Anemia

Richard D. Moore, M.D.

Anemia is a topic covered in the Johns Hopkins HIV Guide.

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CLINICAL

Prevalence 1-10% in asymptomatic HIV, 10-25% with CD4-defined AIDS, 30-60% with AIDS-defining illness
Hypoproliferative anemia more common than hemolytic anemia
Earliest Sx affect functional status: easy fatigue, weakness, exertional dyspnea, slowed cognition (Hgb < 10-11)
Later Sx include rapid heart rate, bounding pulse, dyspnea, severe fatigue, confusion, angina, CHF (Hbg < 8-9)
HIV can directly cause suppression of hematopoietic precursor cells in marrow through inflammatory cytokine suppression, inhibition of endogenous erythropoietin response
Hypogonadism (low testosterone level) can cause anemia.
Anemia associated with worse survival in HIV, but unlikely causal. May be impaired erythropoiesis from HIV associated chronic inflammation. Hgb independent factor in prognostic indices for mortality and morbidity.

MORE CLINICAL

Cause	Laboratory
Decreased RBC Production 1. HIV-induced (probably inflammation-associated) 2. Iron-deficiency (blood loss, most commonly GI, or menstrual in pre-menopausal women) 3. Neoplasm infiltrating bone marrow (lymphoma, KS, other) 4. Infection in marrow (MAC, MTB, parvovirus B19, CMV, fungal) 5. Drugs (zidovudine, cancer chemotherapy, interferon-alfa, gancyclovir, pyrimethamine, amphotericin, phenytoin)	Reticulocyte count low Indirect bilirubin normal MCV low in iron-deficiency, anemia of chronic disease MCV high with zidovudine
Ineffective RBC Production 1. Folic acid deficiency 2. Vitamin B12 deficiency	Reticulocyte count low Indirect bilirubin high MCV high
RBC Destruction (Hemolysis) 1. Coomb’s positive hemolytic anemia 2. TTP 3. DIC 4. Drugs: sulfonamides, oxidant drugs such as dapsone, primaquine with G6PD deficiency, ribavirin	Reticulocyte count high Indirect bilirubin high High LDH, low haptoglobin, Peripheral smear may have fragmented RBCs, spherocytes, schistocytes

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CLINICAL

Prevalence 1-10% in asymptomatic HIV, 10-25% with CD4-defined AIDS, 30-60% with AIDS-defining illness
Hypoproliferative anemia more common than hemolytic anemia
Earliest Sx affect functional status: easy fatigue, weakness, exertional dyspnea, slowed cognition (Hgb < 10-11)
Later Sx include rapid heart rate, bounding pulse, dyspnea, severe fatigue, confusion, angina, CHF (Hbg < 8-9)
HIV can directly cause suppression of hematopoietic precursor cells in marrow through inflammatory cytokine suppression, inhibition of endogenous erythropoietin response
Hypogonadism (low testosterone level) can cause anemia.
Anemia associated with worse survival in HIV, but unlikely causal. May be impaired erythropoiesis from HIV associated chronic inflammation. Hgb independent factor in prognostic indices for mortality and morbidity.

MORE CLINICAL

Cause	Laboratory
Decreased RBC Production 1. HIV-induced (probably inflammation-associated) 2. Iron-deficiency (blood loss, most commonly GI, or menstrual in pre-menopausal women) 3. Neoplasm infiltrating bone marrow (lymphoma, KS, other) 4. Infection in marrow (MAC, MTB, parvovirus B19, CMV, fungal) 5. Drugs (zidovudine, cancer chemotherapy, interferon-alfa, gancyclovir, pyrimethamine, amphotericin, phenytoin)	Reticulocyte count low Indirect bilirubin normal MCV low in iron-deficiency, anemia of chronic disease MCV high with zidovudine
Ineffective RBC Production 1. Folic acid deficiency 2. Vitamin B12 deficiency	Reticulocyte count low Indirect bilirubin high MCV high
RBC Destruction (Hemolysis) 1. Coomb’s positive hemolytic anemia 2. TTP 3. DIC 4. Drugs: sulfonamides, oxidant drugs such as dapsone, primaquine with G6PD deficiency, ribavirin	Reticulocyte count high Indirect bilirubin high High LDH, low haptoglobin, Peripheral smear may have fragmented RBCs, spherocytes, schistocytes

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