The added value of peripheral blood cell morphology in the diagnosis and management of infectious diseases—part 2: illustrative cases

I Potasman; M Prokocimer

doi:10.1136/pgmj.2008.069617

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The added value of peripheral blood cell morphology in the diagnosis and management of infectious diseases—part 2: illustrative cases

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Miron Prokocimer
Published on: 11 March 2009
Less widely recognised mechanisms of functional hyposplenism
oscar,m jolobe
Published on: 10 March 2009

Published on: 11 March 2009
Author Reply.
- Miron Prokocimer, Professor in Hematology MD
16/2/09
To the Editor,
The additional examples detailed above regarding TB-associated DIC and HIV/AIDS-associated splenic hypofunction are indeed noteworthy. The association with AIDS appears to be complex and multi-factorial, attributable not only to the effects of HIV(1) and/or various opportunistic infections on the immunologic function of the spleen (e.g Mycobacterium avium comlex as mentioned,...
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16/2/09
To the Editor,
The additional examples detailed above regarding TB-associated DIC and HIV/AIDS-associated splenic hypofunction are indeed noteworthy. The association with AIDS appears to be complex and multi-factorial, attributable not only to the effects of HIV(1) and/or various opportunistic infections on the immunologic function of the spleen (e.g Mycobacterium avium comlex as mentioned, and Babesiosis (2), but also to several other AIDS-related conditions including accompanying neoplastic diseases (e.g. Kaposi sarcoma, lymphoproliferative diseases), and treatment modalities. In fact, in the study of Grotto and Costa mentioned above (3), one of the three hyposplenic HIV-infected patients, belonging to the CDC Class IVD, had Burkitt's lymphoma infiltrating the spleen. Moreover, high-dose corticosteroid therapy, splenic irradiation, and splenic infarction complicating various overwhelming sepsis/infections (4) may also cause splenic hypofunction (5). As to alcoholic liver disease: the very long list of causes of hyposplenism, (including this entity among many others), was beyond the scope of our articles.
Miron Prokocimer, M.D. Rabin Medical Center, Tel Aviv University, Israel.
Israel Potasman, M.D. Bnai Zion Medical Center, Technion, Israel; israel.potasman@b-zion.org.il
1. Bender BS, Frank MM, Lawley TJ, et al. Defective reticuloendothelial system Fc-receptor function in patients with acquired immunodeficiency syndrome. J Infect Dis 1985; 152:409-12. 2. Ong KR, Stavropoulos C, Inada Y. Babesiosis, asplenia and AIDS. Lancet 1990; 336:112. 3. Grotto HZW, Costa FF. Hyposplenism in AIDS. AIDS 1991; 5:1538- 40. 4. Eshel Y, Sarova-Pinhas I, Lampl Y, et al. Autosplenectomy complicating pneumococcal meningitis in an adult. Arch Intern Med. 1991 May; 151:998-9. (5) William BM, Corazza GR. Hyposplenism: A comprehensive review. Part I: basic concepts and causes. Hematology 2007, 12:1-13.
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Conflict of Interest:
None declared.
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Published on: 10 March 2009
Less widely recognised mechanisms of functional hyposplenism
- oscar,m jolobe, retired geriatrician
In addition to the underlying causes and mechanisms of functional hyposplenism mentioned by the authors, namely, overwhelming phagocytosis attributable to severe haemolysis, or presence of a largely non-functional spleen(1), hyposplenism can also be a clue to the presence of disorders such as HIV/AIDS where it may be attributable either to the virus itself(2) or to opportunistic infection(3), and chronic alcoholic liver...
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In addition to the underlying causes and mechanisms of functional hyposplenism mentioned by the authors, namely, overwhelming phagocytosis attributable to severe haemolysis, or presence of a largely non-functional spleen(1), hyposplenism can also be a clue to the presence of disorders such as HIV/AIDS where it may be attributable either to the virus itself(2) or to opportunistic infection(3), and chronic alcoholic liver disease(4)(5) where it may, arguably, be attributable to alcohol-related toxicity(4). In one study splenic function was evaluated using the pitted erythrocyte count in the peripheral blood in 25 HIV-antibody positive patients, 16 of whom belonged to Group IVC and 3 of whom(including one with a palpable spleen) belonged to Group IVD of the Centre for Disease Control classification. Thirty seven percent of the CDC Group IVC patients, and one hundred percent of the CDC group IVD subjects were documented as having > 2% pitted erythrocytes in the peripheral blood smear, and these findings were compatrable to those documented in all 26 of the splenectomised non HIV/AIDS subjects also evaluated in that study(2). In a subsequent case report, Howell-Jolly bodies were identified in the presplenectomy peripheral blood smear of an HIV/AIDS patient who subsequently underwent splenectomy for severe thrombocytopenia. Following splenectomy, microscopic examination of the spleen demonstrated multiple granulomas with numerous acid fast organisms belonging to the mycobacterium avium complex, replacing normal splenic tissue. It was, arguably, the latter process which gave rise to splenic hypofunction(3). Pitted erythrocyte counts comparable to those in splenectomised patients(4), and Howell-Jolly bodies have also been identified in patients with alcoholic liver disease(4)(5), where it has been postulated that alcholic toxicity is the underlyng cause(4). Accordingly, identification of hyposplenism can lead to diagnosis of HIV/AIDS and related opportunistic infection, and it can also lead to a diagnosis of chronic alcoholism, thereby generating an opportunity to initiate lifestyle advice. References (1) Prokocimer M., Potasman I The added value of peripheral blood cell morphology in the diagnosis and management of infectious diseases-Part 2:illustrative cases Postgraduate Medical Journal 2008;84:586-9 (2) Grotto HZW., Costa FF Hyposplenism in AIDS AIDS 1991;5:1538-40 (3) Khan AM., Harrington RD., Nadel M., Greenberg BR Hyposplenism fro myocobacterium avium complex infection in a patient with AIDS and Immune Thrombocytopenia Acta Haematologica 1998;99:45-48 (4)Muller AF., Toghill PJ Functional hyposplenism in alcoholic liver disease; A toxic effect of alcohol/ Gut 1994;35:679-82 (5) Satapathy S., Nrayan S., Varma N et al Hyposplenism in alcoholic cirrhosis, facts or artifacts? A comparative analysis with nonm-alcoholic cirrhosis and extrahepatic portal venous obstruction Journal of Gastroeneterology and Hepatology 2001;16:1038-43
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Conflict of Interest:
None declared.
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