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==Treatment==


*'''Asymptomatic with mild to moderate pericardial effusion:'''
::*usually idiopathic and will resolve spontaneously.
::*However, asymptomatic effusions in [[HIV]] occurs in advanced stages of the disease or heralds the onset of full-blown AIDS and hence requires treatment to improve survival.<ref name="pmid14533546">Barbaro G (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14533546 Pathogenesis of HIV-associated cardiovascular disease.] ''Adv Cardiol'' 40 ():49-70. PMID: [http://pubmed.gov/14533546 14533546]</ref> [[HAART]] therapy has significantly reduced the incidence and severity of cardiac complications associated with [[HIV]].<ref name="pmid16330702">Ntsekhe M, Hakim J (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16330702 Impact of human immunodeficiency virus infection on cardiovascular disease in Africa.] ''Circulation'' 112 (23):3602-7. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.549220 DOI:10.1161/CIRCULATIONAHA.105.549220] PMID: [http://pubmed.gov/16330702 16330702]</ref> <ref name="pmid16781213">Sudano I, Spieker LE, Noll G, Corti R, Weber R, Lüscher TF (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16781213 Cardiovascular disease in HIV infection.] ''Am Heart J'' 151 (6):1147-55. [http://dx.doi.org/10.1016/j.ahj.2005.07.030 DOI:10.1016/j.ahj.2005.07.030] PMID: [http://pubmed.gov/16781213 16781213]</ref>


*'''Symptomatic large effusions even without [[cardiac tamponade]]:''' require [[pericardiocentesis]] and obtain cultures, cytology to identify the possible etiology.
*'''Pericarditis with [[cardiac tamponade]]:''' occurs in 33-40% patients.<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> This warrants immediate [[pericardiocentesis]] and a catheter is left in the pericardial sac to drain fluid by underwater-seal suction for the next 48 hours.
*'''Recurrent pericardial effusion:''' Either subxiphoid pericardiotomy with creation of a pericardial window <ref name="pmid7781340">Flum DR, McGinn JT, Tyras DH (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7781340 The role of the 'pericardial window' in AIDS.] ''Chest'' 107 (6):1522-5. PMID: [http://pubmed.gov/7781340 7781340]</ref> <ref name="pmid9583822">Gouny P, Lancelin C, Girard PM, Hocquet-Cheynel C, Rozenbaum W, Nussaume O (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9583822 Pericardial effusion and AIDS: benefits of surgical drainage.] ''Eur J Cardiothorac Surg'' 13 (2):165-9. PMID: [http://pubmed.gov/9583822 9583822]</ref> or balloon pericardiotomy can be considered.<ref name="pmid8417048">Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC et al. (1993) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8417048 Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases.] ''J Am Coll Cardiol'' 21 (1):1-5. PMID: [http://pubmed.gov/8417048 8417048]</ref> <ref name="pmid15662494">Marcy PY, Bondiau PY, Brunner P (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15662494 Percutaneous treatment in patients presenting with malignant cardiac tamponade.] ''Eur Radiol'' 15 (9):2000-9. [http://dx.doi.org/10.1007/s00330-004-2611-y DOI:10.1007/s00330-004-2611-y] PMID: [http://pubmed.gov/15662494 15662494]</ref>
*'''Large pericardial effusions with unknown etiology:''' empiric therapy with conventional antituberculous therapy for M.tuberculosis have shown some benefit in patients with AIDS. <ref name="pmid1898769">Small PM, Schecter GF, Goodman PC, Sande MA, Chaisson RE, Hopewell PC (1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1898769 Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection.] ''N Engl J Med'' 324 (5):289-94. [http://dx.doi.org/10.1056/NEJM199101313240503 DOI:10.1056/NEJM199101313240503] PMID: [http://pubmed.gov/1898769 1898769]</ref> <ref name="pmid3723722">Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB (1986) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3723722 Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS).] ''JAMA'' 256 (3):362-6. PMID: [http://pubmed.gov/3723722 3723722]</ref> <ref name="pmid17976506">Syed FF, Mayosi BM (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17976506 A modern approach to tuberculous pericarditis.] ''Prog Cardiovasc Dis'' 50 (3):218-36. [http://dx.doi.org/10.1016/j.pcad.2007.03.002 DOI:10.1016/j.pcad.2007.03.002] PMID: [http://pubmed.gov/17976506 17976506]</ref>
*'''Other causes''' of pericarditis such as bacterial or fungal infections also should be identified and treated accordingly.
*'''Pericarditis due to [[lymphoma]]:''' radiation and chemotherapy have been tried. <ref name="pmid1727539">Levine AM (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727539 AIDS-associated malignant lymphoma.] ''Med Clin North Am'' 76 (1):253-68. PMID: [http://pubmed.gov/1727539 1727539]</ref> <ref name="pmid17325873">Licci S, Narciso P, Morelli L, Brenna A, Cione A, Abbate I et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17325873 Primary effusion lymphoma in pleural and pericardial cavities with multiple solid nodal and extra-nodal involvement in a human immunodeficiency virus-positive patient.] ''Leuk Lymphoma'' 48 (1):209-11. [http://dx.doi.org/10.1080/10428190601019880 DOI:10.1080/10428190601019880] PMID: [http://pubmed.gov/17325873 17325873]</ref> The response however has been transient <ref name="pmid9760158">Sanna P, Bertoni F, Zucca E, Roggero E, Passega Sidler E, Fiori G et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9760158 Cardiac involvement in HIV-related non-Hodgkin's lymphoma: a case report and short review of the literature.] ''Ann Hematol'' 77 (1-2):75-8. PMID: [http://pubmed.gov/9760158 9760158]</ref> and associated chemotherapy has a significantly increased the risk of death due to opportunistic infections.<ref name="pmid1727539">Levine AM (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727539 AIDS-associated malignant lymphoma.] ''Med Clin North Am'' 76 (1):253-68. PMID: [http://pubmed.gov/1727539 1727539]</ref> 
==Prognosis==
*Pericarditis in patients with [[HIV]] occurs in advanced stages of the disease or heralds the onset of full-blown [[AIDS]] and hence is a '''bad prognostic sign'''. <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="pmid12934767">Gowda RM, Khan IA, Mehta NJ, Gowda MR, Sacchi TJ, Vasavada BC (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12934767 Cardiac tamponade in patients with human immunodeficiency virus disease.] ''Angiology'' 54 (4):469-74. PMID: [http://pubmed.gov/12934767 12934767]</ref> <ref name="pmid1826690">Blanchard DG, Hagenhoff C, Chow LC, McCann HA, Dittrich HC (1991) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1826690 Reversibility of cardiac abnormalities in human immunodeficiency virus (HIV)-infected individuals: a serial echocardiographic study.] ''J Am Coll Cardiol'' 17 (6):1270-6. PMID: [http://pubmed.gov/1826690 1826690]</ref> <ref name="pmid9579818">Longo-Mbenza B, Seghers KV, Phuati M, Bikangi FN, Mubagwa K (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9579818 Heart involvement and HIV infection in African patients: determinants of survival.] ''Int J Cardiol'' 64 (1):63-73. PMID: [http://pubmed.gov/9579818 9579818]</ref>
*Pericarditis in [[HIV]] patients is also associated with '''shortened survival'''. <ref name="pmid14533546">Barbaro G (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14533546 Pathogenesis of HIV-associated cardiovascular disease.] ''Adv Cardiol'' 40 ():49-70. PMID: [http://pubmed.gov/14533546 14533546]</ref>
'''Supportive trial data:'''
*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<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>.




Revision as of 20:57, 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


Treatment

  • Asymptomatic with mild to moderate pericardial effusion:
  • usually idiopathic and will resolve spontaneously.
  • However, asymptomatic effusions in HIV occurs in advanced stages of the disease or heralds the onset of full-blown AIDS and hence requires treatment to improve survival.[12] HAART therapy has significantly reduced the incidence and severity of cardiac complications associated with HIV.[20] [14]
  • Pericarditis with cardiac tamponade: occurs in 33-40% patients.[9] This warrants immediate pericardiocentesis and a catheter is left in the pericardial sac to drain fluid by underwater-seal suction for the next 48 hours.
  • Recurrent pericardial effusion: Either subxiphoid pericardiotomy with creation of a pericardial window [19] [21] or balloon pericardiotomy can be considered.[22] [23]
  • Large pericardial effusions with unknown etiology: empiric therapy with conventional antituberculous therapy for M.tuberculosis have shown some benefit in patients with AIDS. [24] [25] [26]
  • Other causes of pericarditis such as bacterial or fungal infections also should be identified and treated accordingly.
  • Pericarditis due to lymphoma: radiation and chemotherapy have been tried. [27] [28] The response however has been transient [29] and associated chemotherapy has a significantly increased the risk of death due to opportunistic infections.[27]


Prognosis

  • Pericarditis in patients with HIV occurs in advanced stages of the disease or heralds the onset of full-blown AIDS and hence is a bad prognostic sign. [5] [30] [31] [32]
  • Pericarditis in HIV patients is also associated with shortened survival. [12]


Supportive trial data:

  • 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].


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 5.3 5.4 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 9.2 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. ↑ 12.0 12.1 12.2 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. ↑ 14.0 14.1 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. ↑ 19.0 19.1 Flum DR, McGinn JT, Tyras DH (1995) The role of the 'pericardial window' in AIDS. Chest 107 (6):1522-5. PMID: 7781340
  20. ↑ Ntsekhe M, Hakim J (2005) Impact of human immunodeficiency virus infection on cardiovascular disease in Africa. Circulation 112 (23):3602-7. DOI:10.1161/CIRCULATIONAHA.105.549220 PMID: 16330702
  21. ↑ Gouny P, Lancelin C, Girard PM, Hocquet-Cheynel C, Rozenbaum W, Nussaume O (1998) Pericardial effusion and AIDS: benefits of surgical drainage. Eur J Cardiothorac Surg 13 (2):165-9. PMID: 9583822
  22. ↑ Ziskind AA, Pearce AC, Lemmon CC, Burstein S, Gimple LW, Herrmann HC et al. (1993) Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol 21 (1):1-5. PMID: 8417048
  23. ↑ Marcy PY, Bondiau PY, Brunner P (2005) Percutaneous treatment in patients presenting with malignant cardiac tamponade. Eur Radiol 15 (9):2000-9. DOI:10.1007/s00330-004-2611-y PMID: 15662494
  24. ↑ Small PM, Schecter GF, Goodman PC, Sande MA, Chaisson RE, Hopewell PC (1991) Treatment of tuberculosis in patients with advanced human immunodeficiency virus infection. N Engl J Med 324 (5):289-94. DOI:10.1056/NEJM199101313240503 PMID: 1898769
  25. ↑ Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB (1986) Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). JAMA 256 (3):362-6. PMID: 3723722
  26. ↑ Syed FF, Mayosi BM (2007) A modern approach to tuberculous pericarditis. Prog Cardiovasc Dis 50 (3):218-36. DOI:10.1016/j.pcad.2007.03.002 PMID: 17976506
  27. ↑ 27.0 27.1 Levine AM (1992) AIDS-associated malignant lymphoma. Med Clin North Am 76 (1):253-68. PMID: 1727539
  28. ↑ Licci S, Narciso P, Morelli L, Brenna A, Cione A, Abbate I et al. (2007) Primary effusion lymphoma in pleural and pericardial cavities with multiple solid nodal and extra-nodal involvement in a human immunodeficiency virus-positive patient. Leuk Lymphoma 48 (1):209-11. DOI:10.1080/10428190601019880 PMID: 17325873
  29. ↑ Sanna P, Bertoni F, Zucca E, Roggero E, Passega Sidler E, Fiori G et al. (1998) Cardiac involvement in HIV-related non-Hodgkin's lymphoma: a case report and short review of the literature. Ann Hematol 77 (1-2):75-8. PMID: 9760158
  30. ↑ Gowda RM, Khan IA, Mehta NJ, Gowda MR, Sacchi TJ, Vasavada BC (2003) Cardiac tamponade in patients with human immunodeficiency virus disease. Angiology 54 (4):469-74. PMID: 12934767
  31. ↑ Blanchard DG, Hagenhoff C, Chow LC, McCann HA, Dittrich HC (1991) Reversibility of cardiac abnormalities in human immunodeficiency virus (HIV)-infected individuals: a serial echocardiographic study. J Am Coll Cardiol 17 (6):1270-6. PMID: 1826690
  32. ↑ Longo-Mbenza B, Seghers KV, Phuati M, Bikangi FN, Mubagwa K (1998) Heart involvement and HIV infection in African patients: determinants of survival. Int J Cardiol 64 (1):63-73. PMID: 9579818

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