Utility of Bone Marrow Examination for Workup of Fever of Unknown Origin in HIV Patients
Andres Quesada, Ashok Tholpady, Audrey Wanger, Lei Chen. University of Texas Health Science Center at Houston, Houston, TX
Background: Bone marrow biopsy (BMB) is a diagnostic tool commonly used in the workup of fever of unknown origin (FUO) in patients with HIV/AIDS. Its utility remains a subject of debate. Though HAART has reduced incidence of opportunistic infections, it is important to reassess the efficacy of BMB for the rapid diagnosis of mycobacterial or fungal infections. There are currently no studies performed in a high HIV incidence area in Texas. Our county reported the highest incidence in the state with 1,234 (30.1 cases /100,000 population) in 2010.
Design: We reviewed all BMBs performed from 2007 through September 2011 in our hospital. All cases with HIV/AIDS and FUO, persistent cytopenia(s), or those performed to rule out infection were retrieved. BMBs for staging of co-existing malignancy or those deemed suboptimal were excluded. Demographic data, CBC, blood cultures, CD4 counts and HIV viral loads were reviewed. Bone marrow was examined with Wright stain on aspirate smears, H&E stain, and special stains (GMS/AFB) on core biopsy. Concurrent bone marrow aspirate was sent for cultures.
Results: 72 HIV/AIDS patients were found of which 13 cases were excluded. A total of 59 cases were evaluated. There were 36 males and 23 females with a mean age of 38.8 (range=21-59). The mean CD4 count was 89.9 (range = 1-862; 39 patients <100 and 10 <200). Eight patients had HIV viral loads <400 copies/mL, 36 patients had viral loads ranging from 400-750,000 and 14 had >750,000.
Of the 59 cases, BMB revealed 25 in which infection was presumed by AFB/GMS stains (10, 16.9%), presence of granuloma and/or lymphohistiocytic aggregates (20, 33.9%), culture (12, 20.3%), or a combination. Cultures demonstrated Mycobacterium avium (4), tuberculosis (2), gordonae (1); Histoplasma capsulatum (3); and Cryptococcus neoformans (2). In 3 cases the direct examination was negative, however, a pathogen was grown in marrow culture.
Conclusions: This study supports the use of diagnostic BMBs as a rapid decision making tool in HIV patients with FUO when used in the proper clinical setting. This includes endemic areas with a high incidence and prevalence of the virus. The majority of our patients had high viral loads and low CD4 counts rendering them susceptible to opportunistic infections. BMB revealed evidence of infection prior to positive bone marrow culture in 75%. Special stains and blood cultures had similar diagnostic yield, but with BMB offering faster results. This assists in clinical decision making and refining treatment.
Wednesday, March 21, 2012 1:00 PM
Poster Session VI # 244, Wednesday Afternoon