Introduction:
Hematological abnormalities are among the most common clinicopathological manifestations in human immunodeficiency virus/ acquired immunodeficiency diseases (HIV/AIDS). They may cause symptoms that are life-threatening and impair the quality of life of these patients. As per the recently released, India HIV estimation 2017 report, National adult (15-49 years) HIV prevalence in India is estimated at 0.22% (0.16%-0.30%) in 2017.[1]
The earliest hematological manifestations of HIV infection occur at the time of primary infection when atypical lymphocytes appear in the peripheral blood, often in association with a febrile illness, which clinically can resemble infectious mononucleosis. Primary HIV infection also occasionally cause transient pancytopenia. Patients with established infection may cause lymphocytosis, consequent to the increase in CD-8 positive lymphocytes. Subsequently followed by lymphopenia. Neutrophils may show dysplastic changes, and the presence of immature monocytes and reactive lymphocytes.[2]
Hematological abnormalities are among the most common clinicopathological manifestations of HIV infection. These involve all lineages of blood cells. Leucopenia seen in these patients typically involves lymphocytes and granulocytes although monocytopenia has also been reported.[3] Neutropenia is the most common leucopenia occurring in HIV infected individuals. It may occur in 10-30% of HIV patients with an advanced disease.[4] Many studies have been done on hematological manifestation of HIV. However, very few have been done on peripheral changes in HIV and fewer have focused on morphological changes in white blood cells, which may have a considerable impact on the patient’s wellbeing and treatment. Hence, this study was done to emphasize the need to look for morphological changes in white blood cells in HIV in antiretroviral (ART)naïve patients and compare them with HIV seronegative patients to improve their quality of life.
Materials and Methods
Study Design: Prospective Case Control Study
Cases: The study targeted HIV positive adults which were ART naive i.e. were first time diagnosed of HIV at Integrated counselling and testing centre, Shimla. (n=50)
Patient exclusion criteria: Patients less than 18 years and those on ART were excluded from the study to rule out haematological effects of therapy.
Controls: Those patients who visited ICTC and were found to be HIV negative were taken as controls. (n=50)
Study participants were enrolled after agreeing and signing an informed consent form.
Laboratory Investigation: A peripheral blood smear was made to study morphology of various white blood cells.
Statistical analysis: Statistical analysis was done using Epi info version 3.5.4 and SPSS version 20.0 (manufacture- IBM Corp released 2011.IBM SRSS Statistics for window version 20.0. Armonk, NY: IBM corp).
Results
We studied 100 participants who reported for HIV test to the ICTC. Of these 50 were HIV seropositive.
The following spectrum of morphological changes were observed in WBC’s in the peripheral smears
1) Neutrophils:
| Table 1: Morphological findings in neutrophils in HIV positive cases (n= 50) |
Abnormality in neutrophils |
Number |
Percentage (%) |
Hypogranular |
17 |
34 |
Toxic granules |
6 |
12 |
Nuclear protrusions |
7 |
14 |
Pseudo-pelger huet |
3 |
6 |
Hypersegmented |
13 |
26 |
Apoptotic |
3 |
6 |
Shift to Left |
4 |
8 |
Cytoplasmic vacuolations |
8 |
16 |
Macropolycte |
2 |
4 |
Leucoagglutination |
1 |
2 |
Normal |
15 |
30 |
Table 1 shows various morphological abnormalities found in neutrophils in HIV positive patients. Many patients showed more than one abnormality in the neutrophils. Most common abnormality was hypogranulation (Fig no 1b) (34%) followed by hypersegmented nuclei (Fig 1a) (26%) and cytoplasmic vacuolations (16%). Although toxic granulations (Fig no 1c) and cytoplasmic vacuolations in neutrophils were seen in seronegative patients also, other abnormalities were not observed in the latter.
2) Lymphocytes:
| Table 2: Morphological abnormality in lymphocyte (n=50) |
Abnormality in lymphocyte |
Number |
Percentage (%) |
Nuclear lobulation |
39 |
78 |
Nuclear convolution |
12 |
24 |
Plasmacytoid lymphoid cells |
11 |
22 |
Monocytoid lymphoid cells |
11 |
22 |
Cytoplasmic vacuolations |
5 |
10 |
Cytoplasmic projection |
1 |
2 |
Flowing cytoplasm |
1 |
2 |
Intranuclear vacuolations |
1 |
2 |
Table 2 shows various morphological abnormalities in lymphocytes in seropositive patients. Many patients had more than one abnormality. Most common abnormality seen was nuclear lobulation followed by nuclear convolution (Fig no 2 a-g), plasmacytoid and monocytoid (Fig no 2h) features. Smudge cells were present in 08(16%) subjects in HIV positive cases.
3) Monocytes :
| Table 3: Comparison of morphological abnormalities in monocytes in HIV positive and control cases |
Abnormality in monocytes |
HIV Positive Patients |
HIV Negative Patients |
p-value |
Number |
Percentage |
Number |
Percentage |
Nuclear irregularity |
17 |
34 |
02 |
04 |
0.022 |
Cytoplasmic vacuolations |
24 |
48 |
16 |
32 |
Among the HIV positive cases, nuclear irregularities (Fig no 3b and 3c) and vacuolations (Fig no 3a and 3b) were found in 17(34%) and 24(48%) cases. These were found to be statistically significant when compared to HIV negative control group patients.
Discussion
A variety of hematological manifestations are seen at every stage of HIV infection and often pose a great challenge in the comprehensive management of these patients. Possible mechanisms of hematologic abnormalities include infection of marrow mesenchymal stem cells with HIV, histiocytic reaction including hemophagocytic syndrome, defects in bone marrow progenitor cells and reduced colony growth factors for multipotent hematopoietic, megakaryocytic, erythroid and granulocyte-macrophage progenitor cells.[5] However, ART can also induce changes leading to hematological abnormalities.
Morphological abnormalities:
1) Neutrophils
Morphological abnormalities in the neutrophils are well known in HIV infection and appear as early as their formation in bone marrow and have been attributed to infection of their precursor cell.[6] However, many of these abnormalities are also attributed to opportunistic infections.[2] Common morphological abnormalities in the neutrophils in HIV positive patients include toxic granulation, detached nuclear fragments/nuclear protrusions, cytoplasmic vacuolations, hypogranularity, pseudo-Pelger-huet anomaly and shift to left. Other less common abnormalities observed by other investigators in HIV positive patients were presence of hypersegmented macropolyctes, EDTA independent neutrophil agglutination and circulating myelocyte and metamyelocyte. [6,7]
In a study by Kulkarni et al,[8] most common dysplastic feature found was presence of detached fragments in 97% cases. Other dysplastic features reported were cytoplasmic vacuolations (90%) hypogranular neutrophils with pseudo-pelger huet anomaly, (87.3%) and shift to left (7.3%). However, we found hypogranular neutrophils and pelger-huet anomaly to be the most common finding. We also noticed presence of apoptotic neutrophils and leucoagglutination, each in 2% of HIV positive patients, respectively.
2) Lymphocytes
As in other viral infection, atypical lymphocytes are also seen in HIV infection. In the present study, atypical lymphocytes were found in all seropositive patients. In a case report, Dowshen et al[9] found atypical lymphocytes ranging from 2-13% in the differential counts during the hospital stay of a 15-year-old patient. In our study, we found 4-60% of lymphocytes to be atypical showing a wide range of abnormalities including bilobed, multilobulated, mushroom shaped and convoluted nuclei, cytoplasmic vacuolations and plasmacytoid features. Other investigators have also observed similar atypical lymphocytes in HIV positive patients. [10,11]
3) Monocytes
Monocytopenia has also been observed in HIV seropositive patients.[12] Crowne et al[4] mentioned that monocytopenia can occur in up to 35% of cases but in the present study, monocytopenia was recorded in 72% of cases.
In addition, monocytes can also show nuclear irregularities, cytoplasmic vacuolations and atypical features in HIV patients. [4,14] Similar morphological abnormalities were also observed in our study.
Conclusion
Morphological abnormalities in the lymphocytes had been the most significant finding in the peripheral smears of HIV patients, which included nuclear lobulation, nuclear convolution and plasmacytoid and monocytoid features. Reactive changes seen in neutrophils were hypogranulation, hypersegmented nuclei and cytoplasmic vacuolations in descending order of frequency. Monocytes also revealed few morphological abnormalities including nuclear irregularities and cytoplasmic vacuolations. Hence, all the patients of HIV should be assessed for hematological and morphological examination of peripheral blood and treated accordingly to improve mortality and morbidity rate and the quality of life of patient.
References
- National AIDS Control Organization. Annual report NACO 2017. New Delhi: NACO, Ministry of Health and Family Welfare. 2017; 8-53.
- Bain JB, Clark DM, Wilkins BS. Bone Marrow Pathology. 5th edition: Wiley Blackwell 2019. Chapter 3: Infections and reactive changes. pp 159-160
- Hoffbrand AV et al. Postgraduate hematology. 6th edition: Blackwell Publishing 2011;954.
- Crowe S, Hoy J, Mills J. Management of the HIV-infected Patient. In Street A, Milliken S. Hematological manifestations in HIV. Cambridge university press. 1996; 1st edition: p 281-290
- Wang L, Mondal D, La Russa VF et al. Suppression of clonogenic potential of human bone marrow mesenchymal stem cells by HIV type 1, putative role of HIV-1 tat protein and inflammatory cytokines. AIDS Res Hum Retroviruses. 2002; 18:917-31.
- Nayak DM, Patil A, Dhakal R. Leucoagglutination in vitro. Journal of Evolution of Medical and Dental Sciences. 2013;2(5):467-472.
- d'Onofrio G, Zini G. Morphology of Blood Disorders. In myelodysplastic syndrome. Wiley. 2014; 2nd ed: p181-245
- Kulkarni CV, Sharma S, Panchonia A. Dysplastic neutrophils on peripheral blood smear –hematological finding in HIV infection. Indian Journal of Basic and Applied Medical Research. June 2014;3(3);352-357.
- Dowshen N, Pierce VM, Zanno A et al. Acute HIV Infection in a Critically Ill 15-Year-Old Male, Pediatrics. 2013 March;131(3): e959–e963.
- Nopachai A, Garwacki CP, Mol S. Diffuse Infiltrative Lymphocytosis Syndrome. American Journal of Hematology. 2004; 75:173–175.
- Betty C. Hematology in practice. In Abnormalities in of White Blood Cells: Quantitative, Qualitative, and the Lipid Storage Diseases. Davis Plus 2nd ed. 2012; 10:151-3.
- Kaushansky K, Liichtmann MA, Kipps TJ et al. 9th edition. Williams Hematology. 2017: chapter 34; p269-270.
- Treacy M, Lai L, Costello C, Clark A. Peripheral blood and bone marrow abnormalities in patients with HIV related disease. Br J Haematol. 1987 Mar;65(3):289-94.
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