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:

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

Electrocardiography

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

Micro-voltage with electrical alternans


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

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  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
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  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
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