Abstract
Bone marrow aspiration and biopsy is a commonly utilized procedure to evaluate cytopenias and to diagnose disseminated infection and malignancy in patients with the acquired immunodeficiency syndrome (AIDS). The diagnostic utility of these studies is controversial and has not been evaluated extensively in the era since the development of highly active anti-retroviral therapy (HAART). The objective of this study was to analyze which variables are the strongest predictors for identifying a unique diagnosis on bone marrow biopsy, aspiration and culture in patients with AIDS. A unique diagnosis was defined as a previously unrecognized disorder that was not identified through other diagnostic studies (e.g. blood cultures, lymph node biopsy). We reviewed 1198 bone marrow biopsies performed at the Dallas VA Medical Center from January 1, 1998 to February 1, 2008 and identified 26 patients with AIDS who had the procedure. In 4 of these 26 patients (15.4%) a unique diagnosis was identified with bone marrow biopsy, aspiration or culture. The 4 diagnoses were disseminated mycobacteria avium, diffuse large B - cell lymphoma, acute myelogenous leukemia, and immune-mediated thrombocytopenia. The following variables were analyzed as predictors in a logistic regression model with unique diagnosis as the dependent variable (laboratory values were those performed closest to the time of bone marrow biopsy): CD4 count, viral load, white blood count, hemoglobin, platelets, lactate dehydrogenase, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, presence or absence of fever, and whether the patient was on HAART therapy. In addition, the following indications for the bone marrow biopsy were analyzed as predictors for identifying a unique diagnosis: pancytopenia, anemia, leucopenia, thrombocytopenia, fever, lymphadenopathy. None of the variables or indications analyzed was a statistically significant predictor for identifying a unique diagnosis. However, certain indications for bone marrow biopsy were strongly suggestive: patients with fever (odds ratio 2.7; 95% CI .3 – 23.4; p = .38) or leucopenia (odds ratio 2.1; 95% CI 0.16 – 27.6; p = .57) as the indication for biopsy were more likely to be identified with a unique diagnosis. Conversely, patients with anemia as the indication were less likely to be found to have a unique diagnosis (odds ratio .4; 95% CI .04 – 4.4; p = .46). Kaplan-Meier survival analyses indicated that the median survival for the group as a whole was 8.5 months, and there was no difference in survival between those patients with a unique diagnosis and those without. One interesting and unanticipated finding was a sharp decline in the number of referrals for bone marrow biopsy in patients with AIDS at our institution during the time period analyzed despite an increase in the number of AIDS patients followed at the institution. From 1998–2004, 24 biopsies were performed and from 2005 – 2008 only 4 were done. We hypothesize this may be due to advancements in antiretroviral medications with less myelosuppressive profiles in addition to increased compliance with HAART among our patients with AIDS. This may be a topic of future study. In conclusion, bone marrow biopsy in patients with AIDS seldom provides a unique diagnosis. Patients with fever or leucopenia as the indication for biopsy may be more likely to be found to have a unique diagnosis.