ASH Image Bank (2001); doi:10.1182/ashimagebank-2001-100182
Copyright © 2001 by the American Society of Hematology.
HIV-Related Thrombocytopenia
John Lazarchick, M.D.
Medical University of South Carolina
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Figure 1. Peripheral smear showing large platelet. The platelet count was 28,000/uL but the mean platelet volume (MPV) was elevated reflecting the presence of large, young platelets in the periphery.
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Figure 2. Bone marrow aspirate with three relatively small megakaryocytes with variable numbers of nuclear lobulations. Platelet antibody assay was positive.
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Figure 3. Bone marrow biopsy showing megakaryocytic hyperplasia in response to an immune-mediated thrombocytopenia in this patient with HIV infection.
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Figure 4. Bone marrow biopsy showing a naked mummified megakaryocyte nucleus typically seen in marrows of patients with HIV infection (arrow).
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Figure 5. Peripheral smear showing intracellular Candida albicans from a patient with HIV infection who had fungal sepsis.
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Figure 6. Bone marrow biopsy showing a granulomatous infiltrate with numerous histiocytes, plasma cells, and lymphocytes.
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Figure 7. Lymph node showing almost total effacement by Kaposi's sarcoma. Red blood cells (RBCs) are seen percolating through the vascular channels formed by the interwoven bundles of spindle cells.
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Figure 8. Lymph node showing follicular hyperplasia with infiltration of the germinal centers by small lymphocytes (follicular lysis) (arrows).
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Figure 9. The same node showing the infiltration of the germinal center by the small lymphocytes (follicular lysis) at a higher magnification.
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Figure 10. Bone marrow biopsy showing marrow replacement by a high grade Non-Hodgkin lymphoma occurring in patients with HIV infection. Note residual dysplastic megakaryocyte.
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Clinical Summary
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A 34-year-old African American woman with known human immunodeficiency virus (HIV) infection secondary to intravenous drug abuse complained of pelvic pain and fever. She has also noted weight loss of 15 pounds over the past two months. Her menses have been noticeably heavier for the past four months and she is aware of easy bruising. She is on multiple medications for HIV therapy.
Her temperature is 101.4 F, and she is a chronically ill-appearing female who looks older than her stated age. No significant adenopathy is present and the liver and spleen are not palpable. Scattered rhonchi are heard over left lung field. Multiple scars are evident over venous access on upper extremities.
The pelvic exam results were unrevealing.
Lab: Hemoglobin (Hgb) 9.8g/dL, white blood cells (WBC) 3600/uL, platelets 24,000/uL. Mean platelet volume (MPV) is increased at 12.7. CD4 count 158. Viral load of 21,000 viral copies/mL. Hepatitis B and C serologies are negative. UA 10 WBC/uL, many bacteria.
On multiple past admissions this patient's platelet count has always been between 75,000 and 200,000/uL. The more severe thrombocytopenia noted now with an elevated MPV was suggestive of accelerated platelet turnover. Her evaluation included coagulation panel for disseminated intravascular coagulation (DIC), blood cultures, platelet antibody assay, and bone marrow to assess marrow cellularity and hematopoetic status.
During the course of her hospital stay, she became markedly febrile. A peripheral smear at that time showed fungal organisms within WBCs and blood cultures confirmed Candida sepsis. Despite multiple antibiotic therapies she failed to respond. Bone marrow exam at postmortem showed multiple ill-formed granulomas. In addition, Kaposi's sarcoma was noted in nodal tissue.
Sex
Female
Age
34
Ethnicity
African American
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Diagnosis
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Disseminated intravascular coagulation, Other causes of immune thrombocytopenia, thrombotic thrombocytopenic purpura (TTP).
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Discussion
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Cytopenias in patients with HIV infection are common and mulifactorial in origin. These include bone marrow failure due to defective production or inhibition of progenitor cells, ineffective hematopoiesis, and decreased survival of mature cells. Thrombocytopenia occurs in 16% to 43% of patients during the course of the disease. The thrombocytopenia is usually mild and only infrequently is the platelet count
Indirectly related to the disease itself but potentially compounding the thrombocytopenia in this patient group are several other considerations. The medications used for therapy of the retrovirus and for treatment of opportunistic infections common to this patient group can be cytoxic to the bone marrow. Sepsis with DIC, involvement of the marrow by high grade lymphoma, and granuloma formation add to the thrombocytopenic state. Finally, thrombotic thrombocytopenic purpura (TTP) with microangiopathic hemolytic anemia and thrombocytopenia has been reported with this disease.
In the absence of supervening sepsis, drug-induced marrow suppression or marrow replacement as noted above, the thrombocytopenia is often mild with normal to increased numbers of megakaryocytes note in the bone marrow. Treatment of the retrovirus with zidovadine or protease inhibitor cocktails is the mainstay of therapy. With reduction of the viral load and return of the CD4 count, there is usually a corresponding improvement in the platelet count. If the thrombocytopenia is severe, therapy similar to that used for autoimmune-mediated-thrombocytopenia (e.g. corticosteroids,IVIg, anti-Rh(D)) should be considered.
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Differential Diagnosis
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Disseminated intravascular coagulation, Other causes of immune thrombocytopenia, Drug-induced marrow toxicity, TTP.
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Copyright © 2001 by the American Society of Hematology.
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