I was looking for thoughts/opinions on a recent flow cytometry case. The case is that of a 38 year old male who presented with vague complaints, fever, and malaise that was thought to have a possible viral/infectious etiology. During his brief admission, a CBC was reviewed due to the presence of leukocytosis (WBC-17,300/ul) with an absolute lymphocytosis (68% lymphocytes). Many of the lymphocytes were reactive/atypical, similar to those often seen with EBV infection. A Monospot was negative. Flow cytometry performed on the peripheral blood showed 92% T cells, 7% NK cells and <1% B cells. Of interest, there was a marked predominance of CD8 (85%) and loss of expression of CD7. CD4 was present on 15% of cells and CD2, CD3, and CD5 were present in expected numbers with normal intensity. Because of the unusual loss of CD7 and predominance of CD8, the specimen was sent for PCR for TCR-gamma which apparently preliminary shows a clonal rearrangement. In the course of the patient's admission, the patient was found to be HIV positive (new diagnosis) and also had serologies suggestive of acute infection with CMV. EBV serologies were negative. The above-described flow findings have been well-described with EBV infection. In fact, in one of the recent articles on the Flow Cases Web site (www.flowcases.org), similar findings are described for a child with acute EBV infection. This child also had a positive clonal T cell rearrangement which subsequently disappeared along with the abnormal flow findings when the infection had cleared. Has anyone seen similar findings with either HIV and/or CMV infection. If so, should the patient be followed with repeat flow and/or molecular studies during the course and management of his newly diagnosed infection. Thanks for your thoughts. Christopher S. Bee, M.D. Medical Director, Flow Cytometry Wilford Hall Medical Center San Antonio, TX (210) 292-5455
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