HIV induced pericarditis: Difference between revisions

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


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.  
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 complications 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''' were reported with 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>.


*Another autopsy study reported '''9% cardiac lesions''' consisting of fibrinous pericarditis with or without [[Pericardial effusion|effusion]] in [[AIDS]] patients.<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="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><ref name="pmid12408791">Harmon WG, Dadlani GH, Fisher SD, Lipshultz SE (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12408791 Myocardial and Pericardial Disease in HIV.] ''Curr Treat Options Cardiovasc Med'' 4 (6):497-509. PMID: [http://pubmed.gov/12408791 12408791]</ref>
*Another autopsy study reported '''9% cardiac lesions''' consisting of fibrinous pericarditis with or without [[Pericardial effusion|effusion]] in [[AIDS]] patients.<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="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><ref name="pmid12408791">Harmon WG, Dadlani GH, Fisher SD, Lipshultz SE (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12408791 Myocardial and Pericardial Disease in HIV.] ''Curr Treat Options Cardiovasc Med'' 4 (6):497-509. PMID: [http://pubmed.gov/12408791 12408791]</ref>
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*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>.
*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>.


*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 during the period 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==
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====History and symptoms:====
====History and symptoms:====
The frequency and severity of the symptoms varies with the stage of infection and the degree [[pericardium|pericardial]] involvement.
The frequency and severity of the symptoms varies with the stage of infection and the degree of [[pericardium|pericardial]] involvement.


*Majority of the patients are '''asymptomatic''' and present with an increase in the cardiac silhouette on chest x-ray.
*Majority of the patients may be '''asymptomatic''', presenting with an increase in the cardiac silhouette on chest x-ray.


*Symptomatic patients present with the following:
*Symptomatic patients present with the following:
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*[[Hepatomegaly]]
*[[Hepatomegaly]]


*[[ascites]]
*[[Ascites]]


*[[Hepatojugular reflux]] may be present
*[[Hepatojugular reflux]] may be present
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====CXR:====
====CXR:====
An '''increase in the cardiac silhouette''' is seen in asymptomatic patients and symptomatic patients present with [[pericardial effusion]]<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>
An '''increase in the cardiac silhouette''' may be seen in asymptomatic patients. Symptomatic patients may present with [[pericardial effusion]]<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>


[[Image:Pericardial effusion 4.jpg]]
[[Image:Pericardial effusion 4.jpg]]
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*'''Symptomatic large effusions without [[cardiac tamponade]]:''' requires [[pericardiocentesis]] for both therapeutic and diagnostic purposes, to identify possible etiology.
*'''Symptomatic large effusions without [[cardiac tamponade]]:''' requires [[pericardiocentesis]] for both therapeutic and diagnostic purposes, to identify 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 for the next 48 hours to continuously drain fluid by underwater-seal suction.
*'''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 placed in the pericardial sac for the next 48 hours to continuously drain fluid by underwater-seal suction.


*'''Recurrent pericardial effusion:''' Either [[Pericardial window|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>
*'''Recurrent pericardial effusion:''' Either [[Pericardial window|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:''' [[Tuberculous pericarditis#AAnti-tuberculosis chemotherapy|Empiric 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>
*'''Large pericardial effusions with unknown etiology:''' [[Tuberculous pericarditis#AAnti-tuberculosis chemotherapy|Empiric 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>
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*'''Other causes''' of pericarditis such as bacterial or fungal infections also should be identified and treated accordingly.  
*'''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>   
*'''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 the associated chemotherapy has significantly increased the risk of death secondary 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==
==Prognosis==
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'''Supportive trial data:'''
'''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>.
*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>.


==References==
==References==

Revision as of 14:53, 6 July 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 complications since HIV infection was first reported in 1981.

  • In a small autopsy study, 24% cases were reported with major cardiac pathology [10].
  • Another autopsy study reported 9% cardiac lesions consisting of fibrinous pericarditis with or without effusion in AIDS patients.[5][11][12]
  • 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 during the period 1992 to 1995, the incidence of AIDS-related cardiac disease was 6.5%[13].

Pathophysiology

Patients with advanced HIV have pericardial involvement at some point and the most common abnormality is pericardial effusion[14].

  • Asymptomatic effusions are mostly small and idiopathic.
  • In advanced HIV disease, effusions are a part of generalized seroeffusive process (capillary leak) 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:

Supportive trial data:

  • A retrospective study [20] 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 [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 symptoms varies with the stage of infection and the degree of pericardial involvement.

  • Majority of the patients may be asymptomatic, presenting with an increase in the cardiac silhouette on chest x-ray.
  • Symptomatic patients present with the following:

Physical Examination:

Vitals:

Neck:

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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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Abdomen:

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Extremities: Ankle edema

CXR:

An increase in the cardiac silhouette may be seen in asymptomatic patients. Symptomatic patients may present with pericardial effusion[4]

Echocardiography:

The echocardiogram below demonstrates swinging motion of the heart in cardiac tamponade.[7][8]

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Treatment

  • Asymptomatic with mild to moderate pericardial effusion:
  • Mostly idiopathic and resolves 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.[14] HAART therapy has significantly reduced the incidence and severity of cardiac complications associated with HIV.[22] [11]
  • Pericarditis with cardiac tamponade: occurs in 33-40% patients.[9] This warrants immediate pericardiocentesis and a catheter is placed in the pericardial sac for the next 48 hours to continuously drain fluid by underwater-seal suction.
  • 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. [29] [30] The response however has been transient [31] and the associated chemotherapy has significantly increased the risk of death secondary to opportunistic infections.[29]

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] [32] [33] [34]
  • Pericarditis in HIV patients is also associated with shortened survival. [14]

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 4.2 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 5.5 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. ↑ 7.0 7.1 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. ↑ 8.0 8.1 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. ↑ 11.0 11.1 11.2 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
  12. ↑ Harmon WG, Dadlani GH, Fisher SD, Lipshultz SE (2002) Myocardial and Pericardial Disease in HIV. Curr Treat Options Cardiovasc Med 4 (6):497-509. PMID: 12408791
  13. ↑ 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.
  14. ↑ 14.0 14.1 14.2 Barbaro G (2003). "Pathogenesis of HIV-associated cardiovascular disease". Adv Cardiol. 40: 49–70. PMID 14533546.
  15. ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
  16. ↑ 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
  17. ↑ Decker CF, Tuazon CU (1994) Staphylococcus aureus pericarditis in HIV-infected patients. Chest 105 (2):615-6. PMID: 8306779
  18. ↑ Schuster M, Valentine F, Holzman R (1985) Cryptococcal pericarditis in an intravenous drug abuser. J Infect Dis 152 (4):842. PMID: 4045235
  19. ↑ 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
  20. ↑ 20.0 20.1 Flum DR, McGinn JT, Tyras DH (1995) The role of the 'pericardial window' in AIDS. Chest 107 (6):1522-5. PMID: 7781340
  21. ↑ Lipshultz SE, Fisher SD, Lai WW, Miller TL (2003) Cardiovascular risk factors, monitoring, and therapy for HIV-infected patients. AIDS 17 Suppl 1 ():S96-122. PMID: 12870537
  22. ↑ 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
  23. ↑ 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
  24. ↑ 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
  25. ↑ 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
  26. ↑ 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
  27. ↑ 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
  28. ↑ 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
  29. ↑ 29.0 29.1 Levine AM (1992) AIDS-associated malignant lymphoma. Med Clin North Am 76 (1):253-68. PMID: 1727539
  30. ↑ 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
  31. ↑ 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
  32. ↑ 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
  33. ↑ 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
  34. ↑ 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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