MOFFITT ONCOLOGY REPORT PEARLS 10/14/16: HIV and ITP!

Hi Everyone! Thanks to Jess and Salman for presenting the super interesting case of a young woman with HIV, disseminated AFB infection, and extreme thrombocytopenia felt to be HIV-associated ITP!

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Top pearls:

  • Thrombocytopenia is common in HIV patients, most often due to an ITP-like mechanism.
  • 1st line treatment for ITP (including HIV-associated ITP) is glucocorticoids or IVIG.
  • ITP prognosis is similar to the general population.

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For those who want more info:

Pat Cornett helped us with the differential diagnosis for extreme thrombocytopenia (in this case, undetectable platelets on the CBC!). Generally, still think of broad categories of decreased production, increased destruction, or sequestration. But particularly consider these diagnoses when platelet count is extremely low:

  • ITP
  • Acute leukemia
  • Acute etoh
  • Aplastic anemia
  • Sepsis

*Pearl: TTP does not usually cause extremely low platelet values.

A little more on ITP:

Relatively common acquired bleeding disorder (prevalence 12 per 100,000 adults).

Diagnosis of exclusion; consider the diagnosis when isolated thrombocytopenia is seen (without anemia or leukopenia). Send smear, HIV, and HCV in all patients suspected of having ITP. Anti-platelet antibody testing is not useful (does not correlate with clinical outcomes).

Pathogenesis of ITP is antibody-mediated destruction of platelets and megakaryocytes. Can a severely immunocompromised person with HIV/AIDS develop such an antibody? Yes, according to Pat!

ITP associations to know: HIV, HCV, SLE, CLL, medications.

Threshold for treatment is platelets <20-30K or active bleeding.

1st line tx: Steroids and IVIG (IVIG works faster).

2nd line tx: Splenectomy or rituximab.

3rd line tx: Thrombopoietin receptor agonists (eltrombopag and romiplostim)

Prognosis: Spontaneous remission in 10%, most reach a stable platelet count from either remission or therapy (approx. 50% only require 1st line therapy). Mortality is similar to the general population.

 

HIV and thrombocytopenia: Mechanisms are multifactorial and complicated!

Thrombocytopenia is common in patients with HIV (10-15%) and may even be the initial manifestation.

Most cases are due to immune dysregulation akin to ITP (“HIV-associated thrombocytopenia”).

Other major causes related to HIV include medications, various infections, malignancy, liver disease (hypersplenism), TTP, and DIC.

A small study (PMID 9558379) showed that HIV patients have reduced platelet survival, reduced recovery of infused platelets, reduced bone marrow megakaryocyte progenitors, and increased thrombopoietin concentration compared to controls.

Treatment of HIV-associated thrombocytopenia is similar to treatment for ITP, with the addition of ARVs.

Evernote: https://www.evernote.com/shard/s272/sh/5a9449eb-a0bd-4371-95c3-03c36863c1dc/cf72438c77899d1d6a531bc09524441d

Have a great day everyone!

SamMy

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