A 22-year-old African American male presented to our hospital with a 2-day history of bleeding gums while brushing and “swollen glands” on the neck. He denied any fevers, chills, night sweats, weight loss or appetite changes. No other symptoms were reported. He has a past medical history of Asthma and takes albuterol inhaler as needed. No relevant family history or other medications were reported. On physical exam, he has palpable non-tender, mobile, anterior cervical, posterior cervical and axillary lymph nodes bilaterally. Oral petechiae on soft and hard palate were noticed. Spleen tip was also palpable. Rest of the physical examination was normal. A complete blood count revealed isolated thrombocytopenia with a platelet count of 2000 cells/ mm3. His kidney and liver function were normal. Coagulation parameters and D-Dimers were normal. Peripheral smear revealed normal platelet morphology with decreased numbers. Upon further testing, he was found to be HIV positive with a CD4 count of 354 cells/mm3. Excisional biopsy of right cervical lymph node was consistent with HIV lymphadenitis. He was aggressively treated with 4 doses of intravenous immune globulin (IVIG), intravenous corticosteroids , 13 units of platelet transfusions and Stribilid (a combination of cobicistat, elvitegravir, emtricitabine and tenofovir), with which there was minimal response in the counts. His platelet counts remained in the range of 2000- 17000-cells/mm3. His course was also complicated by spontaneous intracerebral hemorrhage on Day 9. On day 10, a dose of Romiplostim (Thrombopoietin analog) was injected. His platelet counts showed improvement to 40000 cells/mm3 by Day 11 and continued to remain above these counts since then. On Day 16, he was discharged home on Stribilid and tapering doses of corticosteroids. He was given a second dose of Romiplostim prior to discharge. No further complications were reported. At a 2-month outpatient follow up, his platelet counts improved to 143,000 c/mm3. He reported compliance with his HIV medications.
Thrombocytopenia in HIV patients is thought mainly due to 2 important mechanisms – immune destruction of platelets and decreased production. HAART therapy remains the main stay of treatment for HIV related thrombocytopenia. In cases where acute management of thrombocytopenia is required either due to low platelet counts (< 30000 cells/mm3) or active bleeding, additional emergent treatment options include IVIG, steroids or anti Rh-d. Evidence of clinical benefit for Thrombopoietic agents including Romiplostim in HIV-associated-thrombocytopenia is limited and clinical trials are underway. We were able to rescue our patient with Romiplostim and he showed good clinical response with this agent. In certain trials, it was reported that romiplostim is effective in raising the platelet count in over 80% of ITP patients, allowing them to discontinue other therapies, reduce the need for splenectomy, steroid usage and improve their quality of life. Long-term theoretical side effects of treatment include reticulin formation, thromboembolism, and antibody formation to romiplostim. Hence, it appears to be a safer agent with good efficacy. However, more data is needed to confirm this.
By reporting this case, we describe our experience with thrombopoietin analogues in the treatment of a patient with severe HIV-associated-thrombocytopenia who failed conventional regimen.
To cite this abstract:Ganipisetti V, Bollimunta P, Parikh M, Dahar M, Friedman H. When the Coventional Regimen Fails – Romiplostim for the Treatment of Severe Hiv-Associated-Thrombocytopenia. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 523. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/when-the-coventional-regimen-fails-romiplostim-for-the-treatment-of-severe-hiv-associated-thrombocytopenia/. Accessed May 27, 2019.