HIV and haematology

Mike WebbDivision of Clinical Haematology

5 March 2011

HIV

• 5,2 million infected people in RSA• Cause a variety of common conditions:– Bleeding / Thrombosis– Anaemia – Thrombocytosis / Thrombocytopenia– Leucocytosis / Leucopenia

Multi-factorial

• Virus itself• Infections• Drugs – ARV’s– Treatment / prophylaxis of infections

• Malignancy• Nutritional defects• Autoimmune manifestations• Other

Anemia

• Most common hematologic abnormality (80%)– Infections– Anaemia of chronic disease– Drugs – Malignancy– Nutritional

Anaemia

• 35 yr old male• Generalized lymphadenopathy • B-symptoms• Non-productive cough• Hgb 8g/dl• WCC, Plt, MCV - normal

Anaemia

• DDx• Should you investigate?– Empiric TB Rx

• Invasive investigation?– Bone marrow – Node biopsy / Excision biopsy

Tuberculosis

Candida

Cryptococcus

EBV – atypical lymphocyte

ACDInfection

Inhibits EPO

Hepcidin

Decreased Feabsorbtion

Macrophage:Increased iron uptakeDecreased iron release

Iron Deficiency Chronic Disease

Marrow Iron Absent Normal or High

Serum Ferritin Low Normal or High

TIBC High Low

Trans. Sat. Very Low Low / Normal

What malignancies associated with HIV

Karposi Sarcoma – HHV8

NHL Cervix

Anemia - Drugs

• ARV’s – Zidovudine (AZT)• Bactrim• Dapsone• Ampho B• Ganciclovir

Hemolysis

• Drugs – dapsone, ribavirin

• Antibody

• Microangiopathy

Case

• 34 yr old female• Epistaxis• New onset• Known HIV pos• CD4 – 220/mL• Hgb = 12g/dl• WCC = normal• Plt = 5 x10⁹/L (150-450)

Where are the platelets

False result

• Waste of money to treat

Bone marrow failure

• Appropriate to transfuse

Peripheral destruction

• May be lethal to transfuse

What is the DDx?

• Primary – HIV associated• Secondary– Infections viral / bacteria / protozoa / fungal– Malignancy Kaposi / Lymphoma– Drugs– Hypersplenism– TTP– DIC

THROMBOCYTOPENIA

• Common – 40% at some time• May occur at any period of infection • Worse with progressive immunosuppression

• Two groups:– primary HIV-associated thrombocytopenia– secondary thrombocytopenia

HIV related ITP / PHAT

• Most common cause of low platelets• Mechanism:– Decreased platelet survival– Decreased platelet production

HIV related ITP / PHAT

Platelet

GP 160/120GPIIb/IIIa

HIV related ITP / PHAT

Platelet

GP 160/120GPIIb/IIIa

HIV related ITP / PHAT

Platelet

GP 160/120GPIIb/IIIa

Macrophage

• Platelet

Treatment

• Steroids (2mg/kg)• HAART

Case

• 35 yr old male• Known with HIV• CD4= 58• Presents with nose bleed, confusion, mild

jaundice• No focal signs

Fragments

Thrombotic thrombocytopenic purpura (TTP)

• Big five of TTP– Red cell fragmentation– Thrombocytopenia– Fluctuating neurological disturbances– Renal failure– Fever

Normal

Plt

vWF

ADAMTS13

Normal

TTP

Blood moves at 1m/sec

Blood moves at 1m/sec

TTP – big five

• Red cell fragmentation• Thrombocytopenia• Fluctuating neurological disturbances• Renal failure• Fever

Treatment

• Emergency!!!• Scissor infusion

Neutropenia

Neutropenia

• Definitive link not proven but trials suggest:– Increased risk of infection– Increased hospitalizations– Increased morbidity

• Mortality not yet clear

Thrombosis

• Acquired LAC• Chronic inflammation• Immobility• Increased infections – Tissue factor