Cardiac tamponade complicating cytomegalovirus pericarditis in a patient with AIDS

Cardiac tamponade in patients with human immunodeficiency virus disease

The characteristics of cardiac tamponade in patients with human immunodeficiency virus (HIV) disease were examined by evaluating the cases, case series, and related articles, including autopsy series, identified through a comprehensive literature search. One-hundred eighty-five cases of cardiac tamponade have been reported in patients with HIV disease. Sex data were available in 176 patients, of whom 154 (87%) were males. The mean age was 34.7 +/- 10.4 years (range, 11 months to 61 years). Mean CD4 cell count was 98 +/- 95 cells/mm3 (range, 3 to 430 cells/mm3). The most common etiology of pericardial tamponade was mycobacterial infection (78 patients), including Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, and Mycobacterium kansasii. A bacterial cause was found in 20 patients (11%). Staphylococcus aureus was the predominant bacteria, followed by streptococci, Pseudomonas aeruginosa, Listeria monocytogenes, Klebsiella pneumoniae, and Rhodococcus equi. Lymphoma was found in 15 (8%) patients and Kaposi sarcoma in 13 (7%) patients. Numerous unusual organisms, including Cryptococcus neoformans, Nocardia asteroides, Aspergillus species, cytomegalovirus, and herpes simplex were also associated with cardiac tamponade in HIV patients. Occasionally, HIV itself was involved in the pathogenesis. In 48 patients (26%), no cause was found or reported. The most common clinical presentation was dyspnea, followed by fever, cough, chest pain, and cardiac arrest. The predominant pericardial fluid color composition was serosanguineous. The majority of patients died during hospitalization or in the immediate follow-up period. Vigilance for cardiac tamponade in patients with HIV disease, especially in those with opportunistic infections and/or malignancies, and cardiac symptoms, may result in early and proper management of cardiac tamponade in these patients.

Cardiac infections in the immunosuppressed patient

This article presents the various manifestations of cardiac infections found in the immunosuppressed host. Emphasis is placed on the correlation between specific impairments of host defenses and the occurrence of certain types of pathogens. The effect of immunosuppression on the clinical manifestations of these infections is discussed. Finally, appropriate diagnostic modalities are presented for the major types of infections.

Successful diagnosis and management of cytomegalovirus carditis

Cytomegalovirus (CMV)-associated carditis in the immunosuppressed patient carries a 60% mortality. Underlying pathogenesis is poorly understood but may involve either direct viral invasion or autoimmune cardiac damage triggered in response to the infection. Specific anti-cytomegalovirus therapy and/or anti-inflammatory drugs have been shown to benefit in cases where an early diagnosis was established. We report an unusual case of endo-pericarditis which was temporally related to acute cytomegalovirus infection diagnosed by the immediate early antigen detection in cell culture on whole blood.

Tuberculous pericarditis in Tanzanian patients with and without HIV infection

SETTING

Large academic medical center in Tanzania.

OBJECTIVES

To determine the etiologies and outcomes of large pericardial effusions in HIV-infected and uninfected patients.

DESIGN

Prospective cohort study of patients admitted with new large pericardial effusions, confirmed echocardiographically. Patients had pericardial biopsies and drainage with extensive analysis of tissue and fluid specimens, and were followed with clinical and echocardiographic examinations.

RESULTS

Of 28 patients with large pericardial effusions, 19 were infected with HIV-1. 22 had invasive diagnostic procedures: 14 of 14 HIV-infected patients, but only 4 of 8 non-HIV-infected patients, had tuberculous pericarditis (P = 0.01). All but 1 of the HIV-infected patients had strongly positive tuberculin skin tests, and short-term outcomes were similar in the 2 groups.

CONCLUSION

TB is the predominant cause of large pericardial effusion in HIV-infected patients in this setting; non-HIV-infected patients are more likely to have other etiologies. These patients were at an early stage of HIV infection and responded well to treatment. In settings where microbiological studies are not routinely available, HIV-infected patients with large pericardial effusions may be treated empirically for tuberculosis and monitored for improvement. If improvement does not follow within 2-4 weeks further studies are indicated. HIV-negative patients should undergo diagnostic evaluation initially.

HIV-associated pericardial effusions

Following a case of cardiac tamponade in a patient with the acquired immunodeficiency syndrome (AIDS), we examined the frequency and clinical spectrum of pericardial effusions associated with human immunodeficiency virus infection (HIV) at our institution. Of 187 hospitalized patients documented to have pericardial effusions over a one-year period, 14 (7 percent) were known to be HIV-positive at the time of their echocardiograms. One patient presented with a large effusion and cardiac tamponade, three had moderate effusions, and ten had small effusions. The probable effusion etiology was established in four cases and included endocarditis (2), lymphoma (1), and myocardial infarction (1). In hospital mortality was 29 percent (4 of 14). From our study, as well as a growing number of reports in the literature, we conclude that HIV-associated pericardial effusions are frequently seen and that their clinical spectrum is broad.