Mar 17, 2014
Hello, I am infectious disease doctor from Turkey. My patient is 67 years old, women, with 10 years of HIV positive, started treatment 1 years ago. She is on truvada plus kaledra. Shas has diabet, and coronary artery disease. Her current lab results: CD4 85/mm3 (pretreatment: 51), HIV RNA: negative (pretreatment 59.800 copy/ml, leucocyte count: 2,4, hemoglobin:7,3 platelet: 80000. She suffer for the anemia for the 1 year and got eritrocyte transfusions many times. In the past one year, her eritrocyte transfusion requirement abit decreased in the last weeks (at the beginning, she took transfusion every two weeks, but in the last weeks she need every one month). But her hemoglobin level is still decreasing. Now her hemoglobin level again is 7,3 g/dl (last transfusition was 3 weeks ago, 1 unite eritrocyte was gave, and then her hemoglobin level was 9,8). Bone marrow culture gave no growth (including mycobacteria)and no other disease (e.g lenfoma). What do you think her persistant pancytopenia? Do you recommend eritropoietin injection for her anemia to decrease transfusition. Thank you
Response from Dr. Young
Hello and thank you for posting from Turkey. I apologize for my late reply to your questions.
It's good that your patient is on ART and has an excellent viral response.
There are two general areas of responses. First, is related to trying to understand the basis of your patient's anemia and relative pancytopenia. With her very low CD4 cell count, the possibility of a bone marrow infiltrative process, such as Mycobacterial infection or malignancy seems very real, but her marrow biopsy and culture would seem to rule this out. It's also possible, though less likely that she has a toxicity to one of her medications- trimethoprim/sulfa is a common cause of erythrocyte depression/anemia, I've seen some patients with marrow suppression from tenofovir too. Does her bone marrow biopsy show any erythroid precursors? One would predict that this should be the case.
Also, it's conceivable that rather than having a red cell productive problem that she has functional hypersplenism- sometimes seen in advanced HIV/AIDS cases. Her low platelet count would further my concern for this. Does a peripheral blood smear give any abnormal clues?
With regards to her treatment, if an erythropoetin level is available, this can tell you if your patient would benefit from supplemental epo. You've not mentioned her renal function, but clearly patients with end-stage renal disease have low epo levels.
If no other obvious cause can be identified, I'd wonder if holding any unnecessary medications could be done, even to the extent of changing her ART to other medications (the later to address the possibility of ART-induced anemia).
I hope this is helpful. BY
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