Changing patterns of AIDS: impact on the indications and diagnostic yield of bone marrow biopsies

Abstract

After the advent of HAART, the clinical course of HIV infection has dramatically improved. Therefore, it seems appropriate to reevaluate the performance of bone marrow biopsy (BMB) as a diagnostic tool. The aim of the present study was to compare the reasons for performing a BMB and its diagnostic yield in HIV-patients before and after HAART. A total of 165 BMB specimens obtained from HIV-infected patients receiving care at the Hospital of Universidade Federal do Rio de Janeiro in two different periods (1986-1994 and 1999-2004) were analysed. The main reason for BMB examination in the fi rst period was fever (88%), which decreased in the second period (57%, p < 0.0001), when cytopenia (51%) was the leading reason for BMB, whereas in the fi rst period it accounted for only 30% (p = 0.008). A defi nitive diagnosis (infection, granulomas or lymphomas) was obtained in 28% of patients in the fi rst period and in 19% during the second period (p = 0.20). The diagnosis turned out as infections decreased from 16% in period 1 to 2% in period 2 (p = 0.003). Despite the the limitations in the evaluation of fever, the use of BMB must be considered on an individual basis, whenever less invasive alternatives have been exhausted, and should be complemented by a bone marrow aspiration for microbiological studies.

The value of bone marrow examinations performed in the investigation of HIV infected patients with cytopenias

“…The overall diagnostic yield of 32% in this study is comparable to other studies which encompassed all indications for BME in HIV‐infected patients. The diagnostic yields ranged from 19% to 47% in those studies 10–18 . Our diagnostic yield was slightly higher than the range of 14.8% to 30.5% reported where the main or only indication was cytopenia in an HIV‐infected patient 10,11,14–16 .…”

“…Leucopenia of ≤4 x 10 9 /L, absolute neutrophil count of <0,5 x 10 9 /L, haemoglobin of <6 g/dL and previous TB were significantly associated with the establishment of a unique diagnosis 11,12 . Not receiving ART, leucopenia ≤4 x 10 9 /L, haematocrit of <25% and absolute CD4 count of ≤50 cells/μL were significantly associated with a diagnosis of infection 12,13,20 . Identification of further predictive factors may aid in the selection of patients who are likely to benefit from BME.…”

“…Bone marrow (BM) aspirate and trephine biopsy together with adjunctive investigations, herein referred to as BM examination (BME), may be utilised to investigate HIV‐infected patients with unexplained cytopenia 10–18 . International studies show that the diagnostic yield (the percentage of cases in which a diagnosis is made) of BME in HIV‐infected adults ranges from 19 to 47%.…”

“…International studies show that the diagnostic yield (the percentage of cases in which a diagnosis is made) of BME in HIV‐infected adults ranges from 19 to 47%. 10–18 Where the main or only indication for BME was cytopenia in an HIV‐infected person, diagnostic yields of 14.8 to 30.5% were reported 10,11,14–16 …”

“…Morai et al, demonstrated that HIV infected patients receiving ART are less likely to have a diagnosis of BM infection than those not receiving ART (diagnosis of infection of 2% vs 16% respectively; p = 0.003) 13 . In September 2016, all PLHIV in South Africa, regardless of clinical stage of disease and CD4 count, became eligible to receive ART 25 .…”