Bone-marrow diagnosis of opportunistic infections in HIV disease

The Utility of a Bone Marrow Biopsy in Diagnosing the Source of Fever of Unknown Origin in Patients With AIDS

A bone marrow (BM) aspiration and biopsy is often believed to be a needed diagnostic procedure in the work-up of patients with fever of unknown origin (FUO), especially in the setting of AIDS. Is it worthwhile to proceed with this invasive diagnostic method? Clinical information obtained on 104 patients in whom AIDS had been previously diagnosed and who had been admitted with a presumptive diagnosis of FUO was retrospectively analyzed. Seventy-two cases met the inclusion criteria. A BM aspiration and biopsy had a low sensitivity as a diagnostic tool even in patients who had abnormal hematologic parameters. BM biopsy was also not helpful in diagnosing non-Hodgkin lymphoma (NHL) cases in this study. Although the incidence of NHL has risen since the emergence of HIV, the predominant types of lymphoma seen in AIDS patients are intermediate/high-grade lymphomas rather than low grade, and consequently, the incidence of BM involvement is low, decreasing the sensitivity of a BM biopsy as a diagnostic tool. These observations were validated in this study. The majority of BM biopsies in this series revealed diagnostic features of infections. This observation can likely be related to the high prevalence of HIV/AIDS patients in this community and opportunistic infections associated with this disease.

Diagnostic utility of bone marrow sampling in HIV positive patients

OBJECTIVE

To evaluate the diagnostic utility of bone marrow (BM) sampling in HIV positive patients.

DESIGN

Retrospective cohort analysis.

SETTING

Specialist HIV/AIDS service in London.

SUBJECTS

215 consecutive HIV infected patients undergoing 246 BM samplings for investigation of pyrexia without localising signs, haematological abnormalities, or staging/investigation of lymphoma.

MAIN OUTCOME MEASURE

Diagnostic yield from (and impact on management of) BM sampling.

RESULTS

Of 122 BM samples taken to investigate pyrexia, 33 (27%) revealed the cause on microscopy: unexpected lymphoma in seven (6%), mycobacteriosis in 25 (20%), and toxoplasmosis in one (1%). Marrow infiltration was confirmed in 11 of 38 BM samples taken for staging/investigation of lymphoma/leukaemia. In afebrile patients, of 22 with pancytopenia, BM samples showed HIV associated changes in 17 and specific diagnoses in five (mycobacterial infection in three, haemophagocytic syndrome in one, and megaloblastic change due to vitamin B-12 deficiency in one); of 21 with isolated thrombocytopenia, 20 (95%) BM samples showed immune thrombocytopenic purpura to be the cause and the remaining patient had BM changes of aplasia; of 29 with isolated anaemia, 28 had BM changes of HIV associated dysplasia/erythroid dysplasia and one had unsuspected iron deficiency; all 10 with isolated leucopenia/neutropenia had BM changes ascribed to HIV infection exacerbated by concurrent sepsis or medication; of four BM samples taken for other reasons, one showed mycobacterial infection.

CONCLUSIONS

BM sampling has diagnostic utility in HIV infected patients with pyrexia without localising signs, pancytopenia, and staging/investigation of lymphoma; this test has little value in the investigation of afebrile patients with isolated thrombocytopenia, anaemia, or leucopenia as HIV is usually the underlying cause.

Bone marrow aspirates and biopsies in children with human immunodeficiency virus infection

PURPOSE

Hematopoietic abnormalities are common in patients infected with the human immunodeficiency virus (HIV). We evaluated the role of diagnostic bone marrow aspirations and biopsies in HIV-infected children.

METHODS

Seventy-eight bone marrow biopsies and aspirates performed during the last 8 years at the Pediatric Branch of the National Cancer Institute from 60 children with symptomatic HIV infection were reviewed retrospectively. The results were correlated with clinical stage, use of antiretroviral therapy or hematopoietic growth factors, and hematopoietic parameters.

RESULTS

Most patients (84%) showed a normal or hypercellular marrow, associated with diffuse lymphocytosis (50%) or therapy with hematopoietic growth factors (33%). Dyspoietic features were very common in all three cell lineages. Twenty-seven (44%) of the patients had decreased iron stores in the bone marrow that correlated with iron deficiency as documented by serum tests in more than one-third of our study population. Bone marrow cultures were not more helpful than peripheral cultures in establishing the diagnosis of an opportunistic infection.

CONCLUSION

Although bone marrow abnormalities are very common in HIV-infected children, they are rarely specific. The role of diagnostic bone marrow aspirates and biopsies appears to be limited, and this invasive procedure should be reserved for specific situations (e.g., to rule out a malignancy).

Histoplasmosis capsulati and duboisii in Europe: the impact of the HIV pandemic, travel and immigration

The present report describes a fatal case of imported AIDS-related disseminated histoplasmosis capsulati infection associated with multiple coexisting infections, diagnosed with cultural recovery of Histoplasma capsulatum var. capsulatum with a commercial radiometric Mycobacterium medium. The epidemiological and clinical features of histoplasmosis capsulati and duboisii in Europe are reviewed by examining also 69 documented cases of Histoplasma capsulatum var. capsulatum infection (25 in AIDS patients) and 17 cases of Histoplasma capsulatum var. duboisii infection (3 in HIV-infected patients), described since 1980. This draws special attention to the role played during recent years by the emergence of the HIV pandemic and the progressive intensification of travel and immigration as risk factors for this disease in our continent. AIDS patients, who are prone to multiple concurrent opportunistic infections which may share clinical and laboratory features with each other and with other HIV-associated diseases, represent the most relevant current group at risk for severe disseminated histoplasmosis, which may come to medical attention far from their place of origin.

Fever of unknown origin in HIV-infected patients: a critical analysis of a retrospective series of 57 cases

OBJECTIVES

The aim of the study was to assess the incidence and aetiology of fever of unknown origin in human immunodeficiency virus (HIV)-infected patients, and to evaluate the usefulness of the main diagnostic procedures.

DESIGN

A retrospective study.

SETTING AND SUBJECTS

We reviewed the records of 270 HIV-infected patients who were hospitalized for the first time in a department of infectious and tropical diseases during the 27 month study period.

MAIN OUTCOME MEASURES

Fifty-seven patients (21%) had a history of fever of unknown origin.

RESULTS

The aetiology was found in 49 cases (86%). The major cause of the fever was mycobacteriosis: atypical mycobacteria in 10 cases, Mycobacterium tuberculosis in 10, mycobacteria of unspecified type in two, and BCG strain in one. A liver biopsy and a thoracic CT scan greatly contributed to the diagnosis of mycobacterial infection. Seventeen patients were given empiric antimycobacterial therapy as a therapeutic test, of whom seven had a favourable response. The other main causes of fever were cytomegalovirus infection in five patients, leishmaniasis in four, and lymphoma in four.

CONCLUSIONS

Fever of unknown origin is a frequent occurrence in the course of HIV infection, and mycobacterial infection should be considered as a first-line diagnosis in such cases. The place of empiric antimycobacterial therapy in the diagnostic strategy requires further evaluation, but appears to be an alternative to multiple investigative procedures.