Postoperative Bleeding in a HIV-Positive Patient Operated for Oral Cancer: A Case Report

Abstract

Human immunodeficiency virus(HIV) is transmitted sexually, through blood transfusions, sharing intravenous needles, and from the mother to a child during the birth process and breastfeeding. Most of the patients diagnosed with HIV develop AIDS within ten years if left untreated. HIV infected patients have a higher risk of complications than those who are not having the disease. Surgical site infections and pneumonia are the most common short term postoperative complications in patients suffering from this disease. The use of antiretroviral therapy against HIV infection can result in an increased risk of cardiovascular disease by changing the profile of lipids and platelet aggregation. HIV associated thrombocytopenia can also cause bleeding. Here we present a case of a 47 year old patient who was operated for oral cancer and developed postoperative bleeding as a complication apart from postoperative infection. There was no thrombocytopenia in our patient, but anemia occurred due to blood loss. There was also substantial increase in TLC count when he developed infection.

Introduction

HIV is a lentivirus (slowly replicating retrovirus) which can be transmitted through the blood, semen, vaginal fluid, pre-ejaculate, breast milk, and other bodily fluids. When helper T cells (specifically CD4⁺ T cells), which are the major cells of the human immune system, get infected with HIV, there occurs a decrease in the number of CD4⁺ T cells and the cell-mediated immunity gets destroyed, as a result of which, the risk of opportunistic infection increases [1]. Increase of viral burden in peripheral blood CD4 + T-cells is directly associated with a progressive decline in CD4 + T cells and deterioration of the clinical course in HIV-infected patients [2]. In addition, when macrophage and dendritic cells get infected with HIV, immune function disorders are likely to develop [1]. Surgical site infections (25%) and pneumonia (32%) are the most common short term postoperative complications in patients suffering from HIV [3]. Here we present a case of a 47 year old patient who was operated for oral cancer and developed postoperative bleeding as a complication apart from postoperative infection.

Case Presentation

The patient reported to the Department of Surgical Oncology at Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India with a complaint of non-healing ulcer on the left side of the intra-oral cheek region since six months. He was clinically and radiologically diagnosed case of oral squamous cell carcinoma of the right buccal mucosa. He was also a diagnosed case of HIV infection(HIV-1 viral load of 23 copies/ml, Log value of 1.36) which was detected one year back, and he was also on some antiretroviral therapy(Dolutegravir, Lamivudine and Disoproxil Fumarate tablets) from some district hospital in the town. Pre-anesthetic clearance was obtained and the patient was operated under general anesthesia. Bite composite resection including MRND was performed under general anesthesia, and tracheostomy was also done. Reconstruction of the defect with PMMC flap was done. No free flap was used as HIV patients are at higher risk of complications. Postoperative care was taken and the patient was discharged on the 5th postoperative day in a stable condition with Ryle’s tube in-situ. On the 12th postoperative day, the patient reported to us with a history of bleeding from the drain site on the chest region since 2 days. The patient had got the area bandaged at some hospital outside 2 days back. After we removed that bandage, we found that the blood was continuously coming out through the drain site(Fig. 1), and it was contolled by applying pressure dressing, and injection tranexamic acid 1 g was given stat intramuscularly. The patient was then put on tablet tranexamic acid 500 mg through the Ryle’s tube for 5 days and asked to review. After he reported to us again after 5 days, the bleeding was not there, but a huge amount of pus drained out from the same site where there was bleeding found 5 days back(Fig. 2). Pus culture sample was sent and the patient was found to be infected with Klebsiella pneumoniae and Pseudomonas aeruginosa. Both these isolates were sensitive to the antibiotic piperacillin/tazobactam and hence injection piptaz was advised in a dose of 4.5 g in 100 ml NS TDS. On account of raised blood urea(74 mg/dl) and creatinine(1.7 mg/dl), the dose was reduced to 2.5 g in 100 ml NS on the second day of this injection, but after these settled the former dose was resumed. With regular cleaning of the wound with betadine and hydrogen peroxide solution, and also by washing it with ciprofloxacin and metronidazole, followed by betadine dressing, we were able to control the infection and there was a reduction in TLC from 17,570/mm³ to 8,830/ mm³ in 4 days. However, the patient had microcytic hypochromic anemia, which had occurred due to the blood loss which the patient had experienced when he reported to us before the development of infection. Hemoglobin was 5.2 g/dl and the patient’s attendants were advised to arrange at least four blood donors. However, only one donor could be arranged and hence one unit of PRBC was transfused. The platelet count remained normal throughout the course of treatment.

Fig. 1.

Cliinical photograph showing continuous bleeding from the drain site

Fig. 2.

Cliinical photograph showing massive pus discharge from the drain site

Discussion

The use of antiretroviral therapy against HIV infection can result in an increased risk of cardiovascular disease by changing the profile of lipids and platelet aggregation [4]. In our patient, mild mitral and tricuspid regurgitation were present along with grade I left ventricular diastolic dysfunction. The purinergic system ectoenzymes also play a major role in the hydrolysis of nucleosides and nucleotides of adenine, which interferes with the signaling cells to stimulate the coagulation parameter changes and thus attenuate the effects of platelet procoagulant [4]. The involvement of coagulopathy in HIV infection is related to the severity of inflammation and is also associated with aging. Hemostatic changes in HIV⁺ individuals aged > 60 years on ART has been described, with low frequency of aging complications [5]. Our patient was < 60 years(47years) of age.

Platelets have been reported to interact with the HIV-1 virus, viral membrane proteins, or dysregulated circulating inflammatory molecules that result from HIV-1 infection. Thus, long-term HIV infections often lead to thrombocytopenia and idiopathic thrombocytopenic purpura (ITP) [6]. However, in our patient the platelet count remained normal throughout the entire course of treatment. It has been found that combined anti-retroviral therapy with zidovudine + nevirapin + efavirenz combination could be the treatment of choice for HIV patients as it significantly improves the coagulation profile [7]. In our patient the antiretroviral therapy with dolutegravir, lamivudine and disoproxil fumarate was used, and his bleeding got controlled by pressure dressing and the use of tranexamic acid drug. Literature has also reported gastrointestinal bleeding as a result of HIV-related causes such as CMV, Kaposi sarcoma, non-Hodgkin’s lymphoma, and herpes simplex virus, among others [8].

In HIV patients, the combination of a low CD4 count and an uncontrolled viral load is associated with an increased risk for postoperative mortality and complications. If surgery is elective and the patient has a viral load level ≥ 200 copies/mL or CD4 count ≤ 200 cells/mm³, clinicians should consult with the patient’s primary care provider or an experienced HIV care provider [9]. In our patient, HIV testing had been done one year back, where the viral load was found to be as 23 copies/ml, which is indicative of the fact that HIV RNA was detected within the linear range of the assay. However, the testing was done one year back using TaqMan real-time PCR assay, which is a technique developed to quantify proviral HIV-1 [10].

Conclusion

While performing surgery in an HIV patient, the surgeon should be aware of postoperative bleeding apart from other postoperative complications. After getting discharged from the hospital, these patients should be told to keep the hemostatic agents with themselves and should also be taught methods to control bleeding in case of emergency when no medical aid is available.

Funding

No funds, grants, or other support was received.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.