Lewis Brad Anemia H I V A I D S G R409

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Brad Lewis: Anemia and H I V A I D S

Transcript of Lewis Brad Anemia H I V A I D S G R409

  • 1.
    • Brad Lewis
  • San Francisco General Hospital
  • Blood alone moves the wheels of history.
    • Benito Mussolini
  • Blood will tell, but often it tells too much.
    • Don Marquis

Anemia in the Patient with HIV 2. Goals of this Talk

  • How to Approach the Anemic Patient
  • Anemias specific to HIV
    • Evaluating hemolysis
    • Iron Deficiency and CDA
    • G6PD
    • B12 Deficiency
    • Marrow Dysfunction

3. Anemia in HIV (EuroSIDA) Mocroft A, AIDS1999; 13:94350 4. An Approach to Anemia Anemia 5. Evaluating Hemolysis The Bucket with The Hole 6. Evaluating Hemolysis The Bucket with The Hole 7. Reticulocytes Retic #=1/mm Retic %= 20% Retic # = 1/mm Retic % = 30% Corr Retic = Retic x hgb/nl hgb RPI = corrected retic. count/Maturation time(Maturation time = 1 for Hct=45%, 1.5 for 35%, 2 for 25%, and 2.5 for 15%.) 8. An Approach to Anemia Retic Hi Retic Low Anemia 9. An Approach to Anemia Retic Hi Retic Low Anemia MCV Hi MCV Nl MCV Lo 10. An Approach to Anemia Retic Hi Retic Low Anemia Destruction Loss MCV Hi MCV Nl MCV Lo Intrinsic Extrinsic Splenic Mechanical Recovery Tissue On Floor Occult Iron (Lead) Thal Frags B12 Folate Liver ETOH Thyroid Toxic MDS Chronic Disease Renal Mixed Mild/Treated Early Transfused Endocrine Intrinsic BM Dilution 11. An Approach to Anemia Retic Hi Retic Low Anemia Destruction Loss MCV Hi MCV Nl MCV Lo Intrinsic Hgbopathy Enzymopathy Membrane HS PNH Extrinsic Splenic Mechanical Recovery Tissue On Floor Occult 12. Retic Hi Retic Low Anemia Destruction Loss MCV Hi MCV Nl MCV Lo Intrinsic Extrinsic AIHA cold warm Drug/Toxins Sepsis Burns Splenic/Hepatic Mechanical MAHA Tissue On Floor Occult Recovery 13. Hemolysis Diagnosis

  • Check the RETIC!
  • Confirmatory Testing
    • LDH, Haptoglobin
      • 1% Population Ahaptoglobinemic
    • Bilirubin
  • Intravascular (massive)
    • Plasma Hgb
    • Urine Hemosiderin (Hemoglobinuria)
      • The Hgb A 1 C of the hematologist

14. SpecificDiagnostic Tests-High Retic

  • Smear
  • Coombs- Direct and Indirect
    • Does NOT diagnose hemolysis
  • G6PD ASSAY (and Retic count)
  • Hemoglobin Electropheresis???

15. What Else Could It Be?

  • 56 yo Hawaiian male
  • Hgb 7, WBC nl, MCV nl, Plt nl, LDH 320,Ind. Bili 2.1
    • Fe studies nl, B12/Folate nl, Coombs 4+IgG
    • Well!

16. What Else Could It Be?

  • 56 yo Hawaiian male
  • Hgb 7, WBC nl, MCV nl, Plt nl, LDH 320,Ind. Bili 2.1
    • Fe studies nl, B12/Folate nl, Coombs 4+IgG
    • Well!
  • Given 12 mo prednisone without effect ---

17. What Else Could It Be?

  • 56 yo Hawaiian male
  • Hgb 7, WBC nl, MCV nl, Plt nl, LDH 320,Ind. Bili 2.1
    • Fe studies nl, B12/Folate nl, Coombs 4+IgG
    • Well!
  • Given 12 mo prednisone without effect ---
  • Retic #20 (0.5%)
  • BM with MDS, evolving AML
    • PNH

18. Microangiopathic Hemolysis

  • DIC
  • TTP , HUS
  • Malignant Hypertension
  • Mechanical
    • Vasculitis
    • Tumor
    • Cardiac Valve
    • SBE
    • TIPSS
    • AVM

19. 20. Microangiopathic Hemolysis 21. MAHA-What Else Could It Be?

  • MDS
    • Malignant
    • HIV
  • B12
  • Iron Deficiency

22. G6PD

  • X-linked, race variable
  • Unable to Reduce Glutathione
    • Susceptible to oxidant damage
  • Drugs
    • Sulfa
    • Methylene Blue
    • Anti-Malarial
    • Nitrates
  • Infections
  • DKA
  • Fava Beans

23. G6PD Deficiency Average G6PD Act. Time in Circulation 24. Italian G6PD Deficiency Average G6PD Act. Time in Circulation Normal Nl mean Severe G6PD Def. 25. African G6PD Deficiency Average G6PD Act. Time in Circulation 26. African G6PD Deficiency Average G6PD Act. Time in Circulation G6PD in hemolysis 27. African G6PD Deficiency hemolysing with oxidant stress Average G6PD Act. Time in Circulation Hemolyzed New Average G6PD Activity Young Retics with more G6PD 28. Retic Hi Retic Low Anemia Destruction Loss MCV Hi MCV Nl MCV Lo B12 Folate Toxic AZT,DDC Chemo Dilantin MDS Hepatic ETOH Thyroid Other Nuclear Maturation Lipid Bilayer 29. Diagnostic Tests- Low ReticMacrocytic

  • Repeat Retic
  • Smear (round vs. oval macrocytes, hypersegmented PMN)
  • B12 and Folate (and Iron)
  • Hepatic
  • Toxic?
    • AZT, DDC, Stavudine, Lamivudine
    • Chemo, ETOH
  • Cold Agglutinin
  • To BM or not to BM

30. B12 Hyperseg PMN 31. B12 Deficiency

  • ??Diagnostic level (