Peripheral Blood Stem Cell Transplantation in a Patient with Acquired Aplastic Anemia and HIV Infection.

Clinically significant hematologic abnormalities are common in persons with human immunodeficiency virus infection(HIV). None the less aplastic anemia (AA) is an unusual entity associated with HIV infection.

We want to communicate the case of an HIV infected patient whit acquired AA and the good results obtained with peripheral blood stem cell trasplantation (PSCT) from an histoidentical twin brother.

A 31 years old man presented with epistaxis and weakness. No physical abnormalities were observed. Blood counts showed: Hb:8,5g/dL;absolute neutrophil count(ANC)1000/mm3;platelets10.000/mm3 and absolute reticulocyte count (ARC)25.000/uL. Bone marrow (BM) aspiration showed severely depressed BM cellularity. There was no morphological evidence of hypocellular myelodysplastic syndrome. Flow cytometric analysis of red cells and granulocytes was performed and there was no evidence of paroxysmal nocturnal hemoglobinuria clone. In the BM biopsy the hematopoietic cells represented 15% of the residual cells. The karyotype was normal. The enzyme immunoassay to detect increases in titers of antibodies against HIV was positive and was confirmed by western blot. Initial CD4+ T cells count: 424/mm3. Initial serum HIV RNA level : 30.000 copies /ml. HIV RNA copies in BM were not detected. Others serologic assays:hepatitis(H) A:(−);HB(−);HC(−). Specific IgM e IgG against parvovirus B19(−)VDRL(−). IgM VCA Epstein-Barr virus (EB)(−) IgG(VCA)E:B(+1/250). Detection of CMV antigens(pp65) was negative in four opportunities during the course of the illness. Blood cultures for Bartonella spp and Histoplasma capsulatum (−) Fetal Hb normal. Direct Coombs test (−). Chest and abdominal computed tomography were normal. Drug/toxin exposure were ruled out. He began highly active antiretroviral therapy (HAART) with zidovudine(AZT), lamivudine(3TC)and efavirenz. While HLA typing was ordered he received supportive treatment with platelet concentrates from single donor and packed red cells leucodepletated on account of his transfusion- dependent anemia, both irradiated. Recombinant erythopoietin 4.000UI 3 times/week during a month was useless to diminish the red cells transfusion requirements. Granulocyte colony-stimulating factor15UI/day increased the (ANC) to 2.500/mm3.

The twin brother showed to be an histocompatible donor. Complementary studies were done and they demonstrated that they were monocorial twins.(Identity index is II=1,37×10²²).

CD4+T cell count pretransplantation:383/mm3. HIVRNAcopies < 50/ml.

Conditioning regimen : cyclophosphamide 5000mg /day for 4 days. The 4^th day he also received intravenous immunoglobulin (20000mg).

PSCT was selected because of its more rapid blood count recovery(platelets and neutrophils)It was infused 11,7×10⁶ CD34/kg. G-CSF was not administered. Neutrophil and platelet engrafment was obtained on day +11. Ten red cell packed units were administered post(PSCT). The only complications were light mucositis and fever during the neutropenic phase which requires broad spectrum antibiotics. 26 days after (PSCT) CD4+T count were 318/mm3 and the viral load was < of 50 copies. It was reinstituded HAART (3TC, efavirenz and abacavir).

Eight months after the(PSCT) the blood counts are:Hb:14,2 g/dl; ANC:5.330/mm3 and platelets:290.000/mm3.

We conclude that in the HAART era the HIV patients are able to receive intensive treatments with low morbidity.