Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
Clinical Manual for Management of the HIV-Infected ... - myCME.com
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5-2 | <strong>Clinical</strong> <strong>Manual</strong> <strong>for</strong> <strong>Management</strong> <strong>of</strong> <strong>the</strong> <strong>HIV</strong>-<strong>Infected</strong> Adult/2006<br />
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Extremities: edema<br />
Neurologic: vibratory sensations, balance and gait,<br />
deep tendon reflexes, Babinski reflexes<br />
Rectal: check <strong>for</strong> occult blood<br />
A: Assessment<br />
Remember that more than one cause <strong>of</strong> anemia may be<br />
present. A partial differential diagnosis includes:<br />
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Chronic disease: <strong>HIV</strong>/AIDS; o<strong>the</strong>r <strong>com</strong>orbid<br />
conditions<br />
Medications<br />
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ZDV or ZDV-containing drugs (Combivir,<br />
Trizivir)<br />
TMP-SMX (Septra, Bactrim, cotrimoxazole)<br />
O<strong>the</strong>r hematotoxic medications<br />
(see list, below)<br />
Iron deficiency<br />
Vitamin B12 or folate deficiency<br />
Malnutrition<br />
Alcoholism<br />
Malignancy<br />
Renal disease<br />
Liver disease<br />
Blood loss (eg, gastrointestinal)<br />
Hemolysis (eg, in patients with glucose-6-phosphate<br />
dehydrogenase [G6PD] deficiency who are exposed<br />
to dapsone, TMP-SMX, or o<strong>the</strong>r oxidants)<br />
Parvovirus B19<br />
Tuberculosis<br />
Mycobacterium avium <strong>com</strong>plex (MAC)<br />
Histoplasmosis, cryptococcosis<br />
Malaria<br />
Sickle cell disease<br />
Thalassemia<br />
Hypogonadism<br />
Hypothyroidism<br />
Pregnancy<br />
Rheumatoid arthritis<br />
Systemic lupus ery<strong>the</strong>matosus<br />
Inflammatory bowel disease<br />
Hookworm infection<br />
P: Plan<br />
Diagnostic Evaluation<br />
Recheck <strong>the</strong> hematocrit and hemoglobin to confirm<br />
anemia, and per<strong>for</strong>m a <strong>com</strong>plete blood count with<br />
differential to determine whe<strong>the</strong>r o<strong>the</strong>r cytopenias are<br />
present.<br />
Per<strong>for</strong>m laboratory work and o<strong>the</strong>r diagnostic studies<br />
as suggested by <strong>the</strong> history, physical examination, and<br />
differential diagnosis. Consider <strong>the</strong> following as initial<br />
tests to determine <strong>the</strong> cause <strong>of</strong> anemia:<br />
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Mean corpuscular volume<br />
Peripheral blood smear<br />
Reticulocyte count<br />
Bilirubin (total and direct)<br />
Iron studies: ferritin, iron, transferrin, total ironbinding<br />
capacity<br />
Hemoccult testing <strong>for</strong> fecal blood<br />
Pregnancy test if indicated<br />
See Figure 1 <strong>for</strong> a possible diagnostic approach.<br />
Figure 1. Diagnostic Evaluation <strong>for</strong> Anemia<br />
Reticulocyte count low (2%)<br />
MCV low<br />
• Iron<br />
de�ciency<br />
secondary to<br />
chronic<br />
blood loss<br />
Indirect bilirubin<br />
normal or low<br />
MCV normal<br />
• Anemia <strong>of</strong> chronic disease<br />
• <strong>HIV</strong><br />
• Drugs<br />
• Tumor in marrow<br />
• Infection in marrow<br />
MCV high<br />
Hb<br />
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