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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Thrombocytopenia

Richard D. Moore, M.D.
08-03-2009

Zambia Specific Information

  • Consider non-HIV-related causes of thrombocytopenia: malaria, typhoid fever, louse-borne relapsing fever, hemorrhagic fevers, leptospirosis, brucellosis, rickettsial infections and kala-azar.
  • Consider non-infectious causes, including nutritional (severe vitamin B12 deficiency) and alcohol abuse.
  • Thrombocytopenia may be common in untreated HIV+ patients in sub-Saharan Africa (up to ~25%), but anemia and lymphopenia more common.
  • No information on idiopathic thrombocytopenic purpura (ITP) in HIV+ African populations.
  • In a study from Uganda of patients on AZT- or d4T-based regimens, incidence of severe thrombocytopenia (<50,000/mm3) was only ~1%.

REFERENCES

Zambia Information Author: Paul Auwaerter, M.D.

CLINICAL

  • 1-yr incidence ranges from 1.7% with asymptomatic HIV to 3.1% with CD4-define AIDS to 8.7% with AIDS-defining illness.
  • Increased risk with decreasing CD4, injection drug use, African-American race, anemia. Other causes include alcohol abuse, sulfonamides, thiazides, folate and vitamin B12 deficiency, IV cocaine.
  • Idiopathic thrombocytopenic purpura (ITP) a major cause. Production of autoantibodies against certain platelet antigens (PA-IgG). Antibody-coated platelets removed by macrophages in the spleen.
  • Increased risk of bleeding with PLT <10,000-20,000.
  • Heparin-induced thrombocytopenia may be more common in HIV-infected than uninfected

DIAGNOSIS

  • Low PLT count, usually with other blood elements normal.
  • Bone marrow shows increase in megakaryocytes in response to PLT phagocytosis in ITP. Megakaryocytes may be decreased in HIV-TP without ITP. Other hematologic elements may be normal.
  • Bone marrow Bx rarely necessary with isolated thrombocytopenia.

TREATMENT

Antiretroviral therapy

  • HIV-associated thrombocytopenia responds to antiretroviral therapy. Best data with AZT:(600 mg/day;sometimes up to1000 mg/day); however, most ART probably effective 
  • Use most appropriate regimen to suppress VL and improve immune status. Consider AZT if no response to initial regimen.
Specific treatment for ITP

  • Prednisone: 80-90% response rate. Initial dose is 1 mg/kg/day or 60-100 mg/d. Unknown whether long-term use may increase risk of HIV progression or fulminant Kaposi's sarcoma in men co-infected with HHV8.
  • Intravenous immune globulin (IVIG) at 1000 mg/kg x 2 days. Response with significant increase (>100,000) in PLT counts within 24-48 hrs. High cost: reserve for acute bleeding or urgent need for invasive surgical procedure. Acute renal failure secondary to sucrose load reported with some preparations (Sandoglobulin, Panglobulin, Gammar-P.I.V, and Gammar-I.V.b.).
  • IV or IM anti-Rh immunoglobulin (anti-D, winRho) in nonsplenectomized Rh-positive pts produces response. Hemolysis with decrease in hemoglobin of >2 gm/dL, fever, and chills seen in 5-10% of pts.
  • Splenectomy, if refractory to above. Long-term response in approximately 60% of pts. Risk of infection with encapsulated bacteria after splenectomy (S. pneumoniae, H. influenzae). Need for pneumococcal vaccine.
  • Other treatment modalities, such as dapsone, interferon, vincristine, danazol, low-dose splenic irradiation have shown limited success in ITP.
  • For active bleeding, packed RBCs and PLT transfusion plus IVIG. (Prednisone has slower onset of action than IVIG).

Drug Comments

DrugRecommendations/Comments
glucocorticoids Preferred treatment for ITP (after HAART).
intravenous immune globulin Reserve use for acute bleeding or urgent need for surgical procedure.
rho (D) immune globulin If prednisone ineffective, use in non-splenectomized Rh-positive pts.

FOLLOW UP

Relapse

  • Even with effective treatment, relapse can occur in 10-20%. Effective HAART may minimize relapse.
  • Consider maintenance dose of prednisone, IVIG, or anti-Rh immunoglobulin.

REFERENCES

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