Thrombocytopenia and Human Immunodeficiency Virus in Children

Abstract

The authors report what they believe is the first case in the English literature of spontaneous resolution of endobronchial Mycobacterium avium-intracellulare (MAI) infection in the lung of a patient with AIDS. The authors comment that none of the medications the patient received for hemotysis or parenchymal lung disease have been reported to have a bactericidal activity against MAI in-vivo, and suggest that either parenchymal MAI is self-limiting or that the spontaneous resolution may indicate immunologic reconstitution, perhaps aided by zidovudine and gamma globulin.

Case Details

Clinical Characteristics

Thrombocytopenia occurs in 13% of children with symptomatic human immunodeficiency virus (HIV) infection. Bone marrow aspirates showed normal to increased numbers of megakaryocytes. Levels of antiplatelet antibodies were increased in 80% of the children and circulating immune complexes were found in 74%. Clinically significant hemorrhage leading to anemia occurred in five patients, and cns bleeding led to a fatal outcome in an additional three children.

Remission Characteristics

Spontaneous remission of thrombocytopenia occurred in three of the 19 subjects. High-dose IV gamma globulin was effective in increasing the platelet counts of six of 15 patients (40%) but resulted in a sustained remission in only one subject. Oral prednisone was effective in increasing the platelet count of two thirds of those whose platelet counts could not be controlled by IV gamma globulin. Bleeding manifestations were eliminated in all patients whose platelet counts increased significantly. Of the 11 children whose counts increased either spontaneously or as a result of therapy, eight remain alive (72%). In contrast, all of the eight patients whose platelet counts did not improve have died.

Treatment & Mechanisms

Proposed Remission Mechanisms

High-dose IV gamma globulin and/or corticosteroids are temporarily effective in increasing the platelet count and reducing bleeding in about half of thrombocytopenic patients and are recommended for use. The ability to respond to therapy correlates with improved survival.

Clinical Treatment

High-dose IV gamma globulin, oral prednisone

Additional Notes

Thrombocytopenia in children with HIV disease is engendered by immune mechanisms and is a major cause of morbidity and mortality. During the course of the study, three patients (16%) had significant spontaneous increases in platelet counts and required no therapy for thrombocytopenia. Detailed data is presented. In this group, the platelet-associated IgG and C1q levels were not predictive of the spontaneous increase.