HIV and haematology

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HIV and haematology

• Rewriting the textbooks

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HIV has changed everything

1. Common findings
2. Rare and life-threatening HIV-related conditions
3. Treatment-related changes

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NEVER FORGET

• People with HIV have other diseases as well

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Anaemia

• Virtually 100 of HIV positive individuals by the
  time AIDS develops.
• Negative prognostic indicator independent of
  CD4 count and viral load

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Cytopenias

• Decreased production
• Increased destruction/ sequestration/ loss

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Decreased red cell production

• Anaemia of chronic disorders
• decreased responsiveness to
  erythropoietin (cytokine related)
• RE iron blockade
• shortened red cell survival
• Ineffective erythropoiesis
• Marrow infiltration

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Increased red cell loss

1. Splenomegaly
2. Immune destruction

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Thrombocytopenia

• Early
• Increased loss gtgtgt decreased production
• Later
• Decreased production becomes increasingly
  important

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ITP in HIV

• Frequently occurs before any other manifestation
  of HIV
• May be severe and life-threatening
• Responds to HAART and standard therapy
  splenectomy contraindicated

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Thrombocytopenia

• Increased loss
• splenomegaly
• Decreased production
• ineffective thrombopoiesis
• marrow infiltration

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Neutropenia

• Decreased production gtgtgt increased loss
• Ineffective marked dysplastic changes
  especially in the presence of additional marrow
  infection.
• Suppression
• Splenomegaly
• Autoimmune destruction

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Neutrophil dysplasia
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Neutrophil dysplasia
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Typical bone marrow findings

• Cellularity
• Normal to reduced
• Few adipocytes
• Increased macrophages
• Tatty and disorganised
• Fine fibrosis
• Open sinusoids
• Serous degeneration

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HIV bone marrow
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Serous degeneration
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Marrow appearances continued

• Evidence of inflammation
• plasma cells
• lymphoid aggregates
• macrophages

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Macrophages
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Marrow appearances continued

• Erythropoiesis
• reduced and right-shifted
• disordered
• increased iron stores
• Granulopoiesis
• normal to reduced
• dysplasia
• Thrombopoiesis
• ITP normal to increased
• dysplasia

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ITP
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Rare and life-threatening conditions
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Microangiopathic haemolysis

• TTP
• HUS
• DIC

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Pure red cell aplasia

• Not on ART Parvovirus B19
• On ART AZT (Zidovudine)
• Consider autoimmune

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Haemophagocytic syndrome
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Dont forget

• Lymphomas
• Myeloma
• Other rarer malignancies
• Infections TB, cryptococcus
• Coagulation antibodies to factors, lupus
  anticoagulant
• Thrombosis inflammation, reduced Protein S,
  endothelium

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Mycobacteria
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Cryptococcus
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Drug effects

• Zidovudine AZT
• pure red cell aplasia reduced
  erythropoiesis
• macrocytosis
• myeloid suppression
• Cotrimoxazole
• neutropenia, thrombocytopenia
• 3TC Lamivudine pure red cell aplasia