Significant Decrease in Hemoglobin and Hematocrit Levels in a Virologically Controlled HIV-Infected Patient

Rajiv M. Naval-Srinivas, MD, L. W. Preston Church, MD


AIDS Read. 2003;13(4) 

In This Article

Case Summary

A 45-year-old African American man, who received a diagnosis of HIV infection in 1995, presented with a CD4+ cell count of 5/µL and an HIV viral load of 150,000 copies/mL. Based on the results of genotype testing, his antiretroviral therapy was changed to a 4-drug regimen of abacavir, stavudine, ritonavir, and saquinavir. Trimethoprim-sulfamethoxazole was given for Pneumocystis carinii pneumonia prophylaxis and azithromycin for Mycobacterium avium complex infection prophylaxis. After 8 weeks, virologic control was achieved, with a 1-log decrease in viral load.

Despite feeling well, the patient was noted to have a significant decrease in hemoglobin and hematocrit levels over the next 12 weeks. Results of the physical examination were normal, and the stool was negative for occult blood. Initial laboratory studies revealed the following values: hematocrit, 19% (baseline, 35%); hemoglobin, 6.5 g/dL (baseline, 14 g/dL); platelet count, 275,000/µL (normal, 130,000 to 400,000/µL); mean corpuscular volume, 99 µm3 (normal, 76 to 100 µm3); and leukocyte count, 3000/µL (normal, 3200 to 9800/µL). A workup for anemia revealed a reticulocyte count of 0.36% (normal, 0.5% to 2.8%); reticulocyte index, 0.06 (normal, 1 to 3); ferritin level, 1350 ng/mL (normal, 30 to 400 ng/mL); iron level, 190 mg/µL (normal, 35 to 140 mg/µL); transferrin saturation (Fe/total iron binding capacity [TIBC]), 95% (normal, 13% to 45%); TIBC, 201 µg/dL (normal, 245 to 400 µg/dL); vitamin B12 level, 987 pg/mL (normal, 243 to 894 pg/mL); folate level, 11.1 ng/mL (normal, 4 to 19 ng/mL); lactate dehydrogenase level, 1939 U/L (normal, 110 to 220 U/L). Liver function test results were normal. Results of electron microscopic examination of bone marrow aspirate and biopsy specimens are as shown (Figures 1 and 2).