Correspondence

Effect of Highly Active Antiretroviral Therapy on Thrombocytopenia in Patients with HIV Infection

N Engl J Med 1999; 341:1239-1240October 14, 1999

Article

To the Editor:

Thrombocytopenia is a common hematologic disorder in persons infected with the human immunodeficiency virus (HIV).1 Although often asymptomatic, the thrombocytopenia in these patients may be associated with a variety of bleeding abnormalities. Corticosteroids, intravenous immune globulin, and interferon can improve HIV-associated thrombocytopenia, although the responses are not sustained after the cessation of treatment.1 Several studies have shown increases in platelet counts in HIV-infected patients with thrombocytopenia who were treated with zidovudine,1,2 but these responses were not sustained. Maness et al. reported a similar effect of indinavir,3 but their report did not include data on the viral load.

During the past two years, we have treated 37 HIV-infected patients who had thrombocytopenia (platelet count, <100,000 per cubic millimeter) with highly active antiretroviral therapy (24 were men). The average age was 31 years (range, 20 to 41). Coinfection with hepatitis C virus was present in 96.4 percent of the patients, and coinfection with hepatitis B virus was present in 8.1 percent (positive tests for hepatitis B surface antigen). Two patients had ultrasonographic evidence of portal hypertension; no patient had a concomitant infection or neoplasm that could have contributed to the thrombocytopenia. The protease inhibitor included in the regimen of highly active antiretroviral therapy was indinavir in 22 patients (59.5 percent), saquinavir in 10 (27.0 percent), and ritonavir in 5 (13.5 percent). Fourteen patients received zidovudine as part of their treatment.

The CD4 count, viral load, and platelet count at base line and after three and six months of highly active antiretroviral therapy are shown in Table 1Table 1Platelet Count, Viral Load, and CD4 Count in 37 HIV-Infected Patients with Thrombocytopenia Who Were Treated with Highly Active Antiretroviral Therapy.. The table also shows the results in patients with a platelet count of 50,000 per cubic millimeter or less and in the patients treated with zidovudine and those treated without it. After three months of highly active antiretroviral therapy, there were significant increases in the platelet count, which were independent of the use of zidovudine and of the base-line platelet count. These increases were sustained for at least six months. In 26 patients (70 percent), the viral load decreased to undetectable levels (<200 copies per milliliter, as determined by reverse-transcriptase–polymerase-chain-reaction assay). Linear regression analysis showed no association between the increase in the platelet count and the number of CD4 T cells (r=0.0049, P=0.97).

Our data indicate that highly active antiretroviral therapy results in a sustained increase in the platelet count in HIV-infected patients with thrombocytopenia and that this increase is independent of the increase in CD4 T cells.

José Alberto Arranz Caso, M.D., Ph.D.
Cristina Sanchez Mingo, M.D.
Jaime Garcia Tena, M.D.
Hospital Universitario Príncipe de Asturias, 28800 Madrid, Spain

3 References

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   Glatt AE, Anand A. Thrombocytopenia in patients infected with human immunodeficiency virus: treatment update. Clin Infect Dis 1995;21:415-423
   CrossRef | Web of Science | Medline

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   Ballem PJ, Belzberg A, Devine DV, et al. Kinetic studies of the mechanism of thrombocytopenia in patients with human immunodeficiency virus infection. N Engl J Med 1992;327:1779-1784
   Full Text | Web of Science | Medline

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   Maness LJ, Blair DC, Newman N, Coyle TE. Elevation of platelet counts associated with indinavir treatment in human immunodeficiency virus-infected patients. Clin Infect Dis 1998;26:207-208
   CrossRef | Web of Science | Medline

Citing Articles (16)

Citing Articles

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   Vani Vannappagari, Ella T. Nkhoma, Julius Atashili, Samantha ST. Laurent, Henry Zhao. (2011) Prevalence, severity, and duration of thrombocytopenia among HIV patients in the era of highly active antiretroviral therapy. Platelets 22:8, 611-618
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2. 2

   Francielle Garcia Nascimento, Paula Yurie Tanaka. (2011) Thrombocytopenia in HIV-Infected Patients. Indian Journal of Hematology and Blood Transfusion
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3. 3

   C. Neunert, W. Lim, M. Crowther, A. Cohen, L. Solberg, M. A. Crowther. (2011) The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 117:16, 4190-4207
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   Marie-Anne Bouldouyre, Isabelle Charreau, Bruno Marchou, Philippe Tangre, Christine Katlama, Philippe Morlat, Vincent Meiffredy, Daniel Vittecoq, Philippe Bierling, Jean-Pierre Aboulker, Jean-Michel Molina. (2009) Incidence and Risk Factors of Thrombocytopenia in Patients Receiving Intermittent Antiretroviral Therapy: A Substudy of the ANRS 106-Window Trial. JAIDS Journal of Acquired Immune Deficiency Syndromes 52:5, 531-537
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   L Aurpibul, T Puthanakit, T Sirisanthana, V Sirisanthana. (2008) Haematological changes after switching from stavudine to zidovudine in HIV-infected children receiving highly active antiretroviral therapy. HIV Medicine 9:5, 317-321
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   Andromachi Scaradavou, Susanna Cunningham-Rundles, John L. Ho, Claudia Folman, Howard Doo, James B. Bussel. (2007) Superior effect of intravenous anti-D compared with IV gammaglobulin in the treatment of HIV-thrombocytopenia: Results of a small, randomized prospective comparison. American Journal of Hematology 82:5, 335-341
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   Davide Gibellini, Francesca Vitone, Marina Buzzi, Pasqua Schiavone, Elisa De Crignis, Ronny Cicola, Roberto Conte, Cristina Ponti, Maria Carla Re. (2007) HIV-1 negatively affects the survival/maturation of cord blood CD34+ hematopoietic progenitor cells differentiated towards megakaryocytic lineage by HIV-1 gp120/CD4 membrane interaction. Journal of Cellular Physiology 210:2, 315-324
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   Jaime R. Torres, Maria A. Torres-Viera, Jorg Schupbach, Hector R. Rangel, Flor H. Pujol. (2007) Non-immune thrombocytopenia responsive to antiretroviral therapy and HIV-2 infection. Journal of Infection 54:1, e21-e24
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   Nikolaos Kosmas, Athanasios Kontos, George Panayiotakopoulos, Antonios Dimitrakopoulos, Theodore Kordossis. (2006) Decreased prevalence of mixed cryoglobulinemia in the HAART era among HIV-positive, HCV-negative patients. Journal of Medical Virology 78:10, 1257-1261
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    Joseph Inungu, Eileen Malone Beach, Reid Skeel. (2003) Challenges Facing Health Professionals Caring for HIV-Infected Drug Users. AIDS Patient Care and STDs 17:7, 333-343
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    Mauro Moroni, Spinello Antinori. (2003) HIV and direct damage of organs. AIDS 17, S51-S64
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    A. Scaradavou. (2002) HIV-related thrombocytopenia. Blood Reviews 16:1, 73-76
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    Jean Servais, Dieudonné Nkoghe, Jean-Claude Schmit, Vic Arendt, Isabelle Robert, Thérèse Staub, Michel Moutschen, François Schneider, Robert Hemmer. (2001) HIV-Associated Hematologic Disorders Are Correlated With Plasma Viral Load and Improve Under Highly Active Antiretroviral Therapy. JAIDS Journal of Acquired Immune Deficiency Syndromes 28:3, 221-225
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    Winston Nara, Ida Ashley, Fred Rosner. (2001) Thrombotic Thrombocytopenic Purpura Associated with Clopidogrel Administration: Case Report and Brief Review. The American Journal of the Medical Sciences 322:3, 170-172
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    David M. Aboulafia, Denise Bundow, Sarah Waide, Charles Bennet, David Kerr. (2000) Initial Observations on the Efficacy of Highly Active Antiretroviral Therapy in the Treatment of HIV-Associated Autoimmune Thrombocytopenia. The American Journal of the Medical Sciences 320:2, 117-123
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    Richard H. Evans, David T. Scadden. (2000) Haematological aspects of HIV infection. Best Practice & Research Clinical Haematology 13:2, 215-230
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