Hematologic abnormalities in the acquired immune deficiency syndrome

Fibrosis and bone marrow: understanding causation and pathobiology

Bone marrow fibrosis represents an important structural change in the marrow that interferes with some of its normal functions. The aetiopathogenesis of fibrosis is not well established except in its primary form. The present review consolidates current understanding of marrow fibrosis. We searched PubMed without time restriction using key words: bone marrow and fibrosis as the main stem against the terms: growth factors, cytokines and chemokines, morphology, megakaryocytes and platelets, myeloproliferative disorders, myelodysplastic syndrome, collagen biosynthesis, mesenchymal stem cells, vitamins and minerals and hormones, and mechanism of tissue fibrosis. Tissue marrow fibrosis-related papers were short listed and analysed for the review. It emerged that bone marrow fibrosis is the outcome of complex interactions between growth factors, cytokines, chemokines and hormones together with their facilitators and inhibitors. Fibrogenesis is initiated by mobilisation of special immunophenotypic subsets of mesenchymal stem cells in the marrow that transform into fibroblasts. Fibrogenic stimuli may arise from neoplastic haemopoietic or non-hematopoietic cells, as well as immune cells involved in infections and inflammatory conditions. Autoimmunity is involved in a small subset of patients with marrow fibrosis. Megakaryocytes and platelets are either directly involved or are important intermediaries in stimulating mesenchymal stem cells. MMPs, TIMPs, TGF-β, PDGRF, and basic FGF and CRCXL4 chemokines are involved in these processes. Genetic and epigenetic changes underlie many of these conditions.

Comorbid disease in children and adolescents with perinatal HIV infection: A pilot study

Background. With the increased use of combination antiretroviral therapy, the mortality of people living with HIV has decreased significantly, which has led to an increase of comorbidity and secondary HIV-related pathology in both adults and also in children and adolescents living with HIV infection. The incidence of children and adolescents with HIV infection and those in the general population varies significantly.The aim. To assess the frequency and range of chronic comorbidities in children and adolescents with perinatal HIV infection Methods. We carried out an observational study. Data on the incidence of 161 children with perinatal HIV infection registered in the Irkutsk Regional AIDS Center were copied.Results. Overall incidence of tuberculosis (18633.5 per 100 000 children), diseases of the digestive system (24844.7 per 100 000 children), diseases of the eye and adnexa (28571.4 per 100 000 children), diseases of the nervous system (18012.4 per 100 000 children), mental and behavioral disorders (13,664.6 per 100 000 children) in children with perinatal HIV infection is the higher than in children of comparable age. The overall incidence values of the endocrine system diseases, eating and metabolic disorders, diseases of the ear and mastoid process, diseases of the circulatory system, diseases of the genitourinary system, as well as congenital disorders and chromosomal disorders in children and adolescents with and without perinatal HIV infection are comparable.Conclusion. The prevalence of diseases of the circulatory, respiratory and genitourinary systems in children with perinatal HIV infection is comparable to that in the corresponding population. Prevalence of tuberculosis, anemia, diseases of the gastrointestinal tract, diseases of the eye and adnexa, diseases of the nervous system, mental and behavioral disorders is higher compared to children not exposed to HIV.

Clinico-hematological profile of pancytopenic adult patients in a tertiary care teaching hospital

Objective:

The causes of pancytopenia vary in different populations depending on age, gender, nutrition, geographic location, standard of living, and exposure to certain infections and drugs. As the severity of pancytopenia and its underlying etiology determine the management and prognosis, identifying the correct etiology in a given case is crucial and helps in implementing timely and appropriate treatment. The objectives of this study were to study the clinical profile and hematological parameters of pancytopenic adults and to identify different etiologies of pancytopenia. This observational study was conducted in the Medicine department of a tertiary care teaching hospital.

Materials and Methods:

The study was conducted on 100 adult patients aged 18–65 years presenting with pancytopenia. All the participants were subjected to detailed clinical examination and relevant investigations including bone marrow (BM) examination. Categorical variables were presented in number and percentage (%). Qualitative variables were correlated using the Chi-square test. A P =0.05 was considered statistically significant.

Results:

A female preponderance was observed, and the majority of patients were aged between 18 and 40 years. The most common clinical features were generalized weakness, fever, and pallor. Seventy-four percent of patients were vegetarians; 58% had vitamin B12 deficiency, 25% had folic acid deficiency and 19% had a deficiency of both. The most common cause of pancytopenia was megaloblastic anemia (MA) (37%), followed by dimorphic anemia (DA) (26%), aplastic anemia (AA) (20%), and hematological malignancies (11%).

Conclusion:

MA, DA, and AA are the most prevalent etiologies of pancytopenia. BM examination is of utmost importance in the definitive diagnosis of pancytopenia and is useful in initiating timely treatment as a significant number of causes of pancytopenia are potentially curable.

Anemia among Patients Attending Anti-retroviral Therapy at a Tertiary Care Center: A Descriptive Cross-sectional Study

INTRODUCTION

Hematologic abnormalities are among the most common complications of infection with Human Immunodeficiency Virus. These abnormalities are due to: impaired hematopoiesis, immune mediated cytopenias and altered coagulation mechanisms. Anemia is the most frequent,however, leukopenia, lymphopenia, and thrombocytopenia have also been observed. The aim of the study was to find the prevalence of anemia in patients attending anti-retroviral therapy at a tertiary care center of Nepal.

METHODS

The study was a descriptive cross-sectional study conducted from August 2018 to August 2019 in patients attending anti-retroviral therapy at a tertiary care hospital. Ethical approval was obtained from the Institutional Review Board of National Academy of Medical Sciences before starting the study (Reference number 267). Convenient sampling was used for this study. Data were analysed using the Statistical package for Social Sciences version 20. Point estimate at 90% confidence interval was calculated along with frequency and proportion for the binary data.

RESULTS

The prevalence of anemia among patients attending anti-retroviral therapy centers in our study was found in 29 (58%) (46.55-69.45 at 90% Confidence Interval). Out of those patients, 20 (63%) were male and 9 (50%) were female. The mean hemoglobin value was 11.946±2.51g/dl.

CONCLUSIONS

The prevalence of anemia among patients attending antiretroviral therapy in our study was found to be high which is consistent with the findings of other similar international studies. These patients should be routinely monitored and treated for the occurrence of hematological abnormalities.

HIV-1 Nef Induces Hck/Lyn-Dependent Expansion of Myeloid-Derived Suppressor Cells Associated with Elevated Interleukin-17/G-CSF Levels

Human immunodeficiency virus (HIV) or simian immunodeficiency virus (SIV) infection causes myelodysplasia, anemia, and accumulation of inflammatory monocytes (CD14⁺ CD16⁺) through largely unknown cellular and molecular pathways. The mouse cells thought to be equivalent to human CD14⁺ CD16⁺ cells are CD11b⁺ Gr1⁺ myeloid-derived suppressor cells (MDSC). We used HIV transgenic (Tg) mouse models to study MDSC, namely, CD4C/Nef Tg mice expressing nef in dendritic cells (DC), pDC, CD4⁺ T, and other mature and immature myeloid cells and CD11c/Nef Tg mice with a more restricted expression, mainly in DC and pDC. Both Tg strains showed expansion of granulocytic and CD11b⁺ Gr1^low/int cells with MDSC characteristics. Fetal liver cell transplantation revealed that this expansion was stroma-independent and abrogated in mixed Tg/non-Tg 50% chimera. Tg bone marrow (BM) erythroid progenitors were decreased and myeloid precursors increased, suggesting an aberrant differentiation likely driving CD11b⁺ Gr1⁺ cell expansion, apparently cell autonomously in CD4C/Nef Tg mice and likely through a bystander effect in CD11c/Nef Tg mice. Hck was activated in Tg spleen, and Nef-mediated CD11b⁺ Gr1⁺ cell expansion was abrogated in Hck/Lyn-deficient Nef Tg mice, indicating a requirement of Hck/Lyn for this Nef function. IL-17 and granulocyte colony-stimulating factor (G-CSF) were elevated in Nef Tg mice. Increased G-CSF levels were normalized in Tg mice treated with anti-IL-17 antibodies. Therefore, Nef expression in myeloid precursors causes severe BM failure, apparently cell autonomously. More cell-restricted expression of Nef in DC and pDC appears sufficient to induce BM differentiation impairment, granulopoiesis, and expansion of MDSC at the expense of erythroid maturation, with IL-17→G-CSF as one likely bystander contributor. IMPORTANCE HIV-1 and SIV infection often lead to myelodysplasia, anemia, and accumulation of inflammatory monocytes (CD14⁺ CD16⁺), with the latter likely involved in neuroAIDS. We found that some transgenic (Tg) mouse models of AIDS also develop accumulation of mature and immature cells of the granulocytic lineage, decreased erythroid precursors, and expansion of MDSC (equivalent to human CD14⁺ CD16⁺ cells). We identified Nef as being responsible for these phenotypes, and its expression in mouse DC appears sufficient for their development through a bystander mechanism. Nef expression in myeloid progenitors may also favor myeloid cell expansion, likely in a cell-autonomous way. Hck/Lyn is required for the Nef-mediated accumulation of myeloid cells. Finally, we identified G-CSF under the control of IL-17 as one bystander mediator of MDSC expansion. Our findings provide a framework to determine whether the Nef>Hck/Lyn>IL-17>G-CSF pathway is involved in human AIDS and whether it represents a valid therapeutic target.

Comparison of pathological clotting using haematological, functional and morphological investigations in HIV-positive and HIV-negative patients with deep vein thrombosis

BACKGROUND

Patients infected with the human immunodeficiency virus (HIV) are more prone to systemic inflammation and pathological clotting, and many may develop deep vein thrombosis (DVT) as a result of this dysregulated inflammatory profile. Coagulation tests are not routinely performed unless there is a specific reason.

METHODS

We recruited ten healthy control subjects, 35 HIV negative patients with deep vein thrombosis (HIV negative-DVT), and 13 HIV patients with DVT (HIV positive-DVT) on the primary antiretroviral therapy (ARV) regimen-emtricitabine, tenofovir and efavirenz. Serum inflammatory markers, haematological results, viscoelastic properties using thromboelastography (TEG) and scanning electron microscopy (SEM) of whole blood (WB) were used to compare the groups.

RESULTS

The DVT patients (HIV positive and HIV negative) had raised inflammatory markers. The HIV positive-DVT group had anaemia in keeping with anaemia of chronic disorders. DVT patients had a hypercoagulable profile on the TEG but no significant difference between HIV negative-DVT and HIV positive-DVT groups. The TEG analysis compared well and supported our ultrastructural results. Scanning electron microscopy of DVT patient's red blood cells (RBCs) and platelets demonstrated inflammatory changes including abnormal cell shapes, irregular membranes and microparticle formation. All the ultrastructural changes were more prominent in the HIV positive-DVT patients.

CONCLUSIONS

Although there were trends that HIV-positive patients were more hypercoagulable on functional tests (viscoelastic profile) compared to HIV-negative patients, there were no significant differences between the 2 groups. The sample size was, however, small in number. Morphologically there were inflammatory changes in patients with DVT. These ultrastructural changes, specifically with regard to platelets, appear more pronounced in HIV-positive patients which may contribute to increased risk for hypercoagulability and deep vein thrombosis.

Parvovirus B19 DNA detection in treatment-naïve HIV anemic patients in Lagos, Nigeria: a case control study

BACKGROUND

Parvovirus B19 (B19) has tropism for cells of the erythroid lineage, which may lead to transient inhibition of erythropoiesis. Several studies and case reports suggested that B19 infection may contribute significantly to severe chronic anemia in HIV infected persons.

OBJECTIVE

To detect parvovirus B19 DNA in treatment-naïve HIV patients.

METHODS

This was a case control retrospective study. One hundred nineteen anemic and 81 non-anemic treatment-naïve HIV infected patients participated in the study at the Lagos University Teaching Hospital, Lagos, Nigeria. Polymerase chain reaction was used to detect B19 DNA.

RESULTS

Out of 200 patients analysed, 13(6.5%) had parvovirus B19 DNA. Eight HIV patients with anemia had B19 DNA while five non-anemic HIV patients had B19 DNA. This suggests that the presence of B19 DNA in the blood of HIV positive individuals may contribute to anemia because the majority (61.5%) who were positive for B19 DNA had anemia as compared to the non-anemic control group (38.5%).

CONCLUSION

This study shows that the presence of B19 DNA in anemic HIV infected patients is not associated with chronic anaemia in HIV infection because no significant association exist.

Molecular prevalence of parvovirus B19 among HIV1-infected patients in Iran

Background: Different outcomes of parvovirus B19 (B19V) infection in immunocompromised patients, including HIV1-infected persons, may be life-threatening. Considering the hematologic disorders associated with B19V infection, this study aimed to investigate the prevalence of B19V infection among HIV1-infected individuals in Iran.

Methods: Serum samples from 100 HIV1-infected patients were analyzed for B19 viral DNA using real-time PCR assay. COBAS TaqMan HIV-1 test was performed for quantitative measurements of HIV-1 RNA in the patients’ sera.

Results: Real-time PCR analysis revealed that 10 out of 100 cases (10%) were positive for B19V infection. Across various age groups, the B19V infection was more prevalent among patients within the age range of 21-40 years. Higher prevalence of B19V infection was observed among HIV1-infected patients with a viral load of higher than 400 copies/mL.

Conclusion: Despite limitations, this study may set the stage for further evaluations with larger sample sizes to elucidate the potential role of B19V in hematologic disorders, which may result in exacerbation of the disease in HIV1-infected patients. Moreover, as it has been shown that B19V infection can be treated using intravenous immunoglobulin (IVIG) therapy, available treatments may help improve the quality of life in HIV-infected persons.

Behavioural traits propagate across generations via segregated iterative-somatic and gametic epigenetic mechanisms

Parental behavioural traits can be transmitted by non-genetic mechanisms to the offspring. Although trait transmission via sperm has been extensively researched, epidemiological studies indicate the exclusive/prominent maternal transmission of many non-genetic traits. Since maternal conditions impact the offspring during gametogenesis and through fetal/early-postnatal life, the resultant phenotype is likely the aggregate of consecutive germline and somatic effects; a concept that has not been previously studied. Here, we dissected a complex maternally transmitted phenotype, reminiscent of comorbid generalized anxiety/depression, to elementary behaviours/domains and their transmission mechanisms in mice. We show that four anxiety/stress-reactive traits are transmitted via independent iterative-somatic and gametic epigenetic mechanisms across multiple generations. Somatic/gametic transmission alters DNA methylation at enhancers within synaptic genes whose functions can be linked to the behavioural traits. Traits have generation-dependent penetrance and sex specificity resulting in pleiotropy. A transmission-pathway-based concept can refine current inheritance models of psychiatric diseases and facilitate the development of better animal models and new therapeutic approaches.

Physiological effects of psychological stress and infection in mothers can increase the incidence of anxiety and psychiatric diseases in offsprings and in subsequent generation. Here, Miklos Toth and colleagues show that intergenerational inheritance of neurological traits is propagated across multiple generations independently by parallel non-genetic mechanisms involving independent segregation of epigenetic specific loci.

Profile of HIV-Infected Hispanics with Pancytopenia

Pancytopenia is seen in late HIV infection; it is associated with medical complications and with decreased survival. We determined the prevalence of pancytopenia at baseline in a cohort of HIV-positive Hispanics living in Puerto Rico, and compared their socio-demographic, immunological and clinical characteristics. A total of 1202 patients enrolled between 2000 and 2010 were included. They were grouped according to pancytopenia status, defined by having: platelets <150,000 μL, white cell count <4000 μL, and hemoglobin <12 g/dL (women) or <13 g/dL (men). Differences were evaluated using Student's t-test, Chi-square test and Kaplan-Meier method. The prevalence of pancytopenia was 8.7%. Patients with pancytopenia had lower BMI and lower CD4 count, as well as higher HIV viral load and higher proportions of unemployment, clinical AIDS and antiretroviral treatment (ART) use (p < 0.05). One-year mortality rate was significantly higher in patients with pancytopenia (18.1% vs. 5.1%, p < 0.001). When stratifying for ART this association persisted for patients who did not receive ART (41.4% vs. 5.2%, p < 0.001), but it was not seen in patients who received treatment (9.2% vs. 5.6%, p = 0.196). Pancytopenia was associated with elements of advanced stages of HIV. ART could reduce the mortality of HIV-patients with pancytopenia to levels comparable to patients without the disorders.

Impact of highly active antiretroviral therapy on hematological indices among HIV-1 infected children at Kenyatta National Hospital-Kenya: retrospective study

Background

HIV infected children experience a range of hematological complications which show marked improvement within 6 months of initiating anti-retroviral therapy. The Objectives of the study was to describe the changes in hematological indices of HIV-1 infected children following 6 months of treatment with first line antiretroviral drugs (ARVs) regimen.

Methods

A retrospective study was conducted between September and November 2008. During this period medical records of children attending Comprehensive Care Clinic at Kenyatta National hospital were reviewed daily. HIV infected children aged 5–144 months were enrolled if they had received antiretroviral drugs for at least 6 months with available and complete laboratory results.

Results

Medical records of 337 children meeting enrollment criteria were included in the study. The median age was 63 months with equal male to female ratio. Following 6 months of HAART, prevalence of anemia (Hemoglobin (Hb) <10 g/dl) declined significantly from 35.9 to 16.6 % a nearly 50 % reduction in the risk of anemia RR = 0.56 [(95 % CI 0.44, 0.70) p < 0.001]. There was significant increase in Hb, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and platelets above the baseline measurements (p < 0.0001) and a significant decline in total white blood cell counts >11,000 cell/mm³ but a none significant decrease in red blood cells (RBC). Pre-HAART, World Health Organization (WHO) stage 3 and 4 was associated with a ten-fold increased likelihood of anemia. Chronic malnutrition was associated with anemia but not wasting and immunologic staging of disease.

Conclusion

Hematological abnormalities changed significantly within 6 months of antiretroviral therapy with significant increase in hemoglobin level, MCV, MCH and platelet and decrease in WBC and RBC.

Anemia in a cohort of HIV-infected Hispanics: prevalence, associated factors and impact on one-year mortality

BACKGROUND

Anemia occurs frequently in HIV-infected patients and has been associated with an increased risk of death in this population. For Hispanic subjects, information describing this blood disorder during HIV is scarce. Therefore, the present study examined data from a cohort of HIV-positive Hispanics to determine the prevalence of anemia, identify its associated factors, and evaluate its relationship with one-year mortality.

METHODS

This study included 1,486 patients who enrolled between January, 2000 and December, 2010 in an HIV-cohort in Bayamón, Puerto Rico. Data were collected through personal interviews and medical record abstractions. To determine the factors independently associated with anemia, a multivariable logistic regression model was used. Kaplan-Meier and Cox proportional hazards models were also performed to estimate survival time and to predict death risk.

RESULTS

The prevalence of anemia at enrollment was 41.5%. Factors independently associated with increased odds of anemia were: unemployment (OR = 2.02; 95% CI 1.45-2.79), CD4 count <200 cells/μL (OR = 2.66; 95% CI 1.94-3.66), HIV viral load ≥100,000 copies/mL (OR = 1.94; 95% CI 1.36-2.78), white blood cell count <4,000 cells/μL (OR = 2.42; 95% CI 1.78-3.28) and having clinical AIDS (OR = 2.39; 95% CI 1.39-4.09). Overweight (OR = 0.43; 95% CI 0.32-0.59) and obese (OR = 0.44; 95% CI 0.29-0.67) BMI's were independently associated with reduced odds of anemia. Survival differed significantly by anemia status (log-rank test: p < 0.001). One-year mortality estimates were: 30.8%, 23.3%, 8.4% and 2.5%, for patients with severe, moderate, mild and no anemia, respectively. Having anemia at baseline was independently associated with an increased one-year mortality risk (severe anemia: HR = 9.06; 95% CI: 4.16-19.72; moderate anemia: HR = 6.51; 95% CI: 3.25-13.06; mild anemia: HR = 2.53; 95% CI: 1.35-4.74).

CONCLUSIONS

A high prevalence of anemia at enrollment was observed in this cohort of HIV-infected Hispanics. Unemployment and several adverse prognostic features of HIV infection were independently associated with this blood disorder. Anemia resulted to be the strongest predictor of one-year mortality, evidencing a dose-response effect. Further investigations are needed to evaluate whether recovering from anemia is associated with longer survival, and to identify the types of anemia affecting this particular group of HIV patients.

Status of immunity against PVB19 in HIV-infected patients according to CD4(+) cell count, and antiretroviral therapy regimen groups

Background:

Human Parvovirus B19 (PVB19) is among the aetiology of aplastic crisis in human immunodeficiency virus (HIV)-infected patients. Several studies have indicated the importance of an infection agent in bringing about complications in immuno-compromised patients. The current study aims to determine the seroprevalence of IgM and IgG antibodies to PVB19 among HIV-positive patients and its association with clinical and epidemiological factors.

Materials and Methods:

In a case control study, 90 HIV-positive patients were compared with 90 sex and age matched healthy controls in terms of anti-PVB19 IgG and IgM along with other primary clinical and laboratory features.

Results:

The overall prevalence of positive anti-PVB19 IgG among HIV patients and controls were 81.1% and 28.9%, respectively (P < 0.001). None of the subjects showed positive results for anti-PVB19 IgM. Patients with CD4⁺ cell count <200 showed higher seroprevalence of positive anti-PVB19 IgG which did not reach statistically significant. However, anti-PVB19 IgG seropositivity differed significantly between HIV patients on different regimens of antiretroviral therapy (ART) (P < 0.05).

Conclusion:

Immunity against PVB19 is more prevalent among HIV-positive patients compared to healthy controls. However, positive HIV status is not associated with acute PVB19 infection. The presence of anti-PVB19 IgG does not necessarily protect the body from further complications like anaemia. Given the results of the study, AIDS patients are recommended to undergo screening for parvovirus antibody in order to prevent complications like aplastic anaemia.

Neutropenia during HIV infection: adverse consequences and remedies

Neutropenia frequently occurs in patients with Human immunodeficiency virus (HIV) infection. Causes for neutropenia during HIV infection are multifactoral, including the viral toxicity to hematopoietic tissue, the use of myelotoxic agents for treatment, complication with secondary infections and malignancies, as well as the patient's association with confounding factors which impair myelopoiesis. An increased prevalence and severity of neutropenia is commonly seen in advanced stages of HIV disease. Decline of neutrophil phagocytic defense in combination with the failure of adaptive immunity renders the host highly susceptible to developing fatal secondary infections. Neutropenia and myelosuppression also restrict the use of many antimicrobial agents for treatment of infections caused by HIV and opportunistic pathogens. In recent years, HIV infection has increasingly become a chronic disease because of progress in antiretroviral therapy (ART). Prevention and treatment of severe neutropenia becomes critical for improving the survival of HIV-infected patients.

Bone Marrow Abnormalities in HIV Disease

INTRODUCTION

Hematological abnormalities are a common complication of HIV infection. Bone marrow abnormalities occur in all stages of HIV infection. Present work was carried out to study the bone marrow abnormalities in patients with HIV/AIDS.

METHODS

160 patients of HIV +ve were included in the study. A complete blood count, relevant biochemical investigations, CD4 counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and those without AIDS according to NACO criteria. Bone marrow examination was performed for indication of anemia, leucopenia, pancytopenia and thrombocytopenia.

RESULTS

As per CDC criteria 59.81% patients had AIDS in 107 patients. The most common hematological abnormality was anemia, seen in 93.12% patients. Bone marrow was normocellular in 79.06% of non-AIDS and 79.68% of AIDS, hypocellular in 13.95% of non-AIDS and 12.5% of AIDS, hypercellular in 06.97% of non-AIDS and 07.81 % of AIDS patients. Dysplasia was statistically and significantly associated with anemia. For myelodysplasia in bone marrow in HIV patients we noted granulocytic dysplasia in 4.65% in Non - AIDS and 14.06% AIDS patients. Erythroid dysplasia was found in 9.30% in Non - AIDS, 12.5% in AIDS group. Thrombocytopenia was seen in 4 cases of ART (4.93%) and 3 cases (4.68%) of AIDS group. Abnormal cells like plasma cell, histiocyte and toxic granule were found in bone marrow.

CONCLUSIONS

Myelodysplasia was more common in AIDS than in non AIDS patients. Granulocytic series is most commonly associated with evidence of dysplasia. Anemia in HIV patients can be a good clinical indicator to predict and access the underlying immune status. Thus bone marrow study is imperative to methodically observe and follow clinical and laboratory aberration in such patients in order to improve our diagnostic and therapeutic skills pertinent to HIV/AIDS.

Effects of human immunodeficiency virus on the erythrocyte and megakaryocyte lineages

Anaemia and thrombocytopenia are haematological disorders that can be detected in many human immunodeficiency virus (HIV)-positive patients during the development of HIV infection. The progressive decline of erythrocytes and platelets plays an important role both in HIV disease progression and in the clinical and therapeutic management of HIV-positive patients. HIV-dependent impairment of the megakaryocyte and erythrocyte lineages is multifactorial and particularly affects survival, proliferation and differentiation of bone marrow (BM) CD34+ haematopoietic progenitor cells, the activity of BM stromal cells and the regulation of cytokine networks. In this review, we analyse the major HIV-related mechanisms that are involved in the genesis and development of the anaemia and thrombocytopenia observed in HIV positive patients.

Hematologic abnormalities associated with simian immunodeficieny virus (SIV) infection mimic those in HIV infection

BACKGROUND

Studies of hematologic abnormalities in HIV-infected patients are confounded by a multitude of factors. A retrospective data analysis of simian immunodeficieny virus (SIV)-infected rhesus macaques (RM) of Indian origin was performed to determine the prevalence of hematologic abnormalities free of these confounds.

METHODS

Hematologic data from RM inoculated with SIV and without antiviral therapy were examined pre-inoculation, and throughout infection and the development of AIDS.

RESULTS

Anemia, thrombocytopenia, lymphopenia, eosinophilia, and neutropenia all increased in prevalence with SIV infection. Significant increases in prevalence for both neutropenia and neutrophilia were also detected in SIV-infected macaques. SIV-infected macaques also had lower lymphocyte counts and increased prevalence of lymphopenia compared with non-infected subjects. The prevalence of eosinophilia was significantly increased during SIV infection.

CONCLUSIONS

Concordance of hematologic abnormalities during SIV infection of macaques with similar changes in HIV infection of humans suggests that, like in HIV infection, hematologic abnormalities are major complications of SIV infection.

Erythropoiesis in HIV-infected and uninfected Malawian children with severe anemia

Anemia is common in HIV infection, but the pathophysiology is poorly understood. Bone marrow analysis in 329 severely anemic (hemoglobin <5 g/dl) Malawian children with (n = 40) and without (n = 289) HIV infection showed that HIV-infected children had fewer CD34(+) hematopoietic progenitors (median 10 vs. 15‰, P = 0.04) and erythroid progenitors (2.2 vs. 3.4‰, P = 0.05), but there were no differences in erythrocyte viability and maturation in later stages of erythropoiesis. Despite an HIV-associated reduction in early red cell precursors, subsequent erythropoiesis appears to proceed similarly in HIV-infected and HIV-uninfected children with severe anemia.

Transient elastography discloses identical distribution of liver fibrosis in chronic hepatitis C between HIV-negative and HIV-positive patients on HAART

Objective

Progressive immunodeficiency associated with HIV-infection leads to a progressive course of liver disease in HIV/HCV-co-infected patients. Highly active antiretroviral therapy (HAART) efficiently restores and preserves immune functions and has recently been demonstrated to also result in reduced liver-related mortality in HIV/HCV-co-infected patients.

Methods

To analyse differences in current liver fibrosis as a possible effect of HAART on fibrosis progression we assessed hepatic fibrosis by transient elastography in a cross-sectional comparison between HCV-mono-infected and HIV/HCV-co-infected patients presenting at our outpatient department in 2007.

Results

Overall, we did not find any difference in the distribution of liver stiffness between mono- (n = 84) and double-infected (n = 57) patients (14.4 kPa (10.8 - 18.2) versus 12.4 kPa (9.1 - 16.1), mean (95%-CI)). However, in the 8 HIV+ patients with CD4 counts < 200/μl liver stiffness was markedly greater (18.4 kPa (0.8 - 36.0)) than in HIV+ patients with preserved immunity (11.5 kPa (8.4 - 15.0)).

Conclusions

These findings are in line with other data that show an improved prognosis of chronic hepatitis C in HIV+ patients under effective HAART, and may be a hint that fibrosis progression in well-treated HIV+ patients will no longer be different from that in HCV-mono-infected patients.

Achieving KDOQI Guidelines for Hematocrit in HIV-Infected Hemodialysis Patients

The primary cause of anemia in HIV-infected patients with ESRD is diminished production of erythropoietin. Although most patients respond to recombinant erythropoietin, the response may be blunted in patients with ESRD and concomitant viral or bacterial infections. Previous studies demonstrated a response to erythropoietin by HIV-infected ESRD patients, but hematocrit levels on average were only 27-29%. We were interested in determining if KDOQI guidelines could be met in these patients. Hematocrits and epogen doses of all HIV-positive patients who were undergoing hemodialysis at the Nassau University Medical Center Dialysis Unit between September 2002 and March 2003 were compared to matched controls in our hemodialysis unit. The hematocrit levels in our population were higher than those reported in earlier papers. In our patient population, the mean hematocrit was 37.5, whereas the mean hematocrit levels in the HIV group in previous papers were 27-29%. HIV-infected patients did require higher erythropoietin dosages than controls, but similar doses were used as compared to previous studies. HIV patients on hemodialysis can achieve KDOQI target hematocrits. The difference in route of iron administration and iron stores may explain the higher hematocrit levels in our HIV patient population as compared to previous trials.

Altered iron metabolism in children with human immunodeficiency virus disease

BACKGROUND

Despite the high prevalence of altered iron metabolism in children with human immunodeficiency virus (HIV) disease, these alterations have not been well studied.

PROCEDURES

Twenty-six children with HIV disease underwent laboratory evaluation to determine the presence of anemia, and to classify the anemia as iron-deficiency anemia or anemia of chronic disease.

RESULTS

Half of the children had an alteration in iron metabolism: 6 were iron deficient, 4 had hyperferritinemia, and 3 demonstrated hyperferritinemia with iron deficiency.

CONCLUSIONS

These data indicate that alterations in iron metabolism are common even in the HAART era and warrant further study to identify individuals at risk for these alterations.

HIV-associated anemia in children: a systematic review from a global perspective

OBJECTIVES

To assess the importance of anemia in HIV-infected children in western and tropical settings.

DESIGN

A systematic review with a descriptive component.

METHODS

: Four databases were searched and reference lists of pertinent articles were checked. Studies that reported data on anemia or hemoglobin levels in HIV-infected children were selected and grouped according to the location and the definition of anemia.

RESULTS

Thirty-six studies met the inclusion criteria. Mild (hemoglobin <11 g/dl) and moderate (hemoglobin <9 g/dl) anemia were more prevalent with HIV infection (odds ratio 4.5; 95% confidence interval 2.5-8.3 and odds ratio 4.5; 95% confidence interval 2.0-10.3, respectively). Mean hemoglobin levels were lower (standardized mean difference; 0.79; 95% confidence interval 0.47-1.10). These differences were observed in both western and tropical settings. Anemia incidence ranged from 0.41 to 0.44 per person-year. There was limited data on more severe anemia (hemoglobin <7 or <5 g/dl). As anemia was frequently identified as an independent risk factor for disease progression and death, we next reviewed the limited data to formulate better strategies. Failure of erythropoiesis was the most important mechanism for anemia in HIV-infected children. Therapeutic options include highly active antiretroviral therapy and prevention or treatment of secondary infections. Erythropoietin can improve anemia in children, but it has not been evaluated in developing countries. Micronutrient supplementation may be helpful in individual children. The potential benefits or risks of iron supplementation in HIV-infected children require evaluation.

CONCLUSION

Anemia is a very common complication of pediatric HIV infection, associated with a poor prognosis. With the increasing global availability of highly active antiretroviral therapy, more data on the safety and efficacy of possible interventions in children are urgently needed.

Potential Mechanisms for Altered Iron Metabolism in Human Immunodeficiency Virus Disease

Recently, anemia associated with human immunodeficiency virus (HIV) disease has received more attention as our understanding of the significance of anemia in this population has grown and more emphasis is placed on the quality of life of people living with HIV/AIDS. Although the diagnosis and treatment of anemia in HIV disease has been discussed in great detail, the prevalence and pathophysiology of the two most common forms of anemia, iron deficiency anemia (IDA) and the anemia of chronic disease (ACD), have not received much attention despite the difficulty and importance of differentiating between these two anemias. In addition, little attention has been given to iron overload, which has serious implications in individuals with HIV disease. This article proposes a model of altered iron metabolism in HIV disease as a basis for explaining the pathophysiology and implications of IDA, ACD, and iron overload in this population. Implications for clinical practice and recommendations for future research are discussed.

Thrombocytosis in pediatric HIV infection

Thrombocytopenia has been extensively reported in association with HIV infection. Twenty-four children (6%) from a cohort of 400 children with platelet counts >500,000/mm(3) were reviewed. All had symptomatic disease and 10 (42%) patients died. In 4 children the platelet count exceeded 700,000/mm(3) and in 1 patient the platelet count was 1.5 million/mm(3). There were no thrombotic complications, and no specific therapy was required for the thrombocytosis. Thus HIV-1 infection, a chronic viral infection, is another etiologic agent for thrombocytosis and is associated with severe disease.

Increased microvascular network in bone marrow of HIV-positive haemophilic patients

OBJECTIVES

Angiogenesis has been associated with the pathogenesis of myelodysplastic syndromes (MDSs). However, less is known about the significance of this process in the bone marrow of HIV-positive patients with myelodysplastic features (MDF).

METHODS

Trephines from 22 HIV-positive haemophilic patients were immunostained for CD34 antigen, and the microvessel density (MVD) was quantitatively evaluated and compared with that of 21 biopsies from patients with primary MDS and with that of 12 control bone marrows with no evidence of marrow disease.

RESULTS

Bone marrow MVD in HIV-positive haemophilic patients was similar to that in patients with MDS; however, both groups revealed significantly higher MVD counts than those of control bone marrows (P=0.002). Mean MVD counts of HIV-positive haemophilic patients were significantly associated with HIV RNA levels (P=0.008). In contrast, no correlation was found between MVD and clinical HIV stage or CD4 counts at the time of biopsy.

CONCLUSIONS

These results suggest a direct involvement of HIV in the pathogenesis of MDF in HIV infection. Elucidation of the mechanisms underlying bone marrow angiogenesis in HIV-positive patients may provide further insights into the pathobiology of AIDS.

Increased angiogenesis in the bone marrow of HIV-positive patients with myelodysplasia

AIM

Little is known about the significance of angiogenesis in the bone marrow of HIV-positive patients with myelodysplastic features (MDF). However, this process has been associated with the pathogenesis of primary myelodysplastic syndromes (MDS). The aim of the study was to investigate angiogenesis in the bone marrow of HIV-positive patients.

METHODS

Bone marrow biopsies from 28 HIV-positive patients were immunostained for factor VIII and the microvessel density (MVD) was quantitatively evaluated and compared with that of 32 biopsies from patients with primary MDS and to 18 control bone marrows from patients with no evidence of bone marrow disease.

RESULTS

Bone marrow MVD in HIV-positive patients was similar to that of MDS. However, both groups revealed significantly higher MVD counts compared to those of control bone marrows (MDF vs controls P=0.022, MDS vs controls P=0.001).

CONCLUSIONS

Bone marrow from HIV-positive patients with MDF reveals similar microvessel counts compared to those with primary MDS, although both differ significantly from that of control bone marrow. Elucidation of the mechanisms underlying bone marrow angiogenesis in HIV-positive patients, may provide further insights into the pathobiology of AIDS and might be of value for the development of new therapeutic strategies for this disease.

Low blood CD8+ T-lymphocytes and high circulating monocytes are predictors of HIV-1-associated progressive encephalopathy in children

OBJECTIVE

Human immunodeficiency virus type 1 (HIV-1)-associated progressive encephalopathy (PE) is a common and devastating complication of HIV-1 infection in children, whose risk factors have not yet been clearly defined. Regardless of the age of presentation, PE shortens life expectancy. Paradoxically, as survival of patients has been prolonged as a result of the use of antiretroviral therapy, the prevalence of PE has increased. Therefore, a predictive marker of PE emergence is critical. The objective of this study was to determine in an observational study whether any immunologic (CD4(+) and CD8(+) T-lymphocyte counts, monocyte counts) or virologic (viral load [VL], biological characteristics of viral isolates) marker might be predictive of PE and whether any particular marker may be involved in the timing of clinical onset of PE.

METHODS

A total of 189 children who were vertically infected with HIV-1 were studied retrospectively, 58 of whom fulfilled criteria of the American Academy of Neurology for PE. T-lymphocyte subsets and monocytes in peripheral blood were quantified by flow cytometry. HIV-1 RNA was measured in plasma using a quantitative reverse transcriptase polymerase chain reaction assay. Demographic, clinical, and viro-immunologic characteristics in infants were compared with control groups using logistic regression. Proportions were compared using the chi(2) test or Fisher exact test. For each child, immunologic and virologic markers were analyzed in parallel closely before clinical onset of PE and closely after PE onset and compared by using the Student t test for paired samples.

RESULTS

Overall, mortality of 58 HIV-1-infected children who developed PE was significantly higher than of children who did not develop this complication. Blood CD8(+) T-lymphocytes <25% in the first months of life suggested a relative risk of progressing to PE 4-fold higher than those with CD8(+) >25% (95% confidence interval: 1.2-13.9) and remained statistically significant after adjustment for treatment. When we compared the PE-positive group with the acquired immunodeficiency syndrome (AIDS)/PE-negative group (children who developed clinical category C and without neurologic manifestations) in a cross-sectional study within 12 months before PE or AIDS diagnosis, respectively, the %CD8(+) T-lymphocytes were significantly lower in the PE-positive group. Normalized absolute counts of CD8(+) T-lymphocytes with respect to seroreverting children were significantly lower in the group of children with encephalopathy with respect to the AIDS/PE-negative group (data not shown). It is interesting that a statistically significant increase was observed in circulating monocyte percentages and absolute counts shortly before the first neurologic symptoms compared with values after PE was established and with those from HIV-1-infected controls. With respect to AIDS-related events, PE was strongly associated with anemia and lymphoid interstitial pneumonitis in the PE-positive group with respect to a group of children with AIDS but without PE.

CONCLUSION

HIV-1 infection of the central nervous system (CNS) remains an important clinical concern. The first step toward PE prevention in HIV-1-infected children should be directed at predicting risk of PE and thus the prompt and reliable identification of infants who are at risk for CNS disease progression. Low blood CD8(+) T-lymphocytes is a strong early predictive marker of PE emergence in vertical HIV-1 infection. Indeed, among all of the immunologic and virologic variables assessed in this observational study, the only significant difference during the first months of life are the CD8(+) T-lymphocytes. A peak of significantly higher peripheral monocytes before the onset of PE with respect to established PE has not been previously described, and strengthens the growing evidence that an increased traffic of monocytes to the brain may be a key factor in triggering neurologic symptoms. The suppression of HIV-1 replication is dependent on the presence of a relatively small number of HIV-1-specifof HIV-1-specific CD8(+) T-lymphocytes, and it is possible that the duration of the neurologically asymptomatic phase for any given child may depend mostly on the magnitude of specific CD8(+) T-lymphocyte responses. Thus, a decrease of CD8(+) T-lymphocytes would diminish the host capacity to control viral infection, as reported in animal models, enabling infected macrophages to cross the blood-brain barrier. Our results advocate the use of CD8(+) T-lymphocyte and monocyte counts to follow-up HIV-1-infected children. We suggest that CD8(+) T-lymphocytes may be the nexus for many different aspects of the disease, namely loss of control of HIV-1 replication determining higher VL, increased traffic of activated and/or infected monocytes, spread of infection to immune sanctuaries, and finally clinical neurologic emergence of PE. Moreover, we suggest that CD8(+) T-lymphocytes or/and monocytes may be used as putative biological markers of neuropathogenicity. This might suggest their use in decision making of when to start more effective antiretroviral regimens for HIV-1 infection of the CNS and the need of new therapies either to preserve or to augment an adequate CD8(+) T-lymphocyte immune response. Early detection of children who are at risk for developing PE is particularly important because aggressive highly active antiretroviral therapy improves neurologic symptoms, allows possible use of neuroprotective treatment to prevent further development of encephalopathy, and emphasizes the relevance of developing therapies aimed to enhance CD8(+) T-lymphocyte function. In conclusion, the surrogate markers routinely used in clinical practice for HIV-1 infection (ie, CD4(+) T-lymphocyte counts and VL) seem to be insufficient to evaluate the clinical involvement of the CNS. Other systemic markers, as the recent proposed markers for PE evolution (cerebrospinal fluid VL by lumbar puncture and brain atrophy by cerebral magnetic resonance imaging) are undoubtedly more invasive than measuring CD8(+) T-lymphocyte and monocyte counts, when the neurologic manifestations of PE are still preventable.

Highly active antiretroviral therapy associated with improved anemia among HIV-infected women

Anemia is common during human immunodeficiency virus (HIV) infection and is associated with increased mortality. We conducted a study to examine the impact of highly active antiretroviral therapy (HAART) on anemia in a multicenter cohort of HIV-positive women, the Human Immunodeficiency Virus Epidemiology Research (HER) Study. Among women receiving HAART (n = 188), non-HAART monotherapy or combination antiretroviral therapy (ART) (n = 111), or who had no reported treatment (n = 62), the prevalence of anemia (hemoglobin, <120 g/L) at baseline was 38.3, 36.9, and 43.6%, respectively (p = 0.58) and at 1-year follow-up was 26.1%, 36.9%, 45.2%, respectively (p = 0.01); mean hemoglobin at baseline was 125 +/- 16, 122 +/- 16, and 122 +/- 18 g/L, respectively (p = 0.29) and at 1-year follow-up was 128 +/- 14, 123 +/- 16, and 119 +/- 20 g/L, respectively (p < 0.0001). Adjusted linear regression models showed that HAART was associated with an increase of hemoglobin of 0.20 g/L per month (p = 0.007). After 1 year of treatment, HAART was associated with a 32% reduction in anemia among HIV-infected women (p = 0.01), whereas there was no significant change in the prevalence of anemia among those on non-HAART ART or those who had no reported treatment. HAART is associated with a large reduction in anemia among HIV-infected women.

Mimicry between neurokinin-1 and fibronectin may explain the transport and stability of increased substance P immunoreactivity in patients with bone marrow fibrosis

Bone marrow (BM) fibrosis may occur in myeloproliferative diseases, lymphoma, myelodysplastic syndrome, myeloma, and infectious diseases. In this study, the role of substance P (SP), a peptide with pleiotropic functions, was examined. Some of its functions-angiogenesis, fibroblast proliferation, and stimulation of BM progenitors-are amenable to inducing BM fibrosis. Indeed, a significant increase was found in SP-immunoreactivity (SP-IR) in the sera of patients with BM fibrosis (n = 44) compared with the sera of patients with hematologic disorders and no histologic evidence of fibrosis (n = 46) (140 +/-12 vs 18 +/-3; P <.01). Immunoprecipitation of sera SP indicated that this peptide exists in the form of a complex with other molecule(s). It was, therefore, hypothesized that SP might be complexed with NK-1, its natural receptor, or with a molecule homologous to NK-1. To address this, 3 cDNA libraries were screened that were constructed from pooled BM stroma or mononuclear cells with an NK-1 cDNA probe. A partial clone (clone 1) was retrieved that was 97% homologous to the ED-A region of fibronectin (FN). Furthermore, sequence analyses indicated that clone 1 shared significant homology with exon 5 of NK-1. Immunoprecipitation and Western blot analysis indicated co-migration of SP and FN in 27 of 31 patients with BM fibrosis. Computer-assisted molecular modeling suggested that similar secondary structural features between FN and NK-1 and the relative electrostatic charge might explain a complex formed between FN (negative) and SP (positive). This study suggests that SP may be implicated in the pathophysiology of myelofibrosis, though its role would have to be substantiated in future research. (Blood. 2001;97:3025-3031)

Improvement of anemia among HIV-infected injection drug users receiving highly active antiretroviral therapy

Although anemia is common during HIV infection, it is unclear whether potent antiretroviral therapy would improve or worsen anemia. We conducted a study to examine the impact of highly active antiretroviral therapy (HAART) on anemia in a cohort of HIV-positive injection drug users (IDUs) in Baltimore, Maryland. At baseline, the overall prevalence of anemia was 40%. During mean follow-up of one year, among 102 subjects who received HAART, there was a mean increase in hemoglobin of 3.6 +/- 1.7 g/L (p =.0003) [corrected] and a mean decrease in log(10) plasma HIV load of 0.25 +/- 0.06 copies/ml (p <.0002) [corrected]. Among 103 control subjects who were not receiving antiretroviral medications, there was a mean decrease in hemoglobin of 4.2 +/- 1.1 g/L (p <.04) [corrected] and mean increase in log(10) plasma HIV load of 0.78 +/- 0.17 copies/ml (p <.0001) [corrected]. Multivariate analysis using mixed linear models showed that HAART was associated with an increase of hemoglobin of 0.223 g/L per month (p <.0001) after adjusting for body mass index, opportunistic infections, and gender. HAART was associated with an improvement in anemia, and potential mechanisms that may be involved include a reduction in opportunistic infections and the anemia of chronic disease and an improvement in nutritional status.

NF-kappa B as a central mediator in the induction of TGF-beta in monocytes from patients with idiopathic myelofibrosis: an inflammatory response beyond the realm of homeostasis

Immune-mediated mechanisms have been implicated in the etiology of idiopathic bone marrow fibrosis (IMF). However, the mechanism remains poorly defined. Compared with healthy controls, IMF monocytes are overactivated, with increased production of TGF-beta and IL-1. TGF-beta is central to the progression of fibrosis in different organs. In the lung, fibrosis is associated with up-regulation of TGF-beta-inducible genes. Because IL-1 and TGF-beta have pro- and antiinflammatory properties and neither appears to regulate the high levels of each other in IMF, we studied the mechanism of this paradigm. We focused on the role of RelA, a subunit of the transcription factor, NF-kappaB that is associated with inflammatory responses. We transiently knocked out RelA from IMF monocytes with antisense oligonucleotides and showed that RelA is central to IL-1 and TGF-beta production and to the adhesion of IMF monocytes. Because the NF-kappaB family comprises subunits other than RelA, we used aspirin and sodium salicylate to inhibit kinases that activate NF-kappaB and showed effects similar to those of the RelA knockout system. It is unlikely that RelA could be interacting directly with the TGF-beta gene. Therefore, we determined its role in TGF-beta production and showed that exogenous IL-1 could induce TGF-beta and adherence of IMF monocytes despite the depletion of NF-kappaB. The results indicate that IL-1 is necessary for TGF-beta production in IMF monocytes, but NF-kappaB activation is required for the production of endogenous IL-1. Initial adhesion activates NF-kappaB, which led to IL-1 production. Through autocrine means, IL-1 induces TGF-beta production. In total, these reactions maintain overactivation of IMF monocytes.

The blood in systemic disorders

* The high rate of proliferation required of the bone marrow renders it highly susceptible to the influence of external factors. * Anaemia is the most common haematological abnormality seen in systemic disorders. * In the anaemia of chronic disease, erythropoietin production is reduced and proliferation of erythroid progenitor cells is also impaired; this anaemia can generally be alleviated by correction of the underlying disease process. * The status of the endocrine system must always be considered in evaluation of a normocytic, normochromic anaemia. * Anaemia in infection can be due to host or parasite factors or to the treatment administered. * Anaemia due to malignant disease responds to erythropoietin therapy in many cases; failure to respond is a poor prognostic sign.

Hematological complications and quality of life in hospitalized AIDS patients

The relationships among the biological and physiological indicators of cytopenias in AIDS and measures of quality of life are not well characterized. The purpose of this secondary analysis was to determine the relationships among anemia, neutropenia and thrombocytopenia and characteristics of the individual, physiological markers, symptoms, functional status, general health perceptions, and well-being in people with AIDS. The five dimensions of the Wilson and Cleary model of health-related quality of life provided the conceptual model for this study. In addition to descriptive statistics, logistic regression was used to analyze clusters of variables. The sample of 146 hospitalized patients with AIDS had an 85% prevalence of anemia, a 53% prevalence neutropenia and a 33% prevalence of thrombocytopenia. The mean age was 38 years old, 19% were female, 35% were white, 27% had a history of injection drug use and the mean T-helper cell count was 74 mm3. The five dimensions of the Wilson and Cleary model offered significant predictability for anemia only. Patients with higher symptom scores were more likely to have treatable anemia, defined as a hematocrit of < 30%. Treatable anemia was also associated with lower self-care scores and lower T-helper cells. Fifty-four percent of the cohort were candidates for colony stimulating factors, while only 17% of those eligible received them. These data suggest suboptimal treatment of anemia and neutropenia in this cohort of AIDS patients.

Pathogenesis of HIV-1 infection within bone marrow cells

Mononuclear phagocytic cells and CD4+ T lymphocytes represent the major targets for infection by HIV-1 in vivo. The most severe pathogenic features associated with HIV-1 infection can be attributed to malfunction or premature death of these cells that are of hematopoietic origin. Patients with acquired immunodeficiency syndrome (AIDS), suffer from many hematologic disorders, particularly those persons with long-term infection of HIV-1. These disorders include anemia, lymphocytopenia, thrombocytopenia and neutropenia. The mechanisms that lead to the induction of these disorders are multi-factorial. However, sufficient evidence has accumulated which suggests that HIV-1 infection of cells within the microenvironment of the bone marrow can lead to the induction of hematopoietic deficits. Most studies indicate that marrow-derived hematopoietic stem cells cannot be infected by HIV-1 until they undergo modest differentiation in order to express the appropriate receptors to enable virus entry and subsequent replication. Some cells within the mixed environment of the marrow stroma appear to support HIV-1 replication however. These cells include marrow microvascular endothelial cells, sometimes referred to as blanket cells, stromal fibroblasts, as well as mononuclear phagocytes. Our recent experiments suggest that the HIV-1 accessory protein, Vpr, plays some role in the activation of marrow-derived mononuclear phagocytes which appears to result in premature phagocytosis of non-adherent marrow cells present in the in vitro cultures. This phenomenon could account, in part, for the induction of cytopenias that are typical of individuals infected by HIV-1.

Human immunodeficiency virus infection of human placental cord blood CD34+AC133+ stem cells and their progeny

The AC133 is a novel antigen selectively expressed on primitive CD34bright stem cells and is a valuable marker for the selection of long-term culture-initiating cells (LTC-ICs) and severe combined immunodeficiency (SCID)-repopulating cells. Human placental cord blood (HPCB) is a rich source of CD34+AC133+ cells. Since AC133 antibody is likely to be used as an alternative to CD34 for the selection of stem cells in transplant and gene therapy situations, we examined the susceptibility of HPCB-isolated CD34+AC133+ stem cells to infection with free and cell-associated HIV-1 in vitro. Freshly isolated HPCB CD34+AC133+ stem cells were not susceptible to HIV-1 infection as determined by PCR and reverse transcriptase assays. Inoculation with HIV-1 did not affect the viability and clonogenic ability of HPCB CD34+AC133+ cells. Although the highly purified HPCB CD34+AC133+ stem cells contained mRNA for CD4 and CXCR4 receptors, CD4 and CXCR4 proteins were not expressed on these cells. Similarly, CCR5 protein, the major macrophage-tropic HIV-1 coreceptor, was not expressed in freshly isolated HPCB CD34+AC133+ stem cells, although the transcript for CCR5 was identified in these cells. Expression of CD4, CXCR4, and CCR5 receptor proteins on the progeny derived from HPCB CD34+AC133+ stem cells was detected and correlated with susceptibility to HIV-1 infection in vitro. These findings suggest that freshly isolated HPCB CD34+AC133+ stem cells are not susceptible to HIV-1 infection and may not be a viral reservoir. These data have important implications for the use of AC133 antibody as a means of enriching for primitive hematopoietic stem cells from placental cord blood and in the design of stem cell or progenitor cell-based gene therapeutic strategies for perinatal HIV-1 infection.

Virus-associated haemophagocytic syndrome caused by rubella in an adult

Haemophagocytic syndrome is a systemic clinicopathological entity characterized by systemic proliferation of benign haemophagocytic histiocytes, fever, cytopenia, abnormal liver function and, frequently, coagulopathy and hepatosplenomegaly. Its occurrence has been documented in association with viral, bacterial, fungal and parasitic infections, a wide spectrum of malignant neoplasms, autoimmune diseases and drugs. We report a case of rubella virus-associated haemophagocytic syndrome in a previously healthy 29-year-old woman. Blood tests showed cytopenia, especially severe thrombocytopenia, liver dysfunction, hyperferritinaemia and hypercytokinaemia. Bone marrow examination showed many mature histiocytes with active haemophagocytosis. A skin biopsy from the rash revealed perivascular lymphohistiocytic infiltrates with haemophagocytic histiocytes in the upper and mid-dermis. The patient was treated with antibiotics and immunoglobulin, and by supportive measures including platelet transfusion, and recovered completely.

Usefulness of a low-dose intravenous immunoglobulin regimen for the treatment of thrombocytopenia associated with AIDS

Infection with the human immunodeficiency virus (HIV) frequently is complicated with thrombocytopenia (HIV-Thr) during all stages of the infection. The treatments for autoimmune thrombocytopenic purpura (ITP) are used in HIV-Thr; however, their effects upon the immune status of patients with acquired immunodeficiency syndrome (AIDS) are unknown. Intravenous immunoglobulin (IVIg) is used in patients with ITP and HIV-Thr; however, its usefulness in thrombocytopenic AIDS patients has not been directly addressed. We used a low-dose IVIg regimen (0.04 g/kg per week during five weeks) for the treatment of HIV-Thr complicating AIDS. Thirteen patients received IVIg. We observed a response to IVIg in 13 patients by the end of week one and in 10 patients by the end of week five. Long-term response, evaluated three months after stopping IVIg, was present in four cases. IVIg was well tolerated and no opportunistic infections were observed during the study period. Compared with previous reports, we used 10% of the previously proposed dosage with an important decrease in the cost of treatment. Our results suggest that this low-dose IVIg regimen is a highly effective, nonexpensive alternative in treating HIV-Thr in AIDS. If sustained responses can be obtained with a similar low-dose maintenance regimen, IVIg may be the first choice for the treatment of HIV-Thr in AIDS patients.

HIV influence on hematopoiesis at the initial stage of infection

Alterations in the parameters responsible for the characteristic anemic condition of AIDS patients who are at the final stage of infection have already been established. However, the development of these alterations at the initial stage of infection, where no opportunistic infections occur, needs further study. The goal of this study was to verify whether laboratory alterations observed on patients at the final stages of the disease could already be seen at the beginning of HIV infection, or were the result of opportunistic infections. To that end, HIV-seropositive patients identified by the ELISA test and confirmed by immunofluorescence were screened by infectologist doctors and classified as per the Walter Reed Army Institute System. Results showed that thrombocytopenia occurred at an early stage during HIV infection. The number of leukocytes and erythrocytes diminished progressively as the disease advanced, and levels of hemoglobin, transferrin and serum iron were also diminished with the progression of the disease. These results indicate that the laboratory alterations observed in HIV-seropositive patients during the initial stages were, probably, due to virus infection, because these patients did not present opportunistic infections.

Systemic transforming growth factor-beta in patients with bone marrow fibrosis--pathophysiological implications

Idiopathic myelofibrosis (IMF) and secondary myelofibrosis (MF) are characterized by bone marrow (BM) fibrosis, neoangiogenesis, and increased extracellular matrix (ECM) proteins. These characteristics may be partially attributed to transforming growth factor beta (TGF-beta), a cytokine produced by monocytes. In myelofibrosis, monocytes are increased and activated with concomitant up-regulation of intracytoplasmic TGF-beta. We have therefore determined systemic TGF-beta in patients with either BM fibrosis: IMF, n = 18; MF, n = 16; or without BM fibrosis: hematologic disorders with normal platelets (n = 31); high platelets (n = 9); or normal controls (n = 27). Compared with nonfibrosis sera, there was significant TGF-beta elevation in BM fibrosis sera (P < 0.0001). Most (>80%) of the TGF-beta is active and belongs to the-beta1 isoform. In situ hybridization and immunohistochemical analyses in BM biopsy sections showed a marked increase in TGF-beta1 only in patients with fibrosis. Moreover, TGF-beta protein was detected mainly in myelomonocytic-like predominant areas. To determine if another functionally similar cytokine, basic fibroblast growth factor (bFGF), may be important to BM fibrosis, we quantitated sera levels and found elevation in 57% compared with 100% elevation for TGF-beta. The data indicate that irrespective of etiology, systemic TGF-beta is elevated in patients with BM fibrosis. TGF-beta likely plays an important role in the development of BM fibrosis. The study also provides a significant parameter for early therapeutic intervention in BM fibrosis.

[Etiological aspects of reactive hemophagocytoses: retrospective study in 99 patients]

We describe the causes of reactive hemophagocytic process in a retrospective study including 99 patients. The main diagnosis were: lymphomas (18 cases), pyogenic bacteria infections (15 cases), herpes virus infections (12 cases), other infections (multiple, parasitic, fungal, mycobacterial, unidentified) (11 cases), acute hepatitis (five cases), systemic lupus erythematosus (three cases). We also found numerous other diseases involving the reticuloendothelial system. The cause remained undetermined in 16 cases. Lymphoma accounted for 64% of the cases in previously healthy patients who had been febrile for more than 10 days at the time of the diagnosis of reactive hemophagocytic process, and for 31% in HIV-positive patients. Lymphomas were rare (5%) in non HIV-positive, immunosuppressed patients. In this setting and in previously healthy patients who had been febrile for less than 10 days, infectious diseases were widely dominant (respectively 60% and 86% of the cases). Those were mainly due to pyogenic bacteria and to herpes virus. A rapidly fatal evolution occurred in some cases of lymphomas-related hemophagocytic process. These data support the choice of aggressive investigations in order to diagnose lymphoma in previously healthy patients presenting with reactive hemophagocytic process who have been febrile for more than 10 days, and in selected HIV-patients. Such a procedure is not recommended in the other cases.