HIV and haematology Mike Webb Division 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

ACD Infection Inhibits EPO Hepcidin Decreased Fe absorbtion Macrophage: Increased iron uptake Decreased iron release

Iron DeficiencyChronic Disease Marrow IronAbsentNormal or High Serum FerritinLowNormal or High TIBCHighLow Trans. Sat.Very LowLow / 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 ( )

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 160/120 GPIIb/IIIa

HIV related ITP / PHAT Platelet GP 160/120 GPIIb/IIIa

HIV related ITP / PHAT Platelet GP 160/120 GPIIb/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

TTP – big five Red cell fragmentation Thrombocytopenia Fluctuating neurological disturbances Renal failure Fever

Treatment Emergency!!! Scissor infusion

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