Test Catalog

Test ID: RBCS    
Relative B-Cell Subset Analysis Percentage, Blood

Useful For Suggests clinical disorders or settings where the test may be helpful

Screening for humoral or combined immunodeficiencies, including common variable immunodeficiency (CVID), hyper IgM syndrome, among others, where B-cell subset distribution information is desired


Assessing B-cell subset reconstitution after hematopoietic cell (HCT) or bone marrow transplant


Assessing B-cell subset reconstitution following recovery of B cells after B-cell-depleting immunotherapy

Testing Algorithm Delineates situations when tests are added to the initial order. This includes reflex and additional tests.

This test should be ordered only when percentages (relative distribution of B cell subsets within the total B-cell population) are needed for the reportable B-cell subsets. If both percentages and absolute counts are needed for the reportable B-cell subsets, order IABCS / B-Cell Phenotyping Profile for Immunodeficiency and Immune Competence Assessment, Blood.

Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test

The adaptive immune response includes both cell-mediated (mediated by T cells and NK cells) and humoral immunity (mediated by B cells). After antigen recognition and maturation in secondary lymphoid organs, some antigen-specific B cells terminally differentiate into antibody-secreting plasma cells or become memory B cells. Memory B cells are of 3 subsets: marginal zone B cells (MZ or nonswitched memory), class-switched memory B cells, and IgM-only memory B cells. Decreased B-cell numbers, B-cell function, or both, result in immune deficiency states and increased susceptibility to infections. These decreases may be either primary (genetic) or secondary. Secondary causes include medications, malignancies, infections, and autoimmune disorders.


Common variable immunodeficiency (CVID), a disorder of B-cell function, is the most prevalent primary immunodeficiency with a prevalence of 1:25,000 to 1:50,000.(1) CVID has a bimodal presentation with a subset of patients presenting in early childhood and a second set presenting between 15 and 40 years of age, or occasionally even later. Four different genetic defects have been associated with CVID, including mutations in the ICOS, CD19, BAFF-R, and TACI genes. The first 3 genetic defects account for approximately 1% to 2%, and TACI mutations account for 8% to 15% of CVID cases.


CVID is characterized by hypogammaglobulinemia usually involving most or all of the Ig classes (IgG, IgA, IgM, and IgE), impaired functional antibody responses, and recurrent sinopulmonary infections.(1,2) B-cell numbers may be normal or decreased. A minority of CVID patients (5%-10%) have very low B-cell counts (<1% of peripheral blood leukocytes), while another subset (5%-10%) exhibit noncaseating, sarcoid-like granulomas in different organs and also tend to develop a progressive T-cell deficiency.(1) Of all patients with CVID, 25% to 30% have increased numbers of CD8 T cells and a reduced CD4:CD8 ratio (<1). Studies have shown the clinical relevance of classifying CVID patients by assessing B-cell subsets, since changes in different B-cell subsets are associated with particular clinical phenotypes or presentations.(3,4)


The B-cell phenotyping assay can be used in the diagnosis of hyper-IgM syndromes, which are characterized by increased or normal levels of IgM with low IgG and/or IgA.(5) Patients with hyper-IgM syndromes can have 1 of 5 known genetic defects—mutations in the CD40L, CD40, AID (activation-induced cytidine deaminase), UNG (uracil DNA glycosylase), and NEMO (NF-kappa B essential modulator) genes.(5) Mutations in CD40L and NEMO are inherited in an X-linked fashion, while mutations in the other 3 genes are inherited in an autosomal recessive fashion. Patients with hyper-IgM syndromes have a defect in isotype class-switching, which leads to a decrease in class-switched memory B cells, with or without an increase in nonswitched memory B cells and IgM-only memory B cells.


In addition to its utility in the diagnosis of the above-described primary immunodeficiencies, B-cell phenotyping may be used to assess reconstitution of B-cell subsets after hematopoietic stem cell or bone marrow transplant. This test is also used to monitor B-cell-depleting therapies, such as Rituxan (Rituximab) and Zevalin (Ibritumomab tiuxetan).

Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.

The appropriate age-related reference values will be provided on the report.

Interpretation Provides information to assist in interpretation of the test results

The assay provides semiquantitative (%) information on the various B-cell subsets. Each specimen is evaluated for B-cell subsets with respect to the total number of CD19+ B cells present in the peripheral blood mononuclear cell population, compared to the reference range. In order to verify that there are no CD19-related defects, CD20 is used as an additional pan-B-cell marker (expressed as percentage of CD45+ lymphocytes).


The B-cell panel assesses the following B-cell subsets:

-CD19+=B cells expressing CD19 as a percent of total lymphocytes

-CD19+ CD27+=total memory B cells

-CD19+ CD27+ IgD+ IgM+=marginal zone or non-switched memory B cells

-CD19+ CD27+ IgD- IgM+=IgM-only memory B cells

-CD19+ CD27+ IgD- IgM-=class-switched memory B cells

-CD19+ IgM+=IgM B cells

-CD19+ CD38+ IgM+=transitional B cells

-CD19+ CD38+ IgM-=plasmablasts

-CD19+ CD21-=CD21-negative B cells

-CD19+ CD21+=CD21-positive B cells

-CD19+ CD20+=B cells co-expressing both CD19 and CD20 as a percent of total lymphocytes


For isotype class-switching and memory B-cell analyses, the data will be reported as being consistent or not consistent with a quantitative defect in memory subsets and/or class switching. If a defect is present in any of these B-cell subpopulations, further correlation with clinical presentation and additional functional, immunological, and genetic laboratory studies will be suggested, if appropriate.

Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances

This test should be ordered only when percentages are needed for the reportable B-cell subsets. If both percentages and absolute counts are needed for the reportable B-cell subsets, order IABCS / B-Cell Phenotyping Profile for Immunodeficiency and Immune Competence Assessment, Blood.

This assay and the reference range reported are based on analysis of B cells derived from the mononuclear cell fraction of peripheral whole blood and, therefore, total CD19+ B cell quantitation may not be identical to those performed on whole blood (eg, TBBS / T- and B-Cell Quantitation by Flow Cytometry).


This test is not indicated for the evaluation of lymphoproliferative disorders (eg, leukemia, lymphoma, multiple myeloma).


This test should not be used to monitor B-cell counts to assess B-cell depletion in patients on B-cell-depleting therapies (use CD20B / CD20 on B Cells for that purpose); this test is meant to be used specifically for assessing the relative distribution of B-cell subsets within the total B-cell pool


Timing and consistency in timing of blood collection is critical when serially monitoring patients for lymphocyte subsets.

Clinical Reference Recommendations for in-depth reading of a clinical nature

1. Warnatz K, Denz A, Drager R, et al: Severe deficiency of switched memory B cells (CD27+ IgM- IgD-) in subgroups of patients with common variable immunodeficiency: a new approach to classify a heterogeneous disease. Blood 2002;99:1544-1551

2. Brouet JC, Chedeville A, Fermand JP, Royer B: Study of the B cell memory compartment in common variable immunodeficiency. Eur J Immunol 2000;30:2516-2520

3. Wehr C, Kivioja T, Schmitt C, et al: The EUROclass trial: defining subgroups in common variable immunodeficiency. Blood 2008;111:77-85

4. Alachkar H, Taubenheim N, Haeney MR, et al: Memory switched B-cell percentage and not serum immunoglobulin concentration is associated with clinical complications in children and adults with specific antibody deficiency and common variable immunodeficiency. Clin Immunol 2006;120:310-318

5. Lee WI, Torgerson TR, Schumacher MJ, et al: Molecular analysis of a large cohort of patients with hyper immunoglobulin M (hyper IgM) syndrome. Blood 2005;105:1881-1890