1. HIV and haematology Mike Webb Division of Clinical Haematology 8 Feb 2010

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

6. Anemia (1) DDx Should you investigate? – Empiric TB Rx Invasive investigation? – Bone marrow – Node biopsy / Excision biopsy

7. What is the DDx

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

9. What malignancies associated with HIV

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

12. 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)

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

14. What is the DDx?

15. 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

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

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

18. Macrophage Platelet

19. Treatment Steroids (2mg/kg) HAART

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

21. Case

22. Fragments

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

24. Normal Plt vWF ADAMTS13

25. Blood moves at 1m/sec

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

28. Treatment Emergency!!! Scissor infusion

29. Neutropenia

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