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Unexplained anemia
May 11, 2000

I was hospitalized last week for "ordinary" pneumonia (not PCP) after a week in the Caribbean. Docs discovered severe anemia indicating huge blood loss where none had occurred. Last vl was undetectable <50 copies, t-cells high. Have been on saquinavir, nelfinavir & nevirapine combo for 2 years + after 1 year Crix & AZT & 3TC + prior 5 years AZT monotherapy. Infected at best guess 17 years.

Recent switch in regimen dose from saq. 1800 mg tid, nelf. 1000 mg tid and nevirapine 200 mg bid to: saq 400 bid, nelf 1250 bid, nevirapine 400 bid.

Following is report on discharge -- any ideas?

"46 year old male with ca 20 year history of HIV, undetectable viral load and recent CD4 count in 800 range who presents with 2-3 days increasing shortness of breath, pleuritic chest pain and fevers. He had been in the Caribbean [1 wk] PTA and had noticed onset of some DOE. In ED found to have a LLL opacity felt to be consistent with pneumonia. He was also found to have a normocytic anemia with a hct of 23, with a hct of approx 40 2 mos PTA. He was treated initially with IV Ceftriaxone, and his fever resolved and he felt symptomatically improved. He was then switched to oral cefpodoxime. A full anemia work-up was done, which revealed no obvious source for his low blood count. He had an LDH of 777, but normal bilirubin and haptoglobin. His coombs test was negative. He had negative stool hemeoccult testing. His iron was 5 and TIBC was 221 suggesting some iron deficiency, but his ferritin was above 300, making this a confusing picture. His reticulocyte count was 5.9%, making a primary bone marrow problem unlikely. He was transfused 2 units of PRBCS, with dramatic symptomatic improvement [they told me my hct had returned to normal immediately and that this wasn’t what they expected to happen either]. His hct was stable on 5/7 and he was discharged home with f/u in the heme clinic. His CD4 count during this admission was in the high 600s."

LABORATORY AND STUDIES AT DISCHARGE

HCT 38 WBC 5.34

Response from Dr. Frascino

At this point, the exact cause of your anemia remains unclear. It appears to have developed rapidly. Your hematocrit was 40 two months prior to your admission to the hospital. Your laboratory studies reveal low serum iron and iron binding capacity, which could indicate iron deficiency, but this usually does not occur so rapidly. The elevated ferritin is consistent with chronic HIV disease and also with your recent infection (pneumonia). Anemia of chronic disease can be normocytic with low iron and low TIBC and elevated ferritin, but your reticulocyte count is quite high for this condition. Also, the anemia of chronic disease is not rapid in onset. You did not note any blood loss and your normal bilirubin and haptoglobin would argue against intravascular hemolysis (destruction of red blood cells). The normal Coombs test argues against autoimmune destruction of red blood cells.

The possibilities at this time would include extravascular pooling of blood, perhaps in the spleen, which is known as hypersplenism. What was your platelet count? In hypersplenism, the platelet count is usually low. Also, the possibility exists that you picked up a parasite while in the Caribbean, which could then lead to iron-deficient anemia. Was your eosinophil count elevated? The eosinophil count is typically elevated with significant parasitic infections. Additional work-up at this point should include further evaluation for possible blood loss from the gastrointestinal tract. For example hemoccult tests should be repeated. Your peripheral blood smear will need to be carefully reviewed for additional clues. If these measures fail to elucidate the cause, a bone marrow aspirate may be necessary. Keep that appointment in the hematology clinic, and let us know what the final diagnosis turns out to be.

Good luck.

RJF


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