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 ^[1] ^[2] ^[3] ^[4] ^[5] ^[6]
Myocarditis
Cardiomyopathy
Pulmonary hypertension
Coronary artery disease

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:

Mycobacterium tuberculosis which is the most common etiology for pericardial effusion in African HIV-infected patients^[15]^[11]
Staphylococcus aureus ^[16] ^[17]
Cryptococcus neoformans ^[18]
Herpes simplex ^[19]

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:

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

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.

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

Pericardial rub

Abdomen:

Hepatomegaly

Ascites

Hepatojugular reflux may be present

Extremities: Ankle edema

Electrocardiography

The presence of micro-voltage and electrical alternanssuggests pericardial effusion and tamponade.

CXR:

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

Echocardiography:

Approximately one third of the patients with symptomatic pericardial effusion can develop cardiac tamponade.^[9]

A baseline echocardiography is indicated in HIV patients regardless of the stage of the disease, or in patients with evidence of heart failure, Kaposi's sarcoma, tuberculosis.^[21]

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

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]

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.^[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.

Recurrent pericardial effusion: Either subxiphoid pericardiotomy with creation of a pericardial window ^[20] ^[23] or balloon pericardiotomy can be considered.^[24] ^[25]

Large pericardial effusions with unknown etiology: Empiric antituberculous therapy for M.tuberculosis have shown some benefit in patients with AIDS. ^[26] ^[27] ^[28]

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]