Alcohol abuse has also been associated with a drop in the absolute CD4 count.[12] A rare syndrome called idiopathic CD4 lymphocytopenia has been described which is defined as a low CD4 count in the absence of HIV infection or any other medical conditions that may explain the disease.[13][14]

Clinical Significance

CD4 count depletion is a consequence of HIV infection and leads to devastating opportunistic infections when left untreated. It affects both CD4 helper T cells in the lymphoid tissue as well as T cells circulating in the peripheral blood. In the natural history of HIV infection, there is an abrupt decline in the CD4 count during acute HIV infection that is usually followed by a rebound as a result of CD8 lymphocyte response to viral replication. Without antiretroviral treatment, the CD4 count will then decline over the next several years.[15]

CD4 cell counts are used to monitor immunologic response to ART. With effective viral suppression, CD4 count is expected to increase by at least 50 cells/microliter after 4 to 8 weeks of treatment and by approximately 100 to 150 cells/microliters increase from baseline at one year. This is then followed by an expected increase of 50 to 100 cells/microliter per year. Several factors such as older age, lower CD4 baseline, and severe immunocompromised status have been associated with a less than expected improvement in the CD4 count while on treatment.[16][17]

CD4 count is not a reliable indicator of virologic suppression and medication adherence. In patients who develop virologic resistance while on ART, it may take months for the CD4 count to decline and it may even initially increase. Several factors may falsely increase or decrease CD4 cell counts that may not necessarily reflect a patient’s true immunologic status. Inter-laboratory variability must also be taken into consideration. Thus, any significant but unexpected difference between two CD4 count measurements, which is defined as a 30% change in absolute CD4 count or 3% change in CD4 percentage, must be confirmed with a repeat testing.

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CD4 Count - Questions

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A 29-year-old male with past medical of HIV, well-controlled on antiretroviral therapy for 1 year presents to the clinic for follow up. His CD4 count last week was 500 cells/microliter. He reports constant cough for the last 2 weeks. His chest x-ray shows bilateral infiltrates. Pneumocystis jirovecii pneumonia is confirmed with sputum antigen testing and treatment is started. What is the next step in the management of his HIV?

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A 23-year-old male with a recent diagnosis of HIV presents to the clinic for evaluation. His recent CD4 count is 30% with a total white cell count of 1720 cells/microliter. He is asymptomatic and his physical exam is unremarkable. In addition to starting antiretroviral therapy what other treatment is recommended at this time?

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A 23-year-old male with HIV who was recently started on antiretroviral therapy presents to the clinic with questions regarding his CD4 count. Recent laboratory work reveals that his absolute CD4 count is 150 cells/microliters. He is asymptomatic with unremarkable physical examination findings. Which of the following is true regarding his management?

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CD4 Count - References


Prognostic value of combined response markers among human immunodeficiency virus-infected persons: possible aid in the decision to change zidovudine monotherapy., Graham NM,Park LP,Piantadosi S,Phair JP,Mellors J,Fahey JL,Saah AJ,, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 1995 Feb     [PubMed]
Clinical and epidemiologic features of primary HIV infection., Schacker T,Collier AC,Hughes J,Shea T,Corey L,, Annals of internal medicine, 1996 Aug 15     [PubMed]
HIV preferentially infects HIV-specific CD4+ T cells., Douek DC,Brenchley JM,Betts MR,Ambrozak DR,Hill BJ,Okamoto Y,Casazza JP,Kuruppu J,Kunstman K,Wolinsky S,Grossman Z,Dybul M,Oxenius A,Price DA,Connors M,Koup RA,, Nature, 2002 May 2     [PubMed]
Effects of virologic rebound on CD4 cell counts., Bahrani A,Ramaswamy R,Oldfield EC 3rd,, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2001 Apr 15     [PubMed]
Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel., Günthard HF,Aberg JA,Eron JJ,Hoy JF,Telenti A,Benson CA,Burger DM,Cahn P,Gallant JE,Glesby MJ,Reiss P,Saag MS,Thomas DL,Jacobsen DM,Volberding PA,, JAMA, 2014 Jul 23-30     [PubMed]
T-cell subsets in health, infectious disease, and idiopathic CD4+ T lymphocytopenia., Laurence J,, Annals of internal medicine, 1993 Jul 1     [PubMed]
Within-subject variation in CD4 lymphocyte count in asymptomatic human immunodeficiency virus infection: implications for patient monitoring., Hughes MD,Stein DS,Gundacker HM,Valentine FT,Phair JP,Volberding PA,, The Journal of infectious diseases, 1994 Jan     [PubMed]
CD4 percentage, CD4 number, and CD4:CD8 ratio in HIV infection: which to choose and how to use., Taylor JM,Fahey JL,Detels R,Giorgi JV,, Journal of acquired immune deficiency syndromes, 1989     [PubMed]
Coinfection with human T-cell lymphotropic virus type I and HIV in Brazil. Impact on markers of HIV disease progression., Schechter M,Harrison LH,Halsey NA,Trade G,Santino M,Moulton LH,Quinn TC,, JAMA, 1994 Feb 2     [PubMed]
Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study., Greub G,Ledergerber B,Battegay M,Grob P,Perrin L,Furrer H,Burgisser P,Erb P,Boggian K,Piffaretti JC,Hirschel B,Janin P,Francioli P,Flepp M,Telenti A,, Lancet (London, England), 2000 Nov 25     [PubMed]
The influence of prednisolone on the recirculation of peripheral blood lymphocytes in vivo., Bloemena E,Weinreich S,Schellekens PT,, Clinical and experimental immunology, 1990 Jun     [PubMed]
Improvement of the CD4 cell count after alcohol withdrawal in HIV-positive alcoholic patients., Pol S,Artru P,Thépot V,Berthelot P,Nalpas B,, AIDS (London, England), 1996 Sep     [PubMed]
Discordance between CD4+ T-lymphocyte counts and percentages in HIV-infected persons with liver fibrosis., Claassen CW,Diener-West M,Mehta SH,Thomas DL,Kirk GD,, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2012 Jun     [PubMed]
Unexplained CD4 + T-lymphocyte depletion in persons without evident HIV infection--United States.,, Infection control and hospital epidemiology, 1992 Oct     [PubMed]
CD4+ T cell depletion during all stages of HIV disease occurs predominantly in the gastrointestinal tract., Brenchley JM,Schacker TW,Ruff LE,Price DA,Taylor JH,Beilman GJ,Nguyen PL,Khoruts A,Larson M,Haase AT,Douek DC,, The Journal of experimental medicine, 2004 Sep 20     [PubMed]
Normalisation of CD4 counts in patients with HIV-1 infection and maximum virological suppression who are taking combination antiretroviral therapy: an observational cohort study., Mocroft A,Phillips AN,Gatell J,Ledergerber B,Fisher M,Clumeck N,Losso M,Lazzarin A,Fatkenheuer G,Lundgren JD,, Lancet (London, England), 2007 Aug 4     [PubMed]
A CD4+ cell count <200 cells per cubic millimeter at 2 years after initiation of combination antiretroviral therapy is associated with increased mortality in HIV-infected individuals with viral suppression., Loutfy MR,Genebat M,Moore D,Raboud J,Chan K,Antoniou T,Milan D,Shen A,Klein MB,Cooper C,Machouf N,Rourke SB,Rachlis A,Tsoukas C,Montaner JS,Walmsley SL,Smieja M,Bayoumi A,Mills E,Hogg RS,, Journal of acquired immune deficiency syndromes (1999), 2010 Dec     [PubMed]


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