HIV-positive patients presenting with peripheral blood cytopenias: is bone marrow assessment a priority?

ABSTRACT Introduction: Hematologic abnormalities are frequent among persons living with HIV (PLWH). The bone marrow aspirate (BMA) and biopsy (BMB) are commonly performed in the diagnostic approach of patients with unexplained cytopenias. Changes in antiretrovirals, supportive therapy and increased life expectancy have modified the distribution and etiology of cytopenias, questioning their use. Our aim was to analyze the diagnostic yield of BMA, BMB and marrow cultures for the evaluation of cytopenias in PLWH. Methods: This was a retrospective cohort of ≥ 18-year-old PLWH undergoing bone marrow assessment (MA) for the evaluation of cytopenias between January 2002 and December 2015. Results: A total of 236 cytopenic events were analyzed, 47.9% being PLWH who had a longstanding diagnosis (≥ 1 year). Adherence to antiretrovirals was 63.5%. Anemia was seen in 91.9% and pancytopenia in 39%. Common presentations included fever (52.1%), weight loss (42.8%) and adenopathies (28.8%). Median days from detection to MA was 5 (0 - 63 days). Most common etiologies were non-HIV infectious diseases (31.4%) and benign/malignant hematologic diseases (26.3%). The diagnostic yield was 16.1% for BMA, 20.3% for BMB, 30.5% for both and 35.6% when cultures were added. Patients most likely to have conclusive MA were those with moderate/severe thrombocytopenia (p = 0.007). Fever, splenomegaly, and low CD4+ counts were associated with infectious etiologies, while hematologic diagnoses were related to the presence of adenopathies. Conclusion: As a minimally invasive intervention, the MA has a high yield for identifying the etiology of cytopenic events in PLWH, being conclusive in one in three patients. Early performance could lead to prompt diagnosis and timely therapy initiation.

Clinical and epidemiological characteristics of patients diagnosed with covid-19 in a tertiary care center in Mexico City: a prospective cohort study

ABSTRACT Background: Regional information regarding the characteristics of patients with coronavirus disease (COVID)-19 is needed for a better understanding of the pandemic. Objective: The objective of the study to describe the clinical features of COVID-19 patients diagnosed in a tertiary-care center in Mexico City and to assess differences according to the treatment setting (ambulatory vs. hospital) and to the need of intensive care (IC). Methods: We conducted a prospective cohort, including consecutive patients with COVID-19 from February 26, 2020 to April 11, 2020. Results: We identified 309 patients (140 inpatients and 169 outpatients). The median age was 43 years (interquartile range, 33-54), 59.2% men, and 18.6% healthcare workers (12.3% from our center). The median body mass index (BMI) was 29.00 kg/m2 and 39.6% had obesity. Compared to outpatients, inpatients were older, had comorbidities, cough, and dyspnea more frequently. Twenty-nine (20.7%) inpatients required treatment in the IC unit (ICU). History of diabetes (type 1 or 2) and abdominal pain were more common in ICU patients compared to non-ICU patients. ICU patients had higher BMIs, higher respiratory rates, and lower room-air capillary oxygen saturations. ICU patients showed a more severe inflammatory response as assessed by white blood cell count, neutrophil and platelet count, C-reactive protein, ferritin, procalcitonin, and albumin levels. By the end of the study period, 65 inpatients had been discharged because of improvement, 70 continued hospitalized, and five had died. Conclusions: Patients with comorbidities, either middle-age obese or elderly complaining of fever, cough, or dyspnea, were more likely to be admitted. At admission, patients with diabetes, high BMI, and clinical or laboratory findings consistent with a severe inflammatory state were more likely to require IC.

Factores psicosociales asociados con el inicio tardío de tratamiento antirretroviral en pacientes mexicanos con VIH / Psychosocial factors associated with late HAART initiation in Mexican patients with HIV

Objetivo. Explorar la asociación entre variables psicosociales y el inicio tardío de tratamiento antirretroviral en una muestra de pacientes mexicanos con diagnóstico de VIH. Material y métodos. Estudio transversal en la clínica de VIH del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, donde se aplicaron cuestionarios estructurados a 150 pacientes que iniciaron terapia antirretroviral altamente activa (TARAA) entre enero de 2010 y agosto de 2011. Se consideró inicio tardío (IT) de TARAA cuando los pacientes iniciaron el tratamiento con CD4 <200 células/mm³. Resultados. Mediante el análisis multivariado, se encontró que el principal factor psicosocial asociado con IT fue la percepción de autoestigma relacionada con el VIH/sida. Además, la realización de la prueba del VIH se asoció con la indicación médica y no con la iniciativa del paciente; a su vez, tener uno o más contactos médicos previos se relacionó con un mayor riesgo de presentar IT. Conclusiones. Los resultados sugieren la necesidad de intervenciones psicosociales dirigidas a disminuir la autoimagen negativa y actitudes y comportamientos estigmatizantes en grupos de riesgo.

Objective. To explore the association between psychosocial factors and late highly active antiretroviral therapy (HAART) initiation in a sample of Mexican patients with HIV. Materials and methods. We conducted a cross-sectional study at the HIV Clinic of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), and applied structured questionnaires to 150 patients who initiated HAART between January 2010 and August 2011. Late HAART initiation (LHI) was considered when patients started HAART with CD4 counts of <200+ cells/mm³. Results. By multivariate analysis, the strongest psychosocial risk factor for LHI observed was self-stigma towards HIV/AIDS. In addition, being tested by medical prescription, not by own initiative, as well as having one or more previous medical contacts, were associated with greater risk for LH. Conclusions. Our findings suggest the need to develop psychosocial interventions to decrease negative self-image and stigmatizing attitudes and behaviors in risk groups for HIV in Mexico.

Tuberculosis activa en una cohorte de reclusos infectados por VIH en una cárcel de la Ciudad de México: características clínicas y epidemiológicas / Active tuberculosis in a cohort of HIV-infected inmates in a prison in Mexico City: clinical and epidemiological characteristics

OBJETIVO: Determinar las características clínicas y epidemiológicas de los casos con tuberculosis (TB) activa en población de cárceles con VIH, que se ve especialmente afectada por ambas epidemias. La infección por VIH incrementa significativamente la probabilidad del desarrollo de TB. MATERIAL Y MÉTODOS: Se realizó un estudio de cohorte en sujetos infectados por VIH e internados en un reclusorio de la Ciudad de México. RESULTADOS: Se encontraron 172 pacientes con VIH, 28 con TB activa (16.3%) - 21 (12.2%) con afección pulmonar - con una tasa de incidencia de 7.7 por 100 sujetos/año para TB activa y de 4.7 por 100 sujetos/ año para TB pulmonar. No se encontró drogorresistencia. Dieciocho aislados fueron tipificados por RFLP, con una tasa de transmisión calculada de 11%. CONCLUSIÓN: Se encontró una prevalencia de TB en esta población mil veces superior a la observada en la población general y datos sugerentes de transmisión al interior de la cárcel.

OBJECTIVE: To determine the clinical and epidemiological characteristics of prison inmates with active tuberculosis in HIV-positive prison populations. MATERIALS AND METHODS: We conducted a cohort study in HIV-infected subjects in a prison in Mexico City, with the aim of determining clinical and epidemiological characteristics of cases with active TB. RESULTS: We detected 172 HIV infected inmates and TB in 28 of them (16.3%) - 21 (12.2) with pulmonary TB - with an incidence rate of 7.7/100 persons/year for active TB and 4.7/100 persons/year for pulmonary TB. No drug resistance was found. Two clusters (4 and 2 subjects) were observed after RFLP-typing of 18 isolates, with a transmission rate of 11% by molecular and clinical analysis. CONCLUSIONS: The prevalence of active TB was found to be a thousand times greater than in the general population. Evidence of transmission inside the prison was also found.

High prevalence of late diagnosis of HIV in Mexico during the HAART era

OBJECTIVE: To evaluate the prevalence of late HIV diagnosis (CD4<200 cell/mm³) in an HIV clinic in Mexico City between 2001-2008, to assess changes in this prevalence across the study period, and to determine the risk factors associated to late testing (LT). MATERIALS AND METHODS: Cross-sectional analysis including all patients recently diagnosed as HIV. We estimated the proportion of LT patients and compared demographic characteristics between those and all other. We determine the risk factors associated to LT using logistic regression methods. RESULTS: Sixty one percent of LT patients present when are diagnosed for the first time. The prevalence did not decrease between 2001 and 2008 (p=0.37). Older age (OR: 2.4; 95%CI 1.2-4.7), unemployment (OR: 1.75; 95%CI 1.12-2.75) and less than nine years of education (OR: 2.44; 95%CI 1.37-4.33) were independently associated to LT, in a multivariate analysis. CONCLUSION: LT has high prevalence in Mexico, this impact on antiretroviral effectiveness and perhaps on HIV transmission. Policies for HIV-prevention in Mexico need to be modified to reduce LT prevalence including more aggressive strategies of testing.

OBJETIVO: Estimar la prevalencia de diagnóstico tardío (DT) (CD4<200 cel/mm³) de VIH en una clínica en la Ciudad de México entre 2001 y 2008, evaluar cambios en la prevalencia en este periodo y determinar factores de riesgo asociados con el DT. MATERIAL Y MÉTODOS: Mediante un estudio de cohorte transversal de pacientes de VIH se estimó la proporción de pacientes con DT y se compararon sus características demográficas con pacientes sin DT. Se evaluaron los factores de riesgo asociados a DT usando regresión logística. RESULTADOS: Se encontró una prevalencia de DT de 61%, sin cambios entre 2001-2008 (p=0.37). Mayor edad (RM: 2.4; 95%IC 1.2- 4.7), desempleo (RM: 1.75; 95%IC 1.12-2.75) y menos de nueve años de educación (RM: 2.44; 95%IC 1.37-4.33) fueron independientemente asociados a DT. CONCLUSIONES: El DT tiene alta prevalencia en México. Esto impacta en la efectividad de tratamiento antirretroviral y posiblemente en la transmisión del VIH. Deben dirigirse políticas de prevención a reducir el DT mediante estrategias agresivas de diagnóstico.