HIV induced pericarditis: Difference between revisions

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==Overview==
==Overview==
A wide variety of cardiovascular complications are seen in advanced [[HIV]] infected patients. The most common are:
A wide variety of cardiovascular complications are seen in advanced [[HIV]] infected patients. The most common are:
:*[[Pericarditis]] <ref name="pmid3181175">Corallo S, Mutinelli MR, Moroni M, Lazzarin A, Celano V, Repossini A et al. (1988) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3181175 Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients.] ''Eur Heart J'' 9 (8):887-92. PMID: [http://pubmed.gov/3181175 3181175]</ref> <ref name="pmid2926051">Himelman RB, Chung WS, Chernoff DN, Schiller NB, Hollander H (1989) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2926051 Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study.] ''J Am Coll Cardiol'' 13 (5):1030-6. PMID: [http://pubmed.gov/2926051 2926051]</ref> <ref name="pmid1464334">De Castro S, Migliau G, Silvestri A, D'Amati G, Giannantoni P, Cartoni D et al. (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1464334 Heart involvement in AIDS: a prospective study during various stages of the disease.] ''Eur Heart J'' 13 (11):1452-9. PMID: [http://pubmed.gov/1464334 1464334]</ref> <ref name="pmid8017317">Hsia J, Ross AM (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8017317 Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection.] ''Am J Cardiol'' 74 (1):94-6. PMID: [http://pubmed.gov/8017317 8017317]</ref> <ref name="pmid7586308">Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al. (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7586308 Pericardial effusion in AIDS. Incidence and survival.] ''Circulation'' 92 (11):3229-34. PMID: [http://pubmed.gov/7586308 7586308]</ref> <ref name="pmid9458682">Estok L, Wallach F (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9458682 Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection.] ''Mt Sinai J Med'' 65 (1):33-9. PMID: [http://pubmed.gov/9458682 9458682]</ref>
:*[[Pericarditis]] <ref name="pmid3181175">Corallo S, Mutinelli MR, Moroni M, Lazzarin A, Celano V, Repossini A et al. (1988) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3181175 Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients.] ''Eur Heart J'' 9 (8):887-92. PMID: [http://pubmed.gov/3181175 3181175]</ref> <ref name="pmid2926051">Himelman RB, Chung WS, Chernoff DN, Schiller NB, Hollander H (1989) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2926051 Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study.] ''J Am Coll Cardiol'' 13 (5):1030-6. PMID: [http://pubmed.gov/2926051 2926051]</ref> <ref name="pmid1464334">De Castro S, Migliau G, Silvestri A, D'Amati G, Giannantoni P, Cartoni D et al. (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1464334 Heart involvement in AIDS: a prospective study during various stages of the disease.] ''Eur Heart J'' 13 (11):1452-9. PMID: [http://pubmed.gov/1464334 1464334]</ref> <ref name="pmid8017317">Hsia J, Ross AM (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8017317 Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection.] ''Am J Cardiol'' 74 (1):94-6. PMID: [http://pubmed.gov/8017317 8017317]</ref> <ref name="pmid7586308">Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al. (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7586308 Pericardial effusion in AIDS. Incidence and survival.] ''Circulation'' 92 (11):3229-34. PMID: [http://pubmed.gov/7586308 7586308]</ref> <ref name="pmid9458682">Estok L, Wallach F (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9458682 Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection.] ''Mt Sinai J Med'' 65 (1):33-9. PMID: [http://pubmed.gov/9458682 9458682]</ref>
Line 11: Line 12:
:*[[Pulmonary hypertension]]
:*[[Pulmonary hypertension]]
:*[[Coronary artery disease]]
:*[[Coronary artery disease]]


==Epidemiology and demographics==
==Epidemiology and demographics==


Pericardial diseases in the form of [[pericardial effusion]] or [[cardiac tamponade]]<ref name="pmid2721281">{{cite journal| author=Stotka JL, Good CB, Downer WR, Kapoor WN| title=Pericardial effusion and tamponade due to Kaposi's sarcoma in acquired immunodeficiency syndrome. | journal=Chest | year= 1989 | volume= 95 | issue= 6 | pages= 1359-61 | pmid=2721281 | doi= | pmc= | url= }} </ref><ref name="pmid1582323">{{cite journal| author=Karve MM, Murali MR, Shah HM, Phelps KR| title=Rapid evolution of cardiac tamponade due to bacterial pericarditis in two patients with HIV-1 infection. | journal=Chest | year= 1992 | volume= 101 | issue= 5 | pages= 1461-3 | pmid=1582323 | doi= | pmc= | url= }} </ref><ref name="pmid7586308">{{cite journal| author=Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al.| title=Pericardial effusion in AIDS. Incidence and survival. | journal=Circulation | year= 1995 | volume= 92 | issue= 11 | pages= 3229-34 | pmid=7586308 | doi= | pmc= | url= }} </ref> have been recognized as a complication since HIV infection was first reported in 1981.  
Pericardial diseases in the form of [[pericardial effusion]] or [[cardiac tamponade]]<ref name="pmid7586308">{{cite journal| author=Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al.| title=Pericardial effusion in AIDS. Incidence and survival. | journal=Circulation | year= 1995 | volume= 92 | issue= 11 | pages= 3229-34 | pmid=7586308 | doi= | pmc= | url= }} </ref><ref name="pmid2721281">{{cite journal| author=Stotka JL, Good CB, Downer WR, Kapoor WN| title=Pericardial effusion and tamponade due to Kaposi's sarcoma in acquired immunodeficiency syndrome. | journal=Chest | year= 1989 | volume= 95 | issue= 6 | pages= 1359-61 | pmid=2721281 | doi= | pmc= | url= }} </ref><ref name="pmid1582323">{{cite journal| author=Karve MM, Murali MR, Shah HM, Phelps KR| title=Rapid evolution of cardiac tamponade due to bacterial pericarditis in two patients with HIV-1 infection. | journal=Chest | year= 1992 | volume= 101 | issue= 5 | pages= 1461-3 | pmid=1582323 | doi= | pmc= | url= }} </ref><ref name="pmid10047635">Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10047635 Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature.] ''Am Heart J'' 137 (3):516-21. PMID: [http://pubmed.gov/10047635 10047635]</ref> have been recognized as a complication since HIV infection was first reported in 1981.  


*In a small autopsy study, '''24% cases''' reported major cardiac pathology <ref name="pmid3973269">{{cite journal| author=Cammarosano C, Lewis W| title=Cardiac lesions in acquired immune deficiency syndrome (AIDS). | journal=J Am Coll Cardiol | year= 1985 | volume= 5 | issue= 3 | pages= 703-6 | pmid=3973269 | doi= | pmc= | url= }} </ref>.
*In a small autopsy study, '''24% cases''' reported major cardiac pathology <ref name="pmid3973269">{{cite journal| author=Cammarosano C, Lewis W| title=Cardiac lesions in acquired immune deficiency syndrome (AIDS). | journal=J Am Coll Cardiol | year= 1985 | volume= 5 | issue= 3 | pages= 703-6 | pmid=3973269 | doi= | pmc= | url= }} </ref>.
Line 21: Line 23:


*The incidence of AIDS-related cardiac disease is very high in Africa in comparison to that seen in the developed countries. In the period from 1993 to 1999 in Burkina Faso, '''79%''' of AIDS patients exhibited cardiac involvement, whereas in an Italian study in the period from 1992 to 1995, the incidence of AIDS-related cardiac disease was '''6.5%'''<ref name="pmid15124176">{{cite journal| author=Pugliese A, Gennero L, Vidotto V, Beltramo T, Petrini S, Torre D| title=A review of cardiovascular complications accompanying AIDS. | journal=Cell Biochem Funct | year= 2004 | volume= 22 | issue= 3 | pages= 137-41 | pmid=15124176 | doi=10.1002/cbf.1095 | pmc= | url= }} </ref>.
*The incidence of AIDS-related cardiac disease is very high in Africa in comparison to that seen in the developed countries. In the period from 1993 to 1999 in Burkina Faso, '''79%''' of AIDS patients exhibited cardiac involvement, whereas in an Italian study in the period from 1992 to 1995, the incidence of AIDS-related cardiac disease was '''6.5%'''<ref name="pmid15124176">{{cite journal| author=Pugliese A, Gennero L, Vidotto V, Beltramo T, Petrini S, Torre D| title=A review of cardiovascular complications accompanying AIDS. | journal=Cell Biochem Funct | year= 2004 | volume= 22 | issue= 3 | pages= 137-41 | pmid=15124176 | doi=10.1002/cbf.1095 | pmc= | url= }} </ref>.


==Pathophysiology==
==Pathophysiology==
Line 28: Line 31:
:*In advanced HIV disease, effusions are a part of '''generalized seroeffusive process''' involving pleural and peritoneal surfaces, possibly related to enhanced cytokine expression, resulting in moderate to large effusions.
:*In advanced HIV disease, effusions are a part of '''generalized seroeffusive process''' involving pleural and peritoneal surfaces, possibly related to enhanced cytokine expression, resulting in moderate to large effusions.
:*[[Congestive heart failure]], [[Kaposi sarcoma]], and [[Tuberculosis]] are '''independently''' associated with moderate to large effusions.
:*[[Congestive heart failure]], [[Kaposi sarcoma]], and [[Tuberculosis]] are '''independently''' associated with moderate to large effusions.


==Etiology==
==Etiology==
Line 45: Line 49:


*Another study that evaluated pericardial effusions in 17 patients with HIV <ref name="pmid8017317">Hsia J, Ross AM (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8017317 Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection.] ''Am J Cardiol'' 74 (1):94-6. PMID: [http://pubmed.gov/8017317 8017317]</ref>, revealed etiologic evidence in 5 patients of which 2 were found to have lymphoma, and 1 each had staphylococcus aureus, mycobacterium tuberculosis, and fungal infection.
*Another study that evaluated pericardial effusions in 17 patients with HIV <ref name="pmid8017317">Hsia J, Ross AM (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8017317 Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection.] ''Am J Cardiol'' 74 (1):94-6. PMID: [http://pubmed.gov/8017317 8017317]</ref>, revealed etiologic evidence in 5 patients of which 2 were found to have lymphoma, and 1 each had staphylococcus aureus, mycobacterium tuberculosis, and fungal infection.
==Diagnosis==
====History and symptoms:====
The frequency and severity of the above symptoms varies with the stage of the infection and the degree of involvement of the [[pericardium]].
*Majority of the are '''asymptomatic''' and present with an increase in the cardiac silhouette on chest x-ray.
*Symptomatic patients present with the following:
::*[[Chest pain]]: characteristically sharp and pleuritic in nature, exacerbated by inspiration and relieved by sitting up and leaning forward.
::*[[breathlessness]]
::*[[Malaise]]
::*[[Fever]]
::*[[Cough]]
::*[[Ankle edema]] and/or [[ascites]]
*About a third of patients with symptomatic [[pericardial effusion]] can develop signs of [[cardiac tamponade]]. <ref name="pmid10047635">Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10047635 Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature.] ''Am Heart J'' 137 (3):516-21. PMID: [http://pubmed.gov/10047635 10047635]</ref>
'''Echocardiogram demonstrating swinging motion of the heart in cardiac tamponade:'''
<youtube v=U4xQ3-VRiNg/>
====Physical Examination:====
'''Vitals:'''
*[[Tachycardia]],
*[[pulsus paradoxus]] and
*[[hypotension]] (in [[cardiac tamponade]]),
'''Neck:'''
*[[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]] may be present.
<youtube v=uB1c2zvkaew/>
'''Chest:'''
*[[Ewart's sign]]: Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid may be present.
*'''Pericardial knock'''
<youtube v=Jtk2vVgQuU0/>
*'''[[Pericardial rub]]'''
<youtube v=Yb-JDZGGVK4/>
'''Abdomen:'''
*[[Hepatomegaly]]
*[[ascites]]
*[[Hepatojugular reflux]] may be present
<youtube v=4LIaUCJP2Hc/>>
'''Extremities:''' [[Ankle edema]]






==References==
==References==
{{reflist}}
{{reflist|2}}


[[Category:Cardiology]]
[[Category:Cardiology]]

Revision as of 17:55, 30 June 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

A wide variety of cardiovascular complications are seen in advanced HIV infected patients. The most common are:


Epidemiology and demographics

Pericardial diseases in the form of pericardial effusion or cardiac tamponade[5][7][8][9] have been recognized as a complication since HIV infection was first reported in 1981.

  • In a small autopsy study, 24% cases reported major cardiac pathology [10].
  • The incidence of pericardial effusion in patients with asymptomatic AIDS was 11% per year before the introduction of effective highly active antiretroviral therapy (HAART). The 6 month survival rate of AIDS patients with effusion was significantly shorter (36%) than the survival rate without effusions (93%). This shortened survival rate remained statistically significant after adjustment for lead-time bias and was independent of CD4 count and albumin level[5].
  • The incidence of AIDS-related cardiac disease is very high in Africa in comparison to that seen in the developed countries. In the period from 1993 to 1999 in Burkina Faso, 79% of AIDS patients exhibited cardiac involvement, whereas in an Italian study in the period from 1992 to 1995, the incidence of AIDS-related cardiac disease was 6.5%[11].


Pathophysiology

Patients with advanced HIV have pericardial involvement at some point and the most common abnormality is pericardial effusion[12].

  • Asymptomatic effusions are mostly small and idiopathic.
  • In advanced HIV disease, effusions are a part of generalized seroeffusive process involving pleural and peritoneal surfaces, possibly related to enhanced cytokine expression, resulting in moderate to large effusions.
  • Congestive heart failure, Kaposi sarcoma, and Tuberculosis are independently associated with moderate to large effusions.


Etiology

It is often difficult to identify the etiology of pericardial effusion in HIV-infected patients. The common organisms isolated are:

  • Mycobacterium tuberculosis which is the most common etiology for pericardial effusion in African HIV-infected patients.[13][14]
  • Staphylococcus aureus [15] [16],
  • Cryptococcus neoformans,[17] and
  • Herpes simplex [18].


Supportive trial data:

  • A retrospective study [19] of 29 patients with AIDS-related pericardial effusion who underwent fluid cultures and pericardial biopsy, etiology was established only in 7% patients. The causes included:
  • Another study that evaluated pericardial effusions in 17 patients with HIV [4], revealed etiologic evidence in 5 patients of which 2 were found to have lymphoma, and 1 each had staphylococcus aureus, mycobacterium tuberculosis, and fungal infection.


Diagnosis

History and symptoms:

The frequency and severity of the above symptoms varies with the stage of the infection and the degree of involvement of the pericardium.

  • Majority of the are asymptomatic and present with an increase in the cardiac silhouette on chest x-ray.
  • Symptomatic patients present with the following:

Echocardiogram demonstrating swinging motion of the heart in cardiac tamponade: <youtube v=U4xQ3-VRiNg/>


Physical Examination:

Vitals:


Neck:

<youtube v=uB1c2zvkaew/>


Chest:

  • Ewart's sign: Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid may be present.
  • Pericardial knock

<youtube v=Jtk2vVgQuU0/>


<youtube v=Yb-JDZGGVK4/>


Abdomen:

<youtube v=4LIaUCJP2Hc/>>


Extremities: Ankle edema




References

  1. ↑ Corallo S, Mutinelli MR, Moroni M, Lazzarin A, Celano V, Repossini A et al. (1988) Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients. Eur Heart J 9 (8):887-92. PMID: 3181175
  2. ↑ Himelman RB, Chung WS, Chernoff DN, Schiller NB, Hollander H (1989) Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study. J Am Coll Cardiol 13 (5):1030-6. PMID: 2926051
  3. ↑ De Castro S, Migliau G, Silvestri A, D'Amati G, Giannantoni P, Cartoni D et al. (1992) Heart involvement in AIDS: a prospective study during various stages of the disease. Eur Heart J 13 (11):1452-9. PMID: 1464334
  4. ↑ 4.0 4.1 Hsia J, Ross AM (1994) Pericardial effusion and pericardiocentesis in human immunodeficiency virus infection. Am J Cardiol 74 (1):94-6. PMID: 8017317
  5. ↑ 5.0 5.1 5.2 Heidenreich PA, Eisenberg MJ, Kee LL, Somelofski CA, Hollander H, Schiller NB et al. (1995) Pericardial effusion in AIDS. Incidence and survival. Circulation 92 (11):3229-34. PMID: 7586308
  6. ↑ Estok L, Wallach F (1998) Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection. Mt Sinai J Med 65 (1):33-9. PMID: 9458682
  7. ↑ Stotka JL, Good CB, Downer WR, Kapoor WN (1989). "Pericardial effusion and tamponade due to Kaposi's sarcoma in acquired immunodeficiency syndrome". Chest. 95 (6): 1359–61. PMID 2721281.
  8. ↑ Karve MM, Murali MR, Shah HM, Phelps KR (1992). "Rapid evolution of cardiac tamponade due to bacterial pericarditis in two patients with HIV-1 infection". Chest. 101 (5): 1461–3. PMID 1582323.
  9. ↑ 9.0 9.1 Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M (1999) Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature. Am Heart J 137 (3):516-21. PMID: 10047635
  10. ↑ Cammarosano C, Lewis W (1985). "Cardiac lesions in acquired immune deficiency syndrome (AIDS)". J Am Coll Cardiol. 5 (3): 703–6. PMID 3973269.
  11. ↑ Pugliese A, Gennero L, Vidotto V, Beltramo T, Petrini S, Torre D (2004). "A review of cardiovascular complications accompanying AIDS". Cell Biochem Funct. 22 (3): 137–41. doi:10.1002/cbf.1095. PMID 15124176.
  12. ↑ Barbaro G (2003). "Pathogenesis of HIV-associated cardiovascular disease". Adv Cardiol. 40: 49–70. PMID 14533546.
  13. ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
  14. ↑ Sudano I, Spieker LE, Noll G, Corti R, Weber R, Lüscher TF (2006). "Cardiovascular disease in HIV infection". Am Heart J. 151 (6): 1147–55. doi:10.1016/j.ahj.2005.07.030. PMID 16781213.
  15. ↑ Stechel RP, Cooper DJ, Greenspan J, Pizzarello RA, Tenenbaum MJ (1986) Staphylococcal pericarditis in a homosexual patient with AIDS-related complex. N Y State J Med 86 (11):592-3. PMID: 3467225
  16. ↑ Decker CF, Tuazon CU (1994) Staphylococcus aureus pericarditis in HIV-infected patients. Chest 105 (2):615-6. PMID: 8306779
  17. ↑ Schuster M, Valentine F, Holzman R (1985) Cryptococcal pericarditis in an intravenous drug abuser. J Infect Dis 152 (4):842. PMID: 4045235
  18. ↑ Freedberg RS, Gindea AJ, Dieterich DT, Greene JB (1987) Herpes simplex pericarditis in AIDS. N Y State J Med 87 (5):304-6. PMID: 3035442
  19. ↑ Flum DR, McGinn JT, Tyras DH (1995) The role of the 'pericardial window' in AIDS. Chest 107 (6):1522-5. PMID: 7781340

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