Acute myeloid and leukaemia and human immunodeficiency virsus infection at Chris Hani Baragwanath Academic
Background Acute myeloid leukaemia (AML) is a haematological malignancy that results from the malignant clonal proliferation of myeloid progenitor cells. The clinical presentation of AML is a consequence of bone marrow infiltration and replacement of the normal cellular elements in the bone marrow, resulting in a reduced production of mature blood cells. In the era of antiretroviral therapy, with the resultant increase in longevity of HIV seropositive patients, it is becoming more important for clinicians to be aware of the increasing incidence of solid organ and haematological malignancies in this group of patients. To date, there are no local studies evaluating the rare entity of AML occurring in patients who are infected with HIV in South Africa. Aims and Objectives • To describe the demographics, clinical presentation, laboratory features and management of patients with AML, including HIV seropositive AML from 01/01/2005 to 31/12/2014 • To describe the demographics, clinical presentation, laboratory features and management of patients with HIV seropositive AML from 01/01/1993 to 31/12/2004, in the era of combined antiretroviral therapy not being available Patients and Methods A retrospective study in which patient records of adults with AML diagnosed in the Clinical Haematology Unit, Department of Medicine, at Chris Hani Baragwanath Academic hospital during the period 01/01/1993 to 31/12/2014 were reviewed. The data of patient’s demographics, clinical presentation, laboratory results and management was collected and evaluated. Results A total of 195 patients with AML were evaluated. This included 33 HIV seropositive patients with AML. However, a direct comparison was only made with 27 HIV seropositive patients compared to seronegative patients during the period 01/01/2005 to 31/12/2014. The majority of patients were of Black African ethnicity (91.5%). There was a male predominance of 52% in the overall population, while the HIV seropositive AML subgroup showed a female predominance of 59%. The median age at presentation was 45 years (range 18-88 years). The clinical presentation was mainly with features of bone marrow failure/infiltration, manifesting with anaemia, infection and bleeding. The incidence of tuberculosis was significantly higher among the HIV seropositive AML patients. Extramedullary disease was found in 21% of patients with 7% of patients having a myeloid sarcoma. Although HIV seropositive patients with AML had lower white cell counts, haemoglobin and platelet counts compared to their HIV seronegative counterparts, this difference was not statistically significant. The most common histological subtypes across the study were AML (M2) in 25% and AML (M3) in 22% of the patients. The most common favourable cytogenetic abnormalities were t(15; 17) and t(8; 21), while the most common unfavourable cytogenetic abnormality was t(9; 22). For induction chemotherapy, patients were treated with the standard “3+7” regimen, which consists of a combination of an anthracycline (daunorubicin) for 3 days and cytosine arabinoside for 7 days. Complete remission was achieved in 60% of all patients who received induction chemotherapy. The most common consolidation therapy given was the combination of an anthracycline (daunorubicin) and high dose cytosine arabinoside. Approximately 18% of the patients were given palliative chemotherapy. The overall patient outcomes were as follows: 76% of the patients demised, 18% of the patients were lost to follow up, and 6% were alive. Conclusion Acute myeloid leukaemia is the most common acute leukaemia seen in adults. AML in association with HIV is uncommon. To our knowledge, the current study encompasses the largest single center experience of this association. HIV seropositive patients with AML present at a younger age, with a slight female predominance. In general, the clinical presentation, treatment and outcome are similar to HIV seronegative AML, with a few exceptions. The similarities and differences are highlighted in this research report. It is hoped that the findings of this retrospective study will form the basis for more detailed and focused prospective studies on the association of AML in HIV seropositive individuals.
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment for the requirements of the degree of Master of Medicine (Internal Medicine), Johannesburg, 2018