HIV and haematology Mike Webb Division of Clinical Haematology 5 March 2011.
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Transcript of HIV and haematology Mike Webb Division of Clinical Haematology 5 March 2011.
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