Extensive vascular calcification in a patient with perinatally acquired AIDS

Efavirenz and ritonavir-boosted lopinavir use exhibited elevated markers of atherosclerosis across age groups in people living with HIV in Ethiopia

BACKGROUND

HIV patients on highly-active antiretroviral therapy (HAART) have shown elevated incidence of dyslipidemia, lipodystrophy, and markers of cardiovascular disease. Evidence is beginning to emerge that implicates efavirenz (EFV) as a potential mediator of early on-set cardiovascular disease.

METHODS

Pediatric and adult HIV-infected HAART-naïve, EFV-treated, nevirapine (NVP)-treated, and ritonavir-boosted lopinavir (LPV/r)-treated subjects were recruited from Black Lion Hospital in Addis Ababa, Ethiopia. Pulse wave velocity (PWV), carotid intima-media thickness (cIMT), carotid arterial stiffness, brachial artery flow-mediated dilation (FMD), body mass index, waist-to-hip circumference ratio, and skinfold thickness were measured. CD4+ cell count, fasting glucose, lipoprotein profiles and triglycerides were also determined. Results were segmented into pediatric (6-17 years of age), young adults (25-39 years old) and older adults (40-60 years old).

RESULTS

PWV was generally elevated in EFV- and LPV/r-treated subjects compared to NVP-treated subjects across age groups. cIMT was elevated in EFV- and LPV/r-treated compared to NVP-treated older adults and in EFV-treated compared to HAART-naïve older adults. FMD was impaired in EFV- and LPV/r-treated compared to HAART-naïve younger adults, in EFV-treated compared to NVP-treated young and older adults, and in LPV/r-treated compared to NVP-treated older adults. Differences in lipoprotein profiles and skinfold thickness with HAART regimen were observed in pediatric and young adults, but less so in older adults.

CONCLUSIONS

Whereas LPV/r and other protease inhibitors have long been recognized as mediators of HIV/HAART-associated atherosclerosis, this report supports the emerging evidence that EFV may also mediate cardiovascular disease in people living with HIV on HAART.

Splenic para-amyloid material: a possible vasculopathy of the acquired immunodeficiency syndrome

We have observed perivascular para-amyloid in the spleens of acquired immune deficiency syndrome (AIDS) patients at autopsy. Whether this phenomenon is unique to AIDS patients or is a common degenerative phenomenon in the spleen has not been determined. Autopsy spleens from 355 patients (171 AIDS, 184 non-AIDS) were graded for presence of splenic para-amyloid material (SPAM) on a scale of 0 to 3. The average ages of the AIDS and non-AIDS groups were 38.4 and 60.4 years, respectively. All SPAM-positive AIDS cases had age-matched non-AIDS controls. Selected positive cases were examined ultrastructurally. Of the 171 AIDS patients, 55 had SPAM; in 30 cases, it was considered grade 2 or 3. Although none of the non-AIDS cases were graded 2 or 3, eight of them were grade 1. SPAM is highly correlated with AIDS (32.1 v 4.3%; P < .0001), with a specificity of 95.6% and a positive predictive value of 87.3%. These perivascular deposits correspond to areas of periarteriolar lymphoid sheaths and appear to be in continuity with arteriolar adventitia. Ultrastructurally, they contain collagen, long-spaced collagen, fibrillin, and occasional residual cells. No viral particles were noted. SPAM appears to be more prevalent and in greater quantity in AIDS patients. It does not correlate with advanced age; it can be mistaken for amyloid. Its consistent association with the adventitia of vessels raises the possibility of a new vasculopathy of AIDS; it also may be related to follicular involution and hyalinization associated with regression of prior follicular hyperplasia.