Manifestations of Bone Marrow Abnormalities of HIV/AIDS Patients

Background: Human immunodeficiency virus can involve almost any organ system. Anemia is the most common hematological manifestation in HIV/AIDS patients. Bone marrow changes include varying degrees of dysplasia in one or more cell lines, plasmacytosis, opportunistic infections and hematological malignancies. There are only a few studies where hematological manifestations of HIV/AIDS patients had been described. Materials and Methods: 100 HIV positive patients, aged between 12-65 years were enrolled in this hospital-based cross-sectional study. The study was conducted from March 2016 to March 2018. A complete blood count, CD4 counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and Non-AIDS, according to NACO criteria. Written informed consent was taken from patients and bone marrow aspiration was done. Results: Total number of patients included in the study was 100. We were able to do a CD4 count of 91 patients. As per criteria, out of 91 patients, 37 cases had AIDS. The most common hematological abnormality was anemia, seen in 95.45%of patients. Bone marrow was normocellular in 86.48% of AIDS and 85.18% of non-AIDS, hypocellular in 8.10% of AIDS and 9.25%o f non- AIDS, hypercellular in 5.40% of AIDS and 5.55% of non-AIDS patients. Dysplasia was statistically and significantly associated with anemia. The commonest dysplastic features are seen in the granulocytic and erythroid series. L.D. bodies were seen in 2 cases and Histoplasma was found in one case. Conclusion: Normocytic normochromic anemia was the most common peripheral smear finding. Hypocellular bone marrow was more common than hypercellular marrow in an advanced stage of the disease. Dysplastic changes were more common in AIDS than Non-AIDS. Granulocytic dysplasia was the most common type of dysplasia. There was evidence of opportunistic infections and gelatinous transformation were detected in our study.


Introduction
Human immunodeficiency virus infection has emerged as a major health problem worldwide. Here, in our study, we aimed to identify the bone marrow abnormalities in patients with HIV disease, who admitted to Government medical colleges and hospitals and attending ART clinics. Both patients on ART and Non ART were included in the present study.

Materials and Methods
The setting of the study: The study was conducted at the Department of Medicine and

Result
We had included 100 patients detected as HIV positive by ELISA method, reporting to ICTC clinic and admitted in medicine ward of our institution. patients. There was a male preponderance with a male to female ratio of 6.69:1.

Pie Chart 1: Occupation of patients.
The commonest population affected was that of drivers (43%) and labourers (25%) [Pie Chart 1] Almost, the same percentage of patients belonging to the Non-AIDS group were suffering from anemia.   8.79 % in both the groups. This hypocellularity of bone marrow was due to serous fatty degeneration.

LD-Bodies in Bone Marrow Aspiration smears.
Gelatinous transformation of marrow could be noted in 2 cases in the ART group whereas seropositivity of HBsAg and anti-HCV could be identified in two and one patient on ART, respectively.
No underlying leukemia or lymphoma was detected in our study.   [18].In our study thrombocytopenia on marrow showed increased megakaryocytes number secondary to increase peripheral destruction of the platelet. It is mainly due to auto-immune mediated destruction of platelet in peripheral blood. Dysplasia of any type in 8(62%) out of 13 group -A, 9(43%)out of 21in group B, erythroid 7 (54%) in group A, 9((43%)in group B, myeloid dysplasia 5(38%) in group A and 5(24%)in group B [11].

Comparison of changes of Bone-
Various dyspoietic features seen in the erythroid series in our study were megaloblastoid change, bi/multinucleation, cytoplasmic vacuolation, nuclear budding, micronormoblast and ringed sideroblasts. Megaloblastoid changes seen in HIV related myelodysplasia is unrelated to serum cobalamin and folate levels, or drug therapy with zidovudine orfolate antagonists, although these drugs may accelerate it [1]. Dysplastic changes involving myeloid series, seen in our study include nuclear dysmorphism, giant metamyelocytes, cytoplasmic vacuolation,hypogranulation and pseudo-pelgerhuet anomaly. Direct infection of marrow precursors by HIV may contribute to these defects, although this issue remains controversial.

Comparison of opportunistic infections and
other changes of bone marrow in our study with other studies: Commonest infection was found to be pulmonary tuberculosis; among them 4 patients also on HAART (Nevirapine, zidovudine) therapy. 2 cases were having seropositivity of HBsAg and 1 case having anti-HCV. These cases were on ART therapy.Plasma cells were often strikingly increased in the marrow of HIV infected patients seen in 31-85% of patients [14]. Our patient population had plasmacytosis in 12.08 % of patients (4 cases of ART-group and 7 cases of the non-ART group). It might represent a physiological response to antigenic stimulation by viruses or other infective agents or may be secondary to dysregulated B-cell proliferation due to HIV [15]. Another interesting aspect of our study was to identify histoplasma (one case) and L-D bodies (2 cases, one case each from ART and non-ART group) in the bone marrow.Bone marrow aspirate stained by Giemsa showed oval globose yeast-like cells measuring 3-4 mm × 2-3 mm in size, suggestive of