A 46 y.o. woman complained of nausea and vomiting, she was treated symptomatically and had a WBC of 4.6 and Hgb of 10.8

She was sent home and called back because her ANC was 1000. Her peripheral smear was viewed in the ED.

What do you see?

hint : the patient has only lymphocytes in the peripheral smear not neutrophils

Our patient was found to be positive for HIV with bone marrow suppression from the virus. The peripheral smear contained mature lymphocyctes with very few PMNs.

  HIV  can cause neutropenia from disease related malignancies,infections , or drug therapy.  Infections, most commonly Mycobacterium avium complex, Mycobacterium tuberculosis or  cytomegalovirus can infiltrate the bone marrow and cause neutropenia.  Vit B12 and folate deficiency can also cause neutropenia in malnourished patients.  While neutropenia in HIV is usually associated with diffuse infection like tuberculosis, it can also occur just because of the virus which has a toxic effect on the bone marrow itself.

Tuberculosis in HIV patients varies according to the CD4 count.  Those with CD4 counts below 50 present with middle and lower lobe disease rather than classic upper lobe disease. 

lower lobe tbc in hiv

Other causes of neutropenia are listed below.

Our patient was not found to have any infiltration of the bone marrow or malignancy.  She was found to have helicobacter pylori as the source of her nausea, and a trichomonas vaginal infection. She was treated for HIV with Biktarvy and received treatment for Helicobacter.  Her symptoms improved and she was discharged.  Although neutropenia is commonly seen in late stage HIV, a small number of patients can present with neutropenia in the intial period of HIV as in our patient.

Shirasaka T. Diagnosis and treatment of tuberculosis of Mycobacterium avium-intracellulare complex infection in HIV-infected patients. Kekkaku 2007 Nov;82(11):845-8

Garcia M.  Neutropenia in HIV infection. 1997 An Med Interna. Apr:14(4):199-208.

Jaresko G. Etiology of neutropenia in HIV-infected patients American Journal of Health-System Pharmacy, Vol 56Issue suppl_5, Dec 1999, Pages S5-S8.

Shi X, Sims M, Hanna M, et al. Neutropenia during HIV Infection: Adverse consequences and remedies. 2014 Int Rev Immunol. Nov-Dec : 33(6):511-536.

Schneider D, Picker L. Myelodysplasia in the acquired immune deficiency syndrome. Am J Clin Pathol. 1985;84:144-52.