Page 312 - SAHCS HIVMed Journal Vol 20 No 1 2019

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 7 Original Research

The diagnostic utility of bone marrow

examination in an infectious disease ward

Authors: Background: Patients with advanced human immunodeficiency virus often present with
Nirvana Bharuthram 1 unexplained fevers or cytopenias. Bone marrow aspirate and trephine examinations are an
Charles Feldman 1
invasive means to aid diagnoses in patients who present with diagnostic dilemmas.
Affiliations:
1 Department of Internal Objectives: A retrospective record review to assess the diagnostic utility of bone marrow
Medicine, Faculty of Health examinations in a South African Infectious Diseases ward.
Sciences, University of the
Witwatersrand, Johannesburg, Methods: The records of patients who had undergone a bone marrow examination in the
South Africa Infectious Disease ward at the Charlotte Maxeke Johannesburg Academic Hospital,
Johannesburg, South Africa, between 01 January 2012 and 31 December 2014 were reviewed.
Corresponding author: A unique diagnosis was considered to be any diagnosis made on bone marrow examination
Nirvana Bharuthram,
nirvana.bharuthram@gmail. alone, or a diagnosis made more timeously on bone marrow examination than with alternative
com investigations.
Dates: Results: Of 327 patients who underwent bone marrow examination, 80 unique diagnoses
Received: 24 Mar. 2019 were obtained in 77 cases (23.5%). The unique diagnoses included the presence of granuloma
Accepted: 05 June 2019 (n = 49), Mycobacterium tuberculosis (n = 17), Mycobacterium avium complex (n = 3),
Published: 30 Sept. 2019
haematological malignancy (n = 4) and pure red cell aplasia (n = 5). A white cell count
9
9
How to cite this article: ≤ 4 × 10 /L predicted a unique outcome (p < 0.01). A white cell count ≤ 4 × 10 /L and CD4 cell
Bharuthram N, Feldman C. count ≤ 50 cells/mm predicted mycobacterial infection of the bone marrow.
3
The diagnostic utility of bone
marrow examination in an Conclusions: The findings of a unique diagnosis in 23.5% of bone marrow examinations
infectious disease ward. S Afr performed suggests that this remains a useful investigative modality in patients in whom less
J HIV Med. 2019;20(1), a974. invasive investigations have not yielded a diagnosis.
https://doi.org/10.4102/
sajhivmed.v20i1.974 Keywords: bone marrow examination; HIV; TB; infectious disease; internal medicine.
Copyright:
© 2019. The Authors.
Licensee: AOSIS. This work Introduction
is licensed under the
Creative Commons South Africa (SA) has an immense burden of infection with human immunodeficiency virus
Attribution License. (HIV). The 2016 data released by Statistics South Africa (SSA) estimated that 12.7% of the
population was infected with HIV. Since 2005, there has been a decline in the annual death rate
1
from the acquired immune deficiency syndrome (AIDS). Despite this, up to a third of HIV-
1
infected patients still present with advanced disease and with low cluster of differentiation 4
(CD4) counts viz. CD4 < 100 cells/mm³. These individuals frequently present a diagnostic
2
challenge to infectious disease (ID) physicians as their presentation is often associated with fever,
non-specific symptomatology and cytopenias.
3,4
A bone marrow aspirate and trephine examination is one of the modalities utilised when
investigating such individuals. Since 1995 several local and international studies have
evaluated the diagnostic utility of the bone marrow examination (BME), particularly in the
setting of HIV. Diagnostic utility in this context refers to the number of diagnoses obtained
from such a procedure. These studies have demonstrated a diagnostic utility in 25% – 47% of
cases. 3,4,5,6,7,8,9,10 Collectively, the most common positive finding is the presence of mycobacterial
infection. 5,6,7,9,11,12,13,14 There are two studies that have focused on the South African population:
3
Karstaedt et al., between 1996 and 1997, found that 38% of BMEs of HIV-seropositive
individuals provided a diagnosis, of which 24% were ‘unique’, that is, diagnoses made on
BME alone. These included Mycobacterium tuberculosis (MTB), Mycobacterium avium
Read online: complex (MAC), disseminated cryptococcal infection and haematological malignancies. Bone
Read online:
4
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smart phone or diagnosis in 47% of 147 HIV-seropositive patients. Of these, 33% were unique diagnoses and
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haematological malignancies.
http://www.sajhivmed.org.za 305 Open Access