Diagnosis of human immunodeficiency virus associated disseminated intravascular coagulation

Abstract

Introduction Disseminated intravascular Coagulation (DIC) is a thrombotic microangiopathy which may complicate a number of severe disease processes including sepsis. Development of microvascular thromboses results in consumption of coagulation factors and platelets and ultimate bleeding. Patients with HIV infection (PWH) often present with baseline dysregulation of the coagulation system which may increase severity and derangement of DIC presentation. Previously, we have shown that HIV is a significant risk factor for development of DIC. Methodology We conducted a retrospective record review of all DIC screens submitted to our tertiary coagulation laboratory in Johannesburg, South Africa, over a one year period and compared the laboratory presentation of DIC in PWH with presentation of DIC in patients without HIV infection. Results Over the year, 246 patients fulfilled the International Society of Thrombosis and Haemostasis (ISTH) diagnostic criteria for DIC– 108 were confirmed HIV-infected and 77 were confirmed uninfected. PWH and DIC presented at a significantly earlier age (41 vs 46 years respectively, p<0.02). The prothrombin time was significantly more prolonged (30.1s vs 26.s), the d-dimer levels were substantially higher (5.89mg/L vs 4.52mg/L) and the fibrinogen (3.92g/L vs 1.73g/L) and platelet levels (64.8 vs 114.8x109/l) were significantly lower in PWH. PWH also showed significant synthetic liver dysfunction and higher background inflammation. Conclusion PWH who fulfil the diagnostic criteria for DIC show significantly more dysregulation of the haemostatic system. This may reflect baseline abnormalities including endothelial dysfunction in the context of inflammation and liver dysfunction.

Distinguishing and overlapping laboratory results of thrombotic microangiopathies in HIV infection: Can scoring systems assist?

“…CRP was a distinguishing parameter between the two cohorts with elevated levels in the HIV‐DIC cohort probably related to underlying concomitant infections and this routine parameter therefore could have clinical utility in distinguishing between HIV‐DIC and HIV‐TTP. D‐dimers and fibrinogen form important components of the ISTH DIC score and should be interpreted with caution in HIV infected patients with a TMA 11,32 . The authors caution against favoring a diagnosis of HIV‐DIC instead of HIV‐TTP based on elevated D‐dimer levels when additional features are compatible with HIV‐TTP.…”

“…HIV infection is prevalent in the African context 5 with secondary HIV‐associated TTP and DIC in the background of HIV infection constituting the most prevalent TMAs in this group of patients 2,22 . The diagnostic distinction between these conditions can be ambiguous resulting in inappropriate treatment due to the background activation of the coagulation system and inflammation in HIV infected patients 9,11,40 . The addition of the LDH/upper‐limit‐of‐normal ratio and objective, automated quantification of schistocytes will probably improve the accuracy of the PLASMIC score 28,41 .…”

“…D‐dimers and fibrinogen form important components of the ISTH DIC score and should be interpreted with caution in HIV infected patients with a TMA. 11 , 32 The authors caution against favoring a diagnosis of HIV‐DIC instead of HIV‐TTP based on elevated D‐dimer levels when additional features are compatible with HIV‐TTP.…”

“…Antiretroviral therapy (ART) is often initiated late in these patients who consequently present with advanced HIV infection and high rates of non‐communicable disease, like malignancy and cardiovascular disease, and opportunistic infections as well as associated complications such as TMAs 5‐8 . HIV‐infected patients with laboratory features of a TMA pose a diagnostic dilemma since infection with HIV predisposes to a number of these disease processes particularly secondary TTP (HIV‐TTP) and DIC with background HIV infection (HIV‐DIC) 9‐14 . Distinguishing these conditions is important since treatment differs.…”

“…5 , 6 , 7 , 8 HIV‐infected patients with laboratory features of a TMA pose a diagnostic dilemma since infection with HIV predisposes to a number of these disease processes particularly secondary TTP (HIV‐TTP) and DIC with background HIV infection (HIV‐DIC). 9 , 10 , 11 , 12 , 13 , 14 Distinguishing these conditions is important since treatment differs. DIC is managed by treatment of the underlying pathogenic cause and HIV‐TTP with therapeutic plasma exchange (TPE) or plasma infusion.…”