FBC

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FBC
Case B
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Ms FBC

• 50 year old
• Diabetes mellitus
• HIV treated with Zidovudine many years
• Chronic renal failure (due to HIV)
• Haemodialysis 3 times a week

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Full blood count
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Explain the haematological parameters which are
consistent with the patients HIV.

• Progressive cytopenias (anemia, thrombocytopenia,
  leukopenia) commonly occur in HIV-infected
  patients
• The pathophysiologic mechanisms are
  multifactorial and include direct effects of HIV
  on haemapoetic precursor cells, alterations in
  the microenvironment of the bone marrow, and
  immulogic destruction of peripheral blood cells.

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Explain the haematological parameters which are
consistent with the patients HIV.

• Anaemia is common in HIV
• Intrinsic factor production is inadequate leading
  to ? absorbance of vitamin B12 folic acid
• Chronic infection with human parvovirus B19
  reduces RBC precursors in the presence of already
  impaired erythropoiesis secondary to HIV
  infection
• Results in ? Hb and low red blood cell

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Explain the haematological parameters which are
consistent with the patients HIV.

• Patients with HIV infection may have severe
  neutropenia and pancytopenia.
• Direct damage on haemopoietic precursor cells,
  which is consistent with the patients low
  neutrophil count.
• Also anti-HIV drugs have additive effect on
  neutropenia as they cause bone marrow suppression
  (known as additive toxicity).

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Explain the haematological parameters which are
consistent with the patients HIV.

• Other parameters includes
• Reduced platelet count.
• Prolonged prothrombin time.
• Due to stimulated macrophages releasing large
  amounts of plasminogen activator.
• In this patient platelets count were within
  range. this may be due to the use of Ziduvodine
• Zidovudine known as AZT _ prevent HIV fragments
  and antibodies from binding to platelets and
  marking them for destruction.

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Explain the haematological parameters which are
consistent with the patients HIV.

• Drugs used for HIV (e.g. acyclovir, AZT,
  ganciclovir) also cause myelosupression to a
  greater extent.
• Opportunistic infections and malignancies in HIV
  potentiates myelosupression
• Lymphocytopenia and Reactive lymphocytosis seen
  in this patient is caused by HIV specifically.

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Explain the haematological parameters which are
consistent with the patients HIV.

• HIV infects CD4 T-cells, causes ? CD4 T-cells
  numbers
• not seen in this patient as the count are within
  the normal range), dramatic decreases only occur
  in untreated HIV cases. When the count fall below
  200cells/mm3 they are said to have AIDS.
• Patients infected with HIV have increased
  eosinophil and basophil levels (will be explained
  later by Tuan).

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Haematological Parameters Which Are Consistent
With Chronic Renal Failure in Ms FBC
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Chronic Renal Failure

• Firstly, there is a defining parameter of renal
  failure which is an elevation of serum creatinine
  levels. This reflects the decrease in kidney
  function and thus GFR.
• Secondly, the patient is displaying anaemia with
  a reduction in red cell counts, haemoglobin and
  haematocrit.
• Finally, the red blood cell indices which
  indicate what type of anaemia are within range
  (MCV, MCH, MCHC and RDW). This indicates that
  this patient is experiencing normocytic,
  normochromic anaemia.

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Allow me to explain

• Normocytic, normochromic anaemia has a few
  possible causes
• acute blood loss
• excessive haemolysis
• anaemia of a chronic disease

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Whats happening in this patient?

• In this patient the anaemia could have been
  caused by acute blood loss or excessive
  haemolysis. However, it is more likely that the
  anaemia is due to the chronic renal failure due
  to a history of diabetes mellitus. The hormone
  required to produce red blood cells
  erythropoietin (EPO) is mainly produced by the
  kidney. With a reduction in functional kidney
  mass, the amount of EPO produced each day is
  reduced leading to normocytic, normochromic
  anaemia. Another possibility is that the patient
  is deficient of iron, folate and vitamin B12 to
  the extent where the RBC indices balance up to
  appear normocytic and normochromic.

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The patient has mild eosinohilia what could
this parameter reflect?

• Eosinophil
• Granular leukocyte (type of white blood cell)
• Phagocytic but less effective than neutrophils
• The primary stimuli for eosinophil production are
  interleukin IL-5, IL-3, and the
  granulocyte-macrophage colony-stimulating factor
  (GM-CSF)
• Manufactured in the bone marrow
• transferred into the bloodstream and the gut
  lining
• Produced by immune system to combat parasitic
  organisms
• once the parasite has been removed, the level of
  eosinophils in the bloodstream is allowed to
  return to normal

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Eosinophilia

• Condition that cause abnormally high levels of
  eosinophils to develop in either the blood or
  body tissues
• Body keep producing eosinophils at a high rate
• Accumulate in the blood and tissues
• Build-up of eosinophils ultimately leads to body
  damage.

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Causes of eosinophilia

• There are many causes of increased eosinophil
  production by the body
• Connective tissue diseases
• Helminthic infections
• Parasitic worm
• Idiopathic hypereosinophilic syndrome
• Neoplasia
• Tumor new and abnormal growth
• Lymphocytic leukemia
• Allergies
• Asthma
• Allergic rhinitis
• Food
• Medications (drug reaction)
• Dialysis and recent blood transfusion

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Eosinophilia and Ms FBCs condition

• High eosinophils level
• HIV
• Cutaneous manifestations
• Frequently occur in patients who are infected
  with HIV
• Due to the alterations in the immune system
• Initial signs of virus-related immunosuppression

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Eosinophilia and Ms FBCs condition

• High eosinophils level
• Zidovudine
• Develop opportunistic infections and other
  complications of HIV infection
• Anaemia
• In severe cases require blood transfusion
• Myalgia
• Eosinophilia-Myalgia Syndrome

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Eosinophilia and Ms FBCs condition

• High eosinophils level
• Dialysis
• Allergic symptoms occur immediately after
  initiation of dialysis
• Possibly due to inadequate rinsing of the dialyser

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Eosinophilia and Ms FBCs condition

• High eosinophils level
• Diabetes mellitus
• Uncontrolled blood glucose level
• Increase risk of skin ulceration and infection

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Treatment of eosinophilia

• There are no direct treatment for eosinophilia
• Treat the underlying caused of eosinophylia
• Once the caused have been removed, the level of
  eosinophils in the bloodstream is allowed to
  return to normal

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HIV pharmacotherapy is likely to be based on
which parameter?

• HIV pharmacotherapy is mainly based on CD4 count.
  
• However Viral Load also plays an important role
  in HIV pharmacotherapy. It helps to decide
  whether to start anti-HIV treatment.
• These two tests are crucial in helping to decide
  when to start treatment, and to monitor the
  effects of the treatment.

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What is CD4 counts?

• CD4 cells, or T-helper cells, are white blood
  cells which organise the immune systems response
  to some imcroorganisms, including bacteria,
  fungal infections and viruses.
• The CD4 count is the measurement of the number of
  CD4 cells, in a cubic millimeter of blood. Ie CD4
  cells/mm3.
• The CD4 count of a person who is not infected
  with HIV may lie anywhere between 500 and 1200.
• However The Human Immunodeficiency Virus (HIV)
  can infect and replicate within cells of CD4 and
  use them to produce more HIV copies, resulting in
  destruction of CD4 cells.

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What CD4 counts predict

• A CD4 count between 500 and 200 indicates that
  some damage to the immune system has occurred.
• If CD4 count drops below 350, or start falling
  rapidly, anti-HIV treatment should be discussed
  whether or not to start.
• If CD4 count falls below 250-200 anti-HIV drugs
  treatment are recommended to start. This is
  because it is the level at which the risk of
  AIDS-related illness is greatly increased.
• It is recommended that people start treatment
  before their CD4 count falls below 200, as people
  who start treatment with a CD4 count below 200
  face a greater risk of death, in the short-term
  than those who start before their CD4 count drops
  below this level.

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Factors that can alter in the CD4 count

• CD4 count can go up and down in response to
  infections, stress, smoking, exercise, the
  menstrual cycle, the contraceptive pill, the time
  of day and even the seasons of the year.
• Different types of CD4 counting-machine also give
  different readings.

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What is the viral load test?

• Viral load is the term used to describe the
  amount of HIV in blood. The more HIV in blood,
  the faster CD4 cells are likely to disappear, and
  the greater risk of developing symptoms or
  further illness within the next few years.
• Viral load tests estimate the number of HIV
  particles in the liquid, or plasma part of the
  blood. The result of a viral load test is
  described as the number of copies of HIV RNA/mm.
• Viral load should ideally only be measured when
  the person is well. If there is an infection or
  have recently had a vaccination, the viral load
  could temporarily increase.

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What information can Viral Load provide in
relation to HIV pharmacotherapy?

• In combination with CD4 count, Viral Load can
  provide information on the likely course of HIV
  infection and may help to predict risk of
  developing symptoms in the future.
• Among people with the same CD4 count, those with
  higher Viral Load tend to develop symptoms more
  quickly than those with lower viral load.
• Among people with the same Viral Load, those with
  lower CD4 counts tend to develop symptoms more
  quickly.

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Relationship between CD4 and Viral Load

• of people who develop AIDS within 3 years
  (assuming no treatment)
• A high viral load, regardless of CD4 cell
  count, increases risk of AIDS-related illness.
• indicates lack of data