ictericia pancitopenia hiv
TRANSCRIPT
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MR1 OSCAR MALPARTIDA TABUCHIHNGAI
30 DE SETIEMBRE 2014
Hepatopatía y pancitopenia en paciente HIV
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Problemas
Varón HIV C3 y Tuberculosis diseminada con:
Hepatopatía (mixta) sub-agudaPancitopenia
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Hepatopatia mixta subaguda
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1. HEPATOPATÍA (MIXTA) SUBAGUDA
- Hepatitis viral - Infiltrativas (no infecciosas e infecciosas)- Oportunistas- Esteatosis hepática- DILI- Colangiopatía asociada al HIV
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DILIDefiniciones
DILI basado en parámetros de laboratorio
Injuria hepática >2 veces VN de ALT o BDInjuria hepatocelular aguda (ALT/AP>5) Injuria hepática hepatocelular (FA>2 veces
VN o ALT/FA<2)Patrón mixto( ALT/FA 2-5 ) asociado a
mecanismo inmunoalérgico
Drug hypersensitivity. KARGER
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Definiciones (continuación)
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Tipos de DILI
Adaptación hepáticaHepatitis inducida por drogas (hepatocelular)Higado graso no alcohólicoHepatitis granulomatosaColestasis*FHF
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Factores de riesgo
JONG, E., et al. Consensus statement: Management of drug-induced liver injury in HIV-positive patients treated for TB. Southern African Journal of HIV Medicine, 2013, vol. 14, no 3, p. 113-119.
Edad (>35 años)NiñosMujeres (controversial)Aumento de TGP basalEstatus de acetiladorVIH (CD4 bajo)TARV: nevirapina,
efavirenz, lopi/ritonavir (dosis doble)
HBV (Ag e +)HCV
Cofactores (alcohol, otras drogas)
Cotrimoxazol, fluconazol
Desnutrición
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DILI
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HEPATITIS VIRAL
DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents December 1, 2009. www.AIDSinfo.nih.gov (Accessed on October 14, 2011).
Causa más común de hepatomegalia en HIV es HBV crónica. HCV segunda causa
La mayoría asintomáticos…
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Infiltración
Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007; 370:59.
Neoplasias relacionadas y no relacionadas al HIV (KS, Linfoma, hepatocarcinoma)
Infecciosas y no infecciosas (MAC y CMV)
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Oportunistas (Hepatitis)
TBCMAC: fiebre , pérdida de peso, elevación FA,
anemiaHistoplasmosis: pancitopenia, elevación de
FA, pérdida de peso, tos…Candida, Pneumocystis, Bartonella henselae
(peliosis), Leishmaniasis visceral
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Colangiopatía asociada al HIV
Síndrome por obstrucción de vías biliares causado por infecciones
CD4 <100Cryptosporidium parvumC. cayetanensis, isospora, Giardia
Otras causas colangiopatía: estenosis papilar, colecistitis acalculosa, colelitiasis, coledocolitiasis
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Pancitopenia
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Zon LI, Arkin C, Groopman JE. Haematologic manifestations of the human immune deficiency virus (HIV). Br J Haematol 1987; 66:251.
2. Pancitopenia
HIV:Trombocitopenia 40%Neutropenia 70%Linfopenia 70%Anemia 70%
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Drogas
Zidovudina (TARV protege de neutropenia)TMP-SMXGanciclovir
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Infecciones
Infiltración médula óseaMAC, TBC, Histoplasmosis, CMVEBV, hepatitis virales, dengue, parvovirus
B19, rickettsias, salmonellosis, brucellosis, leishmaniasis visceral
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Infiltración
Stebbing J, Pantanowitz L, Dayyani F, et al. HIV-associated multicentric Castleman's disease. Am J Hematol 2008; 83:498.
Linfomas no HodgkinE. Castleman multicéntrica (HHV-8) fiebre,
sudoración nocturna, adenopatías, hepatoesplenomegalia, ascitis.
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¿Hiv?
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Gracias !