logic diagnoses of these patients were confirmed by a positive Ham's test and flow cytometric demonstration of deficiency of GPI-linked proteins. There were 6 men and 3 women. The median age at diagnosis was 32 (range, 20-44) years. One patient died 5 years after diagnosis, while another defaulted after 17 years. The median duration of follow-up was 9 (range, 5-20) years. One patient presented with recurrent abdominal pain after
AIDS and Pure Red Cell Aplasia
diagnosis, and investigations revealed splenic venous thrombosis and esophageal varices. He died 5 years after diagnosis of cerebral hemorrhage.
To the Editor: The letter from describes two AIDS Another patient, a chronic smoker, had left coronary artery stenosis successpatients who developed pure red cell aplasia (PRCA). The authors suggest fully treated by percutaneous coronary angioplasty. His symptoms had not that PRCA may be related either to the underlying HIV infection or to recurred. Two patients had pulmonary tuberculosis, and one had chronic antiretroviral medications, and they recommend corticosteroid treatment osteomyelitis that was surgically treated. One patient went through two for these already immunocompromised patients.
pregnancies, one successful and the other terminating in intrauterine death We wish to point out an alternative explanation for PRCA in these cases.
because of severe toxemia of pregnancy. No thrombosis was observed in At the time that the hematologic abnormality occurred, the first patient any of these patients, although prophylatic anticoagulation was not given. was on trimethoprim/sulfamethoxazole (TMP/SMX) prophylaxis and the At the latest follow-up, mild leukopenia (Ο½3 Ο« 10 6 /l) and thrombocytopenia second patient had recently started toxoplasmosis treatment that probably (Ο½100 Ο« 10 6 /l) were present in 3 patients. Five patients have remained included a sulfonamide. We recently described delayed hematologic toxicity transfusion-dependent, with a median annual requirement of six (range, in HIV-infected patients who had undergone desensitization to TMP/SMX 5-15) units of blood. (co-trimoxazole), and we termed this iatrogenic finding co-trimoxazole
The clinicopathological features of this series of patients were similar desensitization syndrome, or CODS [2]. In fact, one of our patients with in many respects to those of Western patients (Table ). Patients presented CODS developed PRCA, and this complication has previously been associmostly in the third decade, with 44-66% of patients showing cytopenias ated with sulfonamide therapy [3]. Thus the patients described by Majlufother than anemia. Two patients (22%) presented initially with aplastic Cruz et al. [1] may have had similar hematologic toxicity from sulfonanemia. Both had gradual improvement of hematologic parameters with amide treatment. the onset of PNH. Although PNH has been considered preleukemic, this A logical remedy would be to discontinue the sulfonamide medication. complication was not observed in the largest series of PNH patients to date This approach avoids the additional immunosuppressive effects of cortico-[3], nor in our patients. steroids in AIDS patients. In view of the increasing concern with iatrogenic The major difference in our series is the rarity of thrombotic complicacomplications of HIV therapy [4], medication-induced hematologic toxicity tions. Only one patient presented with venous thrombosis. Furthermore, should be carefully considered and avoided in HIV-infected patients. our patients went through pregnancies and operations, which were additional risk factors for thrombosis, without complications despite the lack of antico-RAPHAEL B. STRICKER agulation. In another series of 40 Chinese patients with PNH, thrombosis California Pacific Medical Center, San Francisco, California was seen in only 7% of cases [5]. This is in contrast to the reported BILLI GOLDBERG frequency of 39-62% of thrombosis in the West [3,4]. In view of the high DNCB Study Group, San Francisco, California frequency of potentially fatal thrombosis in Western patients, it has been recommended that all PNH patients receive prophylatic anticoagulation [3]. However, we think that this is unwarranted in Chinese PNH patients,