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

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

3. Multi-factorial Virus itself Infections Drugs – ARV’s – Treatment / prophylaxis of infections Malignancy Nutritional defects Autoimmune manifestations Other

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

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

6. Anaemia DDx Should you investigate? – Empiric TB Rx Invasive investigation? – Bone marrow – Node biopsy / Excision biopsy

7. Tuberculosis

8. Candida

9. Cryptococcus

10. EBV – atypical lymphocyte

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

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

14. What malignancies associated with HIV

15. Karposi Sarcoma – HHV8

16. NHL Cervix

17. Anemia - Drugs ARV’s – Zidovudine (AZT) Bactrim Dapsone Ampho B Ganciclovir

19. Hemolysis Drugs – dapsone, ribavirin Antibody Microangiopathy

20. 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)

21. Where are the platelets False result Waste of money to treat Bone marrow failure Appropriate to transfuse Peripheral destruction May be lethal to transfuse

22. What is the DDx? Primary – HIV associated Secondary – Infections viral / bacteria / protozoa / fungal – Malignancy Kaposi / Lymphoma – Drugs – Hypersplenism – TTP – DIC

23. 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

24. HIV related ITP / PHAT Most common cause of low platelets Mechanism: – Decreased platelet survival – Decreased platelet production

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

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

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

28. Macrophage Platelet

29. Treatment Steroids (2mg/kg) HAART

30. Case 35 yr old male Known with HIV CD4= 58 Presents with nose bleed, confusion, mild jaundice No focal signs

31. Fragments

32. Thrombotic thrombocytopenic purpura (TTP) Big five of TTP – Red cell fragmentation – Thrombocytopenia – Fluctuating neurological disturbances – Renal failure – Fever

33. Normal Plt vWF ADAMTS13

34. Normal

35. TTP

40. Blood moves at 1m/sec

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

43. Treatment Emergency!!! Scissor infusion

44. Neutropenia

45. Definitive link not proven but trials suggest: – Increased risk of infection – Increased hospitalizations – Increased morbidity Mortality not yet clear

46. Thrombosis Acquired LAC Chronic inflammation Immobility Increased infections – Tissue factor