HIV induced pericarditis

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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:

• Pericarditis
• Myocarditis
• Cardiomyopathy
• Pulmonary hypertension
• Coronary artery disease

Epidemiology and demographics

Pericardial diseases in the form of pericardial effusion or cardiac tamponade 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 .

• 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.

• 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%.

Pathophysiology

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

• 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.
• Staphylococcus aureus ,
• Cryptococcus neoformans, and
• Herpes simplex .

Supportive trial data:

• A retrospective study 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:

• Mycobacterium tuberculosis (1%),
• Staphylococcus aureus (1%), and
• Neoplasms (2% adenocarcinoma and 3% lymphoma)

• Another study that evaluated pericardial effusions in 17 patients with HIV , 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.

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

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• Pericardial rub

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Abdomen:

• Hepatomegaly

• ascites

• Hepatojugular reflux may be present

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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. HAART therapy has significantly reduced the incidence and severity of cardiac complications associated with HIV.

• 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. 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 or balloon pericardiotomy can be considered.

• Large pericardial effusions with unknown etiology: empiric therapy with conventional antituberculous therapy for M.tuberculosis have shown some benefit in patients with AIDS.

• 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. The response however has been transient and associated chemotherapy has a significantly increased the risk of death due to opportunistic infections.

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.

• Pericarditis in HIV patients is also associated with shortened survival.

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.