A 26-year-old woman comes to the clinic for routine HIV care. She mentions that she had "low platelets" when she was tested 2 months ago in an emergency department following a minor motor vehicle collision. The patient has no mucosal bleeding and does not bruise easily. Her menses have been normal. Two years ago, she was diagnosed with HIV after attempting to donate blood. The patient has not begun antiretroviral therapy, and she takes a multivitamin daily. Her temperature is 36.9 C (98.4 F), blood pressure is 116/78 mm Hg, pulse is 70/min, and respirations are 14/min. On examination, the patient's nasal and oropharyngeal mucosae appear normal. Her abdomen is nontender and nondistended, but the tip of the spleen is palpable on inspiration. There are no purpura or petechiae. Laboratory results are as follows:
Which of the following treatments is the best next step in management?

Question

A 26-year-old woman comes to the clinic for routine HIV care.  She mentions that she had "low platelets" when she was tested 2 months ago in an emergency department following a minor motor vehicle collision.  The patient has no mucosal bleeding and does not bruise easily.  Her menses have been normal.  Two years ago, she was diagnosed with HIV after attempting to donate blood.  The patient has not begun antiretroviral therapy, and she takes a multivitamin daily.  Her temperature is 36.9 C (98.4 F), blood pressure is 116/78 mm Hg, pulse is 70/min, and respirations are 14/min.  On examination, the patient's nasal and oropharyngeal mucosae appear normal.  Her abdomen is nontender and nondistended, but the tip of the spleen is palpable on inspiration.  There are no purpura or petechiae.  Laboratory results are as follows:  
Which of the following treatments is the best next step in management?

Quizplus · Accepted Answer

Explanation: HIV can be associated with deficiencies in all hematologic cell lines. This patient, who has HIV with a normal CD4 cell count off antiretroviral therapy (ART), has asymptomatic thrombocytopenia and splenomegaly with no obvious secondary causes of thrombocytopenia (eg, medications). This is consistent with HIV-associated thrombocytopenia (HIV-TP), which can appear at any time and is thought to be due to immune dysfunction or viral destruction of megakaryocytes. HIV-TP is rarely associated with bleeding (<5% of patients have platelet counts <50,000/mm³). ART generally improves the thrombocytopenia and should be considered in this patient. (Choices B, C, and D) In the setting of active bleeding from HIV-TP, corticosteroids or intravenous immunoglobulin may be used as adjunct therapy, but the effects are transient. Additionally, corticosteroid use can increase the risk of opportunistic infections. Splenectomy may be considered in patients with persistent HIV-TP that is refractory to other therapies; however, the risk of sepsis increases significantly with asplenia. (Choice E) Thrombopoietin levels are generally elevated in HIV-TP due to the infection and destruction of megakaryocytes. Studies have not demonstrated any benefit to administering thrombopoietin. Educational objective: HIV-associated thrombocytopenia can occur at any stage of the disease. The mainstay of therapy is antiretroviral therapy. References: Clinical features, treatment, and outcome of HIV- associated immune thrombocytopenia in the HAART era. (http://www.ncbi.nlm.nih.gov/pubmed/22693513) HIV-related thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/11914001)

A 26-Year-Old Woman Comes to the Clinic for Routine HIV