Diagnostic utility of bone marrow sampling in HIV positive patients

The value of bone marrow examinations performed in the investigation of HIV infected patients with cytopenias

INTRODUCTION

Bone marrow examination (BME) is a reliable and effective tool in the diagnosis of many haematological and non-haematological diseases and may be used to investigate unexplained cytopenia in human immunodeficiency virus (HIV) infected patients. The objective of this study was to determine the diagnoses made, diagnostic yield and unique diagnostic yield of BMEs performed to investigate cytopenias in HIV infected patients.

METHOD

A retrospective cross-sectional descriptive study was performed involving all BMEs performed on HIV-infected adult patients with the main indication of unexplained cytopenia over a period of 5 years and 4 months. Data was extracted from the National Health Laboratory Service's laboratory information system and clinicians' BME request forms.

RESULTS

The study included 128 BMEs, performed on 124 patients. The diagnostic yield was 32% and the unique diagnostic yield was 30.5%. The most common diagnosis was pure red cell aplasia (10.9%), followed by immune thrombocytopenic purpura (ITP) (7%), iron deficiency anaemia (6.3%), malignancy (4.7%) and disseminated infection (3.9%).

CONCLUSION

BME is a useful investigation for unexplained cytopenia in HIV-infected patients. Less invasive investigations to exclude haematinic deficiencies, haemolysis and sepsis are recommended on an individualised basis prior to BME. In HIV-infected patients with therapy refractory ITP or ITP with atypical clinicopathological findings, BME is strongly recommended. As Mycobacterial and other infections are common in this group of patients, staining and culture of specimens are advised if BME is undertaken.

Bone Marrow Aspiration/Biopsy in the Evaluation of Fever of Unknown Origin in Patients with AIDS

BACKGROUND

HIV can interrupt the normal development of bone marrow cell lines. Bone marrow aspiration/biopsy (BMA/B) has been described as a diagnostic tool in AIDS patients with fever of unknown origin (FUO). In this review, we aimed to study patients with AIDS who had undergone a BMA/B to investigate FUO and describe the pathologies diagnosed in the biopsy.

METHODS

Thirty-four BMA/B samples were collected from AIDS patients admitted for work-up of FUO to the infectious disease ward of a tertiary referral HIV center in Tehran, Iran, between September 2014 and September 2015. Data including age, sex, duration of disease, CD4 cell counts, hepatitis B (HBV) and C (HCV) coinfection, the primary presentation of AIDS, and the treatment history were retrieved and analyzed. Patients underwent BMA/B. An expert pathologist reviewed the BMA/B specimens.

RESULTS

The mean age of the patients was 37.5 years (range, 26-56), and 27 (79%) were men. Twenty-seven (79%) patients contracted HIV from injection drug use, and 7 (21%) via sexual transmission. Only 3 (9%) of the BMA/B examinations were normal. Hypocellular bone marrow was diagnosed in 22 (65%) patients. Other pathologies included granulomas in 6 (18%), hematologic malignancies in 2 (6%), and leishmaniasis Aspergillosis, each in 1 (3%) patient. Six (17%) of the specimens were found to have tuberculosis infections.

CONCLUSION

Hypocellular bone marrow was the most common pathology on BMA/B examinations, followed by the presence of granulomas. Tuberculosis, Aspergillosis, and Leishmaniasis the opportunistic infections diagnosed on BMA/B specimens. Our results support BMA/B as an appropriate diagnostic tool for early diagnosis of opportunistic infections and malignancies in AIDS. BMA/B is indispensable in the armament of diagnostic tools of the physicians managing AIDS patients.

HIV-positive patients presenting with peripheral blood cytopenias: is bone marrow assessment a priority?

Introduction

Hematologic abnormalities are frequent among persons living with HIV (PLWH). The bone marrow aspirate (BMA) and biopsy (BMB) are commonly performed in the diagnostic approach of patients with unexplained cytopenias. Changes in antiretrovirals, supportive therapy and increased life expectancy have modified the distribution and etiology of cytopenias, questioning their use. Our aim was to analyze the diagnostic yield of BMA, BMB and marrow cultures for the evaluation of cytopenias in PLWH.

Methods

This was a retrospective cohort of ≥ 18-year-old PLWH undergoing bone marrow assessment (MA) for the evaluation of cytopenias between January 2002 and December 2015.

Results

A total of 236 cytopenic events were analyzed, 47.9% being PLWH who had a longstanding diagnosis (≥ 1 year). Adherence to antiretrovirals was 63.5%. Anemia was seen in 91.9% and pancytopenia in 39%. Common presentations included fever (52.1%), weight loss (42.8%) and adenopathies (28.8%). Median days from detection to MA was 5 (0 – 63 days). Most common etiologies were non-HIV infectious diseases (31.4%) and benign/malignant hematologic diseases (26.3%). The diagnostic yield was 16.1% for BMA, 20.3% for BMB, 30.5% for both and 35.6% when cultures were added. Patients most likely to have conclusive MA were those with moderate/severe thrombocytopenia (p = 0.007). Fever, splenomegaly, and low CD4+ counts were associated with infectious etiologies, while hematologic diagnoses were related to the presence of adenopathies.

Conclusion

As a minimally invasive intervention, the MA has a high yield for identifying the etiology of cytopenic events in PLWH, being conclusive in one in three patients. Early performance could lead to prompt diagnosis and timely therapy initiation.

Hematologic derangements in HIV/AIDS patients and their relationship with the CD4 counts: a cross-sectional study

OBJECTIVE

Hematologic abnormalities are the most common complications of human immunodeficiency virus (HIV) infection being more pronounced during the late stages of the disease, thereby indicating the progressive nature of the disease. Anemia is the most frequent hematologic abnormality in HIV. However, leukopenia, lymphopenia, and thrombocytopenia have also been observed. We undertook this study to evaluate the hematologic abnormalities in HIV patients and their relationship with the CD4 cell counts.

MATERIALS AND METHODS

This is an analytical cross-sectional study that was carried out among patients in Jammu, India for the three years from 2015 to 2018. Data collection pro-forma has two parts. Firstly, socio-demographic details such as age, gender, marital status, and occupation were noted. Secondly, investigations such as HIV testing, complete blood counts and CD4 counts were considered. The Statistical Package for Social Sciences (SPSS) software version 20 was used for data entry and analysis. One way analysis of variance (ANOVA) was applied as appropriate to examine differences between quantitative variables.

RESULTS

Anaemia was present in 72.5% of cases in our study. Leukopenia, lymphopenia and thrombocytopenia were observed in 18.33%, 49.17%, and 15.83% of the cases, respectively. We found statistically significant relationships of anemia, absolute lymphocyte count, and thrombocytopenia with the CD4 counts (P<0.0001, =0.018 and =0.044, respectively). However, CD4 counts at the time of presentation were not significantly related to the total leukocyte count and absolute neutrophil count.

CONCLUSIONS

Anemia was the most frequent hematologic abnormality in HIV patients followed by lymphopenia, leukopenia, and thrombocytopenia. A significant relationship was observed between the anemia, absolute lymphocyte count, and thrombocytopenia with the CD4 counts. We recommend routine hematologic investigations and timely treatment for all the hematologic derangements in HIV patients.

The diagnostic utility of bone marrow examination in an infectious disease ward

Background

Patients with advanced human immunodeficiency virus often present with unexplained fevers or cytopenias. Bone marrow aspirate and trephine examinations are an invasive means to aid diagnoses in patients who present with diagnostic dilemmas.

Objectives

A retrospective record review to assess the diagnostic utility of bone marrow examinations in a South African Infectious Diseases ward.

Methods

The records of patients who had undergone a bone marrow examination in the Infectious Disease ward at the Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, between 01 January 2012 and 31 December 2014 were reviewed. A unique diagnosis was considered to be any diagnosis made on bone marrow examination alone, or a diagnosis made more timeously on bone marrow examination than with alternative investigations.

Results

Of 327 patients who underwent bone marrow examination, 80 unique diagnoses were obtained in 77 cases (23.5%). The unique diagnoses included the presence of granuloma (n = 49), Mycobacterium tuberculosis (n = 17), Mycobacterium avium complex (n = 3), haematological malignancy (n = 4) and pure red cell aplasia (n = 5). A white cell count ≤ 4 × 10⁹/L predicted a unique outcome (p < 0.01). A white cell count ≤ 4 × 10⁹/L and CD4 cell count ≤ 50 cells/mm³ predicted mycobacterial infection of the bone marrow.

Conclusions

The findings of a unique diagnosis in 23.5% of bone marrow examinations performed suggests that this remains a useful investigative modality in patients in whom less invasive investigations have not yielded a diagnosis.

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.

Central pontine myelinolysis complicating treatment of multicentric Castleman's disease and Kaposi's sarcoma in a patient with AIDS

An HIV positive black African woman presented with widespread lymphadenopathy and pancytopenia that had been ascribed to tuberculosis. Lymph node biopsy showed both Kaposi's sarcoma and multicentric Castleman's disease. Despite antiretroviral therapy and chemotherapy the patient deteriorated, developing confusion and dysphasia. A cranial magnetic resonance scan showed central pontine myelinolysis. Despite supportive therapy the patient died.