Welcome to I-TECH India National Distance Learning Seminar Series

Date : 08-05-2013 Time : 2pm 3pm Speaker : Dr. Ravinder Kaur Sachdeva, Centre of Excellence, PGIMER, Chandigarh Title : Hematological manifestations of HIV infection

Introduction
Infection with HIV has been associated with broad range of clinical outcomes particularly evident in the hematopoietic system. Impaired hematopoiesis, immune-mediated cytopenia, and altered coagulation parameters are known in HIV infection. In this session: Clinical manifestation Postulated pathophysiology Current therapeutic approaches
2

Hematological abnormalities
Anemia Leukocytopenia
Lymphopenia Neutropenia Monocytopenia

Thrombocytopenia Thrombotic disorders HIV associated malignancies

Lymphomas
Moses A et al, Blood 1998, 91:1479 3

Causes of the hematological changes

The hematological abnormalities may be attributed to the:
Direct and indirect effect of HIV infection Opportunistic infections Toxicity of the drugs

Mechanisms
Marrow suppression by
Direct factors
Infection of marrow progenitor cells Suppression of marrow by HIV viral proteins

Indirect factors
Immune dysregulation Alteration of stromal microenviroment

Direct factors
CD34+ cells have receptors for HIV
Only committed progenitor cells are infected Most immature cells are resistant to infection
CD4 and coreceptor expression increases with maturation in CD34 cells and the expression correlates with potential chances of infection.
(Chelucci et al. Blood 1999;94:1590-1600)

 However marrow cells do not represent a significant reservoir of HIV HIV was detected in CD34 cells in only 14% to 36% of HIV infected persons
(Stanley et al. J Immunol 1992;149:689-97)

Indirect factors
Viral products like gp120, gp160, viral tat proteins induce secretion of array of cytokines, including TNF-, TNF-, IFN- and IL-6 which are potent inhibitors of hematopoiesis, especially TNF-
(Selleri et al. J Cell Physiol 1995;165:538-46)

Indirect factors
Local Production of cytokines by stromal cells might be of more importance than the systemic levels Activated T cells can kill virus infected cells: Apoptosis of hematopoietic progenitor cells may contribute to the hematopoietic inhibition seen in HIV-1 infection
(Kagi et al. Science 1994;265:528-30)

Anemia
Hb < 10g% (AASHD) WHO recommends treatment in women with Hb < 12 g% and men with Hb < 13 g% 10-20 % patients on initial presentation 50-85% patients with overt AIDS Frequency and severity correlated with CD4 cell count HIV RNA levels Presence of clinical HIV defining conditions
10

Etiology
Major cause: Impaired erythropoiesis Direct consequence of HIV infection of erythroid precursors or inappropriate release of inflammatory cytokines such as TNF- Decreased production of erythropoietin

11

 Most HIV infected patients with anemia have adequate erythropoietic capacity but are unable to augment it during periods of demand in large part because of relatively inadequate erythropoietin levels. Inappropriately low endogenous levels (<500 mU/ml) of serum EPO seen in most AIDS patients with anemia Cytokines produced in response to HIV infection, such as IL-1 and TNF-, blunt the normal rise in hemoglobin with rising serum EPO levels Circulating anti-erythropoietin antibodies
Spivak J et al JAMA 1989; 261: 3104-7
12

Cause of anemia
Poor production of RBCs

Etiology
HIV infection Anemia of Chronic Disease HIV infection of stromal cells Infection CMV, parvovirus B19, MAC Malignancy Lymphoma Kaposi's sarcoma Drugs Sulfonamides, dapsone

Destruction of RBCs

Hemophagocytic syndrome Disseminated intravascular coagulation Drug associated hemolytic anemia Folate and iron deficiency Dietary Intestinal malasorption Vitamin B12 deficiency Infection in stomach or intestine Intestinal malabsorption 13

Ineffective production of RBCs

 Anemia of HIV infection is usually normochromic and normocytic, may be mildly hypochromic and microcytic Usually low serum iron levels and low serum iron binding capacity but a normal to elevated ferritin levels and adequate stores in the bone marrow, low reticulocyte count, macrocytosis in patients treated with Zidovudine
14

Consequences of anemia
Consistent association between anemia and decreased survival in HIV patients The strongest association with decreased survival is for hemoglobin level of less than 10g/dL Associated with progression to AIDS Resolving anemia is associated with improved survival Anemia is also associated with reduced quality of life particularly as it relates to functional status
Scaden DT Blood 1989; 74: 1455-63, Hambleton J 1996; 19: 671-80
15

Evaluation of anemia in HIV infection

Hb < 10-12 g/dl (value to use dependent on functional status)

MCV high Retic high

MCV high Retic low

MCV low Retic low

MCV normal Retic low Serum iron, TIBC low, Ferritin normal Pancytopenia Pure RBC aplasia

Hemolysis: Indirect bilirubin LDH high Haptoglobin low

Vit B12, Folate deficiency

Iron deficiency: Serum Fe, TIBC, Transferrin Ferritin low IDARx

Treat: stop medication Smear: fragmentedTreat Cause Treat RBC, spherocytes, infection schistocytes

Assess GI bleed or other cause

BM aspirate and biopsy Infection: MAC, TB, fungal,

PV B19, dot blot DNA Treat

IVIG

fever

HAART: 6 months Infection; to treat

MAC, TB, fungal Treat

Lymphoma or TTP; elevated creatinine,, fever, other neurological deficit malignancy Treat

Inadequate improvement : EPO

Diagnosis
Iron-deficiency anemia

Diagnosis
Fe < 60 g/dl, transferrin < 300 g/dl, ferritin <40ng/ml, MCV <80, reticulocytes <2.017 Fe < 60 g/dl, transferrin < 300 g/dl, ferritin > 80 ng/ml, normal BM iron, low erythropoietin level, MCV lownormal, retic < 2.0 MCV > 100, retic < 2.0, serum vit B12 (cyanocobalamin) < 125-175pg/ml MCV > 100, retic < 2.0, serum folate < 2-3 ng/ml Severe pure RBC aplasia. HB < 10, Hct < 24%, retics low-absent, positive IgG and Ig M serology, positive PCR of dotblot hybridization for PV B19 MCV 80-100, retics < 2.0, possible pancytopenis, BM biopsy abnormal MCV > 100 (Zidovudine and stavudine) MCV 80-100, increase retics, indirect bilirubin > 1.2 mg/dl, LDH > 220 IU, haptoglobin < 25 mg/dl, spherocytes and fragmented RBCs on smear

Treatment
Ferrous sulfate 300 mg po tid

HIV-induced anemia

HAART (1-2 g% increase in hemoglobin over 6 -12 months), eryrthropoietinalpha Vit B12 1 mg IM daily x 7 days then monthly Folate 1-5 mg po daily x 1 month HAART IVIG 400 mg/kg/day x 5 days Repeat as necessary Treat specific etiology Discontinue drug, epoietin-alpha Discontinue drug, transfusion, Severe methemoglobinemia (G6PD deficiency can be treated with IV methylene blue (1 mg/kg)

Vit B12 deficiency

Folate deficiency Parvovirus B 19

Bone marrow infilteration by infection or tumour Drug induced G6PD deficiency and use of oxidant drugs and other hemolysis

17

Erythropoietin
Glycoprotein regulating the production of hematopoietic cells and the process of terminal differentiation and maturation. Suppresses apoptosis Enhance the function of terminally differentiated hematopoietic cells Placebo controlled trials have shown that small amounts of recombinant human erythropoietin (epoietin alpha) can increase hemoglobin levels and significantly reduce the transfusion requirements of patients with HIV infection and anemia.
18

Erythropoietin (cont)
RCT of epoietin alpha (100-300 IU/kg S/C three times per week) in anemic HIV infected patients in the community setting showed significant increase in hemoglobin levels that were independent of baseline CD4 count. The mean QOL score improved significantly. 16 week randomized trial of 285 HIV patients with anemia (Hb < 12 g%) on stable ART, once weekly epoietin alpha at 40,000 IU S/C was as effective as three times weekly dosing in hemoglobin
Henry D et al Ann Intern Med; 117: 739 Abrams DI Int J STD AIDS; 11:659
19

Erythropoiesis stimulating protein

Darbepoetin alpha Alternative to epoetin alpha for treating anemia Longer t Less frequent dosing Currently darbepoetin alpha shown to effectively treat anemia associated with cancer chemotherapy and in renal failure with limited data assessing its effectiveness in HIV infection Currently only approved for use in patients with anemia as a result of AZT induced anemia is Epoietin alpha 100 IU/kg three times weekly
20

EPO 40 000 IU/week S/C (plus iron supplement) Monitor Hb every week

Hb 1g% at 4 weeks

Hb < 1 g% at 4 weeks

Decrease by 10 000 IU/week when Hb > 11 g %. Continue to titrate to maintain Hb 11-12 g %. Monitor Hb every 2-4 weeks

Increase to 60 000 IU/week

If Hb 12 g % discontinue EPO and restart when Hb 10-11 g %

21

If > 1 g % at 8 weeks , continue

If < 1 g % at 8 weeks and iron, B 12 and folate levels adequate discontinue EPO

Role of Blood Transfusion

Some patients with HIV infection have significant anemia, requiring frequent transfusion. Clinical and experimental evidence suggests that transfusion may be associated with substantial morbidity in HIV-infected patients. Transfused patients with advanced disease have an increased incidence of cytomegalovirus infection and death.
Sloand E, et al. Transfusion 1994;34:4853
22

Role of Blood Transfusion

Laboratory data suggest that transfusion may be associated with viral activation: Allogenic lymphocytes present in transfused blood components activate viral production by HIV-infected lymphocytes in vitro. Busch
MP, et al Blood 1992;80:21282135

When quantitative polymerase chain reaction (PCR) was used to measure circulating HIV, viral load was increased in HIV-infected patents 5 days after transfusion. Mudido PM, et al Transfusion 1996;36:860865 There appeared to be no significant differences in viremia or infectious complications when leukodepleted blood components were used, however.
Ariga H, et al Transfusion 2003;43:98106
23

 Administration of hematopoietic growth factors offers an alternative to transfusion and its potential morbidity and mortality

24

Thrombocytopenia
Thrombocytopenia was defined as total platelet count < 150 103/l Thrombocytopenia can occur independently of other cytopenias and at all stages of HIV infection Occur in 30-60% of HIV infected patients Presenting symptom in 10% of patients Most patients with HIV related immune thrombocytopenia have only minor submucosal bleeding, characterized by petechiae, ecchymosis and occasional epistaxis Splenomegaly occurs in some
25

Etiology of thrombocytopenia
Immune mediated destruction Impaired hematopoiesis Toxic effects from medications Syndrome mimicking Hemolytic Uremic Syndrome (HUS) Thrombotic Thrombocytopenic Purpura (TTP)

Most commonly isolated thrombocytopenia is associated with normal or increased megakaryocytes in bone marrow and parallels the syndrome of Immune Thrombocytopenic purpura (ITP) 26

Etiology of thrombocytopenia
Non specific binding of immune complexes to platelets and more specific molecular mimicry between gp 160/120 antigens of HIV and gp IIb/IIIa of platelets lead to specific platelet associated antibodies Specific IgG antiplatelet antibody binds to 25kDa antigen on platelet membrane resulting in platelet destruction Non specific binding of anti-HIV immune complexes to the platelet Fc receptor make platelet more susceptible to phagocytosis by macrophages Reduced bone marrow production due to suppressive effect of HIV Subpopulation of megakaryocytes express CD4 and CXCR4
Basch RS et al Proc Natl Acad Sci USA 1990; 87: 8085-9, Riviere C et al Blood 1999; 93:1511-23 27

TTP in HIV
Thrombotic thrombocytopenic purpura (TTP) is more common among patients with HIV infection. Emergency situation, needs rapid diagnosis Clinically: Fever, Thrombocytopenia, neurological symptoms, renal derangement The risk of TTP has declined significantly after institution of HAART No controlled studies comparing HIV related TTP with classical TTP have been conducted HIV-related TTP is generally thought to be associated with a milder course and a better response to therapy than classical TTP 28

Treatment
Assess peripheral smear, creatinine, PT, PTT TTP: fragmented RBCs, elevated creatinine, fever, neurological deficits, anemia

Platelet < 20,000/l

On myelosuppressive therapy
Discontinue/change dose

Acute bleeding

DIC: fragmented RBCs infection

BM Bx Aplastic anemia
Lymphoma, infection, other hematological process

Stop bleeding with platelets and IVIG, RBC transfusion

ITP

Plasmapheresis

Treat infection, consider heparin

Optimize HAART Corticosteroids , IVIG Platelet <5000, splenectomy, vincristine, IFN-

Treat

29

 Leucopenia was defined as total WBC count less than 4000 cells/l. Lymphopenia was considered when absolute lymphocyte count <800 cells/l.

30

Neutropenia
Neutropenia was defined as absolute neutrophil count <1000 cells/l. Symptomatic HIV infection 10-30% neutropenic Progress to 75% with frank AIDS

31

Etiology
Myelotoxic medications, including ART drugs, OI drugs and drugs to treat malignancy are important cause of neutropenia in HIV patients Impaired myelopoiesis in patients with leukopenia and HIV infection Accelerated neutrophil apoptosis described in HIV patients
32

Cause of neutropenia

Etiology

Decreased WBC growth Decreased number of progenitor cells in the bone factors marrow: Decreased number of granulocytes and monocytes Decreased serum levels of GCSF: Decreased number of neutrophils Drugs Antiretrovirals: AZT, 3TC, DDI, d4T Antiviral agents: Ganciclovir, foscarnet Antifungal agent: Amphotericin, flucytosine Pneumocystis prophylaxis drugs: Sulfonamides, trimethoprim, pentamidine Antineoplastic agents: Doxorubicin, cyclophosphamide, methotrexate, cytarabine
33

Neutropenia and infections

Increased risk of bacterial infections in patients receiving chemotherapy for malignancy treatment when ANC < 1000 cells

34

ANC < 1000/l

On myelosuppressive medication Fever/signs of infection Evaluate cause Lymphadenopathy/ signs of lymphoma

Discontinue meds or use GCSF optimize HAART ANC < 1000/l

BM biopsy Non diagnosti c

LN Biopsy

Treat

Non diagnostic

Lymphom a or infection Treat

ANC < 500/l BM biopsy Treat: GCSF

Lymphoma, infection, other diagnosis

Treat

35

Thrombotic diseases
Retrospective epidemiological studies have found that the incidence of thrombosis in HIVinfected patients increased two to ten fold over what would be expected in a healthy control population of the same age Increased levels of proinflammatary cytokines
TNF alpha, IL-1, IL-6
Increased levels of factor VIII and decreased protein S

Higher titres of anti cardiolipin antibodies

36

 Patients with HIV are more likely to develop antiphospholipid antibodies such as lupus anticoagulant (found in 1% of patients), anti-phosphatidylcholine and anti-cardiolipin antibodies (found in about 50% of patients with HIV infection). Apart from diagnostic problems related to a falsely elevated partial prothrombin time, these anti-bodies do not appear to be associated with an increased frequency of thrombosis, like they are in uninfected patients
37

Lymphoproliferative disorders in AIDS

The incidence of NHL is increased 60-200 fold in patients with AIDS. The incidence of Hodgkins Lymphoma may be increased to 8-folds.

38

39

Therapy related changes

40

41

Profile of hematological abnormalities of Indian HIV infected individuals Byomakesh Dikshit, Ajay Wanchu, Ravinder K Sachdeva, Aman Sharma, Reena Das BMC Blood Disorders 2009, 9:5 March 2007March 2008 The most common hematological abnormality was anemia, seen in 65.5% (131/200) patients. Iron deficiency anemia was seen in 49.2% cases while anemia of chronic disease occurred in 50.7% cases 92.4% (n = 121) cases were those with CD4 counts <200 cells/L The mean platelet count in our cohort was 239.8 101.3 103/l (range 13.6685 103/l) We did not detect any case of neutropenia with ANC of less than 1000 cells/mm3.
42

Hematological malignancies in human immunodeficiency viruspositive individuals in North India Ravinder kaur Sachdeva, Aman Sharma, Ajay Wanchu, Pankaj Malhotra, & Subhash Varma Leukemia & Lymphoma, August 2011; 52(8): 15971600 The study retrospectively analyzed records of all HIV-infected individuals enrolled in the immunodeficiency clinic of the Department of Internal Medicine, Post Graduate Institute of Medical Education & Research, Chandigarh, India, from April 2004 to September 2009. Retrospective analysis of 5100 HIV-infected individuals between April 2004 and September 2009 was carried out. Hematological malignancy was found in 14 individuals (0.3%) 10 NHL, 1 ALL, 1 CML, 2 Hodgkin lymphoma
43

Thank you!
Email: dlcsinfo@itech-india.org

Welcome to I-TECH India National Distance Learning Seminar Series

Next session : 22-05-2013 Time : 2pm - 3pm Speaker : Dr. Anwar Sayed Parvez