Hematological complications are a common cause of mortality in HIV infected patients. Cytopenias are most frequent during the advanced stage of disease . We evaluated various hematological manifestations on 200 consecutive HIV seropositive patients who presented to the Immunodeficiency clinic PGIMER, Chandigarh, irrespective of their ART status. We also correlated the final hematological diagnosis of the patients with the CD4 count.
Anemia was the most common presentation. Among 200 individuals, 131 (65.5%) were found to be anemic out of which 4 (3%) cases were in asymptomatic group and 127 (97%) were in symptomatic group (p < 0.001). Our results on prevalence of anemia showed comparable results with other studies from India [9–11]. In a study by Mir et al on a cohort of 60 HIV infected individuals reported anemia, thrombocytopenia, leucopenia and various permutations of these in majority of individuals . The highest rate of anemia occurs in patients with advanced HIV disease. In our study out of 131 patients, 92.4% (n = 121) cases were those with CD4 counts <200 cells/μL, while 7.6% (n = 10) patients were those with CD4 counts >200 cells/μL and there was statistically significant difference (p < 0.001) between both the groups. Severe anemia (defined as hemoglobin less than 7.5 gm/dl) was observed in 18.5% (n = 37) patients as compared to 7% in a study by Kasthuri et al .
The cumulative incidence of anemia was highest among patients who had CD4 lymphocyte count < 200 cells/μL and was lowest with CD4 lymphocyte count > 500 cells/μL, showing an inverse correlation between anemia and CD4 cell count (p < 0.001). HIV infected individuals with anemia are at increased risk for progression to AIDS and mortality, recovery from anemia has been associated with a decreased risk of deaths. We did not estimate the survival in patients with and without anemia, as this was a descriptive study, though the literature clearly indicates that it does affect the survival .
The hemoglobin, PCV, MCV, MCH, and MCHC showed statistically significant correlation with CD4 counts (p < 0.001) in both males and females. Iron studies were done in 126 patients out of which 65.1% (n = 82) were males and 34.9% (n = 44) were females. Iron deficiency anemia was found in 49.2% cases (n = 62; 34 males, 28 females). Anemia of chronic disease was found in 50.8% cases (n = 64; 48 males, 16 females) among which 2 males showed macrocytosis with MCV >100, a possibility of coexisting megaloblastic anemia could not be ruled out as serum vitamin B12/folic acid level was not done. Among patients with anemia 25.9% (34/131) males and 21.3% (28/131) females had iron deficiency anemia, while 36.6% (48/131) males and 12.2% (16/131) females had anemia of chronic disease. The parameters of iron profile serum iron, TIBC, and saturation were not significantly correlated but the serum ferritin level was significantly correlated to CD4 counts (p < 0.05). This result was similar to that reported in the study by Semba et al .
In this study we did not find any patient with hemolytic anaemia. Viral markers were also performed in anaemic patients None of the infective agents evaluated by serology, including EBV, CMV, Parvo B 19 or Hepatitis B were positive, except for 3 patients positive for Hepatitis C. These 3 patients had CD4 counts <200 cells/μL and serum ferritin more than 500 μg/dl which suggests anemia of chronic disease.
Thrombocytopenia is known to be a frequent complication of HIV infection (1, 2). The mean platelet count in our cohort was 239.8 ± 101.3 × 103/μl (range 13.6–685 × 103/μl). It had no significant correlation with CD4 counts confirming to the data with the previous study . Prevalence of thrombocytopenia is reported to be higher among persons with AIDS, older persons, homosexuals and injecting drug users .
We did not detect any case of neutropenia with ANC of less than 1000 cells/mm3. The result differ from previous study by Suresh et al in which 22.7% cases had neutropenia . We also did not find any patient with coagulation abnormalities. Bone marrow examination was carried out in 7% (n = 14) patients. Among 14 patients, 6 each had hypocellular and hypercellular marrow while 2 patients had a normocellular marrow. The bone marrow trephine biopsy showed epithelioid cell granulomas in 6 patients (4 were positive for AFB, 2 were positive for fungal profiles, morphologically and cytochemically consistent with cryptococci). Hemophagocytosis was prominently seen in 3 cases, without evidence of any co-infection. Two patients with lymphoma (NHL) showed no infiltration by lymphoma cells. HIV infection may lead to anemia in different ways; the important causes are defective iron metabolism and reutilization, nutritional deficiencies, opportunistic infections, ART, administration of chemotherapeutic agents and advanced stage of disease with its complications. Therefore, consideration should be given to monitoring anemia in all HIV-positive individuals and to offer supplements like iron preparations, vitamin B12 or folic acid, and in severe cases to provide erythropoietin treatment or blood transfusions, in case indicated.