Cardiovascular disease in HIV infection

The survival of patients with HIV infection who have access to highly active antiretroviral therapy has dramatically increased. In HIV-infected persons, cardiovascular disease can be associated with HIV infection, opportunistic infections or neoplasias, use of antiretroviral drugs or treatment of opportunistic complications, mode of HIV acquisition (such as intravenous drug use), or with the classic non-HIV-related cardiovascular risk factors (such as smoking or age). Diseases of the heart associated with HIV infection or its opportunistic complications include pericarditis and myocarditis. Pericarditis may lead to pericardial effusion rarely causing tamponade. Cardiomyopathy is often clinically silent with asymptomatic left ventricular systolic dysfunction. Endocarditis is mainly the consequence of intravenous drug abuse, possibly leading to life-threatening valvular insufficiency with the need for cardiac surgery. A further serious condition associated with HIV infection is pulmonary hypertension potentially leading to right heart failure. The cardiovascular complications of HIV infection such as cardiomyopathy and pericarditis have been reduced by highly active antiretroviral therapy, but premature coronary atherosclerosis is now a growing problem because antiretroviral drugs can lead to serious metabolic disturbances resembling those in the metabolic syndrome. Lipodystrophy, a clinical syndrome of peripheral fat wasting, central adiposity, dyslipidemia, and insulin resistance, is most prevalent among patients treated with protease inhibitors. These patients should thus be screened for hyperlipidemia, hyperglycemia, and hypertension, and they may be candidates for lipid-lowering therapies. When initiating lipid-lowering therapy, interactions between statins and HIV protease inhibitors affecting cytochrome P450 function must be considered. Restenosis rate after percutaneous coronary intervention may be unexpectedly high.     

Cardiovascular disease in patients with HIV

With the progressive increase in life expectancy of HIV-positive patient, thanks to “highly active antiretroviral therapy” (HAART), new comorbidities, and especially cardiovascular diseases (CVDs) are emerging as an important concern. An increased risk of coronary artery disease, often in a younger age, has been observed in this population. The underlying pathophysiology is complex and partially still unclear, with the interaction of viral infection—and systemic inflammation—antiretroviral therapy and traditional risk factors.After an accurate risk stratification, primary prevention should balance the optimal HAART to suppress the virus—avoiding side-effects—the intervention on life-style and the treatment of traditional risk factors (hypertension, dyslipidemia, and diabetes). Also the management after a cardiovascular event is challenging: revascularization strategies—both percutaneous and surgical—are valuable options, keeping in mind the higher rates of recurrent events, and caution is essential to avoid drug–drug interactions.Large evidence-based data on HIV-infected patients are still lacking, and recommendations often follow those of general population. Therefore we performed a comprehensive evaluation of the literature to analyze the current knowledge on CVD’s prevalence, prevention and treatment in HIV-infected patients.     

Cardiovascular complications of Salmonella enteritidis infection

Salmonella has the ability to adhere to damaged endothelium, predisposing individuals to complications rarely seen with other Gram-negative organisms. Potential complications include endocarditis, infected atheroma or aneurysms, myocarditis and pericarditis. The present report describes two cases of Salmonella enteritidis-associated cardiovascular disease. Patient 1 is a young adult who presented with myopericarditis complicated by recurrent cardiac arrests following return from a tropical climate. This patient was successfully treated with a 14-day course of ciprofloxacin. Patient 2 is an elderly man who developed a pseudoaneurysm of the ascending aorta complicating S enteritidis bacteremia, and died of this complication. Recognition of potential complications of salmonellosis, especially in individuals with risk factors, is paramount in correctly diagnosing and managing these patients.     

Pulmonary complications of HIV infection

Abstract:   The AIDS epidemic has had a devastating global impact in the last two decades; although prevalence rates are low in Asia and the Pacific, their enormous population is associated with an estimated 1 million people infected with HIV in 2006 alone. Survival from what had been a uniformly fatal illness has improved markedly with combination antiretroviral therapy and restoration of the immune system, but these treatments are expensive and difficult to distribute to the millions who need them around the world. In addition, millions more do not know they are infected with HIV until they develop an opportunistic infection. The lungs are the most frequent sites of these infections, and in different geographic regions, tuberculosis, bacterial pneumonia and Pneumocystis jiroveci are the dominant pathogens. The incidences of lung cancer and HIV-associated pulmonary arterial hypertension are also increasing in patients with HIV infection, and with the use of antiretrovirals, inflammatory disorders associated with immune restoration are being recognized.     

Cardiovascular and endothelial disease in HIV infection

As combination antiretroviral therapy improves outcome for HIV-infected patients, more focus is directed on the durability of these regimens and the prevention of long-term adverse events. Given the prevalence of metabolic complications associated with combination therapy, namely insulin resistance, dyslipidemia, and truncal adiposity, interest in whether these complications predispose patients to cardiovascular disease prematurely is appropriate. This paper reviews the most recent data regarding the effects of HIV and its treatment on endothelial dysfunction, serum biomarkers, and vascular indices, and provides an update on the risk for cardiovascular events in the HIV-infected patient population.     

Rheumatologic complications of HIV infection

The impact of the global HIV pandemic continues to grow, hence the need for the rheumatologist to keep aware of the wide spectrum of rheumatic diseases that have been described in HIV-positive individuals. Most of these are typical of what is encountered in non-HIV populations (soft-tissue rheumatism, reactive arthritis, polymyositis). Others represent entities that may be specific to the setting of HIV (DILS, HIV-associated arthritis). Effective antiretroviral treatment improves the clinical signs and symptoms of many HIV-associated rheumatic diseases (reactive arthritis, DILS). The introduction of HAART therapy has not only prolonged the lives of patients with HIV infection, it has also introduced a new spectrum of diseases (arthralgia, rhabdomyolysis, osteonecrosis) that must be considered by the practicing clinician, and effective immune reconstitution may reactivate certain rheumatic diseases of which HIV infection itself may have caused remission (RA, SLE, etc). The spectrum of rheumatic disease associated with HIV infection and its treatment continues to be an evolving story which will continue for the indefinite future.

• HIV-associated arthritis differs from HIV-associated spondyloarthritis in the lack of entheseal involvement, less inflammatory synovial fluid, and lack of association with HLA-B27

• treatment of HIV-associated joint disease starts with NSAIDS (once infection or gout have been ruled out); second-line agents such as sulfasalazine and methotrexate can be considered in refractory patients, although methotrexate should be used with great caution in patients with a CD4 count <200/mm³

• effective HIV control is also an important adjunct, especially in patients with psoriais

• the use of anti-TNF blockers in patients with HIV-associated spondyloarthritis is under investigation and is not recommended at present

• care must be taken to rule out non-HIV-related causes of muscle damage (i.e. cocaine use, hypothyroidism, HIV medications) in patients presenting with muscle weakness and creatine kinase elevations

• getting a muscle biopsy is essential to rule out other types of myopathy that are less responsive to corticosteroid/immunosuppressive treatment (i.e. inclusion-body myositis, nemaline rod myopathy)

• treatment is glucocorticoids in moderate to high doses; immunosuppressive agents such as methotrexate or azathioprine can be added in refractory patients whose CD4 counts are >200/mm³

• the overall prognosis of HIV-associated polymyositis is good, and most patients respond to treatment and are in remission 2 years later

• the diagnosis of DILS has classically been made with the right clinical setting (i.e. unexplained parotid enlargement and/or sicca complex) and minor salivary-gland biopsy (in patients not taking HAART treatment)

• patients taking HAART should avoid minor salivary-gland biopsy due to the high rate of false negatives, and instead should have the clinical suspicion confirmed with Ga⁶⁷ scanning

• the first step in treatment is effective antiretroviral control; beyond that, a short-term course of low- to moderate-dose glucocorticoids may provide symptomatic relief of the parotid swelling and discomfort associated with DILS, while pilocarpine or cevimeline can provide relief of the xerostomia and artificial tears the xerophthalmia

• various types of vasculitis have been observed, including polyarteritis nodosa, isolated CNS angiitis, Henoch–Schönlein purpura, Behcet's disease, Kawasaki's disease, hypersensitivity vasculitis, and a focal necrotizing arteritis of the aorta

• corticosteroids remain the mainstay of treatment of HIV-associated vasculitis, although cytotoxic agents have been employed in refractory cases

• cytotoxic agents should be avoided in vasculitis when the CD4 count is <200/mm³

• that certain rheumatic diseases occur more frequently in the setting of immunologic collapse brought on by HIV infection should teach us about the pathogenesis of these diseases, yet we have not learned the lessons from this experiment of nature

• the change in the spectrum of rheumatic diseases occurring in HIV-positive individuals is undergoing marked change with the use of HAART; the ‘immune reconstitution’ that is encountered is introducing autoimmunity as a side-effect, and the extent to which this is happening needs to be further appreciated and steps taken for its prevention

Legionellosis in patients with HIV infection

Summary During the five-year period 1984–1988 we received 192 specimens from 180 patients infected with the human immunodeficiency virus (HIV) for investigation ofLegionella infection. The majority of specimens were bronchoalveolar lavage (BAL) fluids (84%), but tracheal suctions and lung tissue from autopsies were also examined. The diagnostic methods used were a direct immunofluorescence assay (DFA) for the detection ofLegionella antigen, and culture on buffered charcoal yeast extract (BCYE-) media. All specimens were also examined for the presence of other bacterial lung pathogens, and all BAL specimens additionally forPneumocystis carinii and mycobacteria. Legionellosis was not found to be common among HIV-infected patients, as only six specimens (3%) from six patients were found positive by DFA, and no specimens were culture-positive forLegionella species. Dual infection withLegionella andP. carinii occurred in two patients. Clinical data of the six patients are presented, and currently used methods for diagnosing legionellosis are discussed.

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Legionellose bei Patienten mit HIV-Infektion

Zusammenfassung In einem Zeitraum von fünf Jahren (1984–1988) erhielten wir 192 Proben von 180 mit dem menschlichen Immunschwächevirus (HIV) infizierten Patienten zur Untersuchung aufLegionella-Infektion. Die meisten Proben (84%) waren Bronchoalveolarlavageflüssigkeit, außerdem wurde durch Trachealabsaugung gewonnenes Material und autoptisch entnommenes Gewebe untersucht. Zum Nachweis von Legionella-Antigen wurde ein direkter Immunfluoreszenztest (DFA) verwendet; die Kultivierung erfolgte auf gepufferten Kohle-Hefeextrakt-(BCYE-)-Medien. Alle Proben wurden auch auf andere bakterielle Erreger von Atemwegsinfektionen untersucht; Bronchoalveolarlavage-Proben wurden in allen Fällen aufPneumocystis carinii und Mykobakterien getestet. Es zeigte sich, daß die Legionellose bei HIV-infizierten Patienten nicht häufig vorkommt. Nur sechs der Proben (3%), die von sechs Patienten stammten, waren im DFA positiv; in keinem Fall konntenLegionella-Spezies kultiviert werden. Eine Doppelinfektion mitLegionella undP. carinii wurde bei zwei Patienten festgestellt. Die klinischen Daten der sechs Patienten werden mitgeteilt und derzeit gebräuchliche Methoden zur Legionellose-Diagnostik diskutiert.

     

Nocardiasis in patients with HIV infection

The frequency of Nocardia infection in HIV-infected patients has increased during the past few years from 0.3% in 1985 to 1.8% in 1989. Although it is not of great concern as an AIDS-associated infection, the nonspecific clinical presentation in these patients might be confused with other lung infections such as tuberculosis (TB). The mortality rate can be as high as 60%. The authors diagnosed three homosexual men with nocardiasis among 1060 HIV-infected patients (0.2%) in a tertiary care center in Mexico City from 1981 to 1997. The mean age was 32 years. The CD4 count was less than 260 cells/mm3 in all these individuals. The clinical presentations were subacute sinusitis, chronic localized abdominal abscess, and acute disseminated nocardiasis. The respective associated infections were none; TB and cytomegalovirus (CMV); and candidiasis, TB, CMV, Isospora belli, and disseminated Mycobacterium avium complex (MAC). Trimethoprim/sulfamethoxazole (TMP/SMX) was the treatment in all the cases; at the time of this writing, two patients were living and one had died during the acute episode. A literature search uncovered 130 cases of Nocardia infection in HIV patients since 1982. According to the published data and our results, nocardiasis should be suspected in those HIV-infected patients who (1) do not respond to appropriate antituberculous treatment; (2) are intravenous drug users; and (3) develop a characteristic pericardial infection. Finally, adequate surgical or percutaneous drainage of abscesses are extremely valuable for diagnosis and therapy.     

Vaccination in patients with HIV infection

Although vaccine-preventable diseases are common in HIV, concerns about vaccine safety and lack of efficacy in this patient population often lead to missed opportunities for vaccination. In this article, we review the literature regarding vaccine risks and benefits and offer recommendations regarding their use and timing in patients with HIV infection.     

Tuberculosis in patients with HIV infection

In the past 5 years, there have been significant advances in the understanding of the pathogenesis of TB in people infected with HIV and in the approach to diagnosis, treatment, and prevention in patients with HIV. Nucleic acid amplification tests and restriction fragment length polymorphism can contribute to the clinical management of TB patients. New guidelines are available for the treatment of active and latent TB infection in patients with HIV.     

Central neurologic complications of HIV infection

Human immunodeficiency virus enters the brain at the time of infection and remains in the central nervous system (CNS) throughout the infection. Three currently active topics of clinical importance will be reviewed. First, the role of cerebrospinal fluid (CSF) viral loads as a function of brain infection and performance will be assessed. Evidence is building that CSF viral load is a useful measure in assessing CNS infection in clinical trial settings with possible application to monitoring the effect of therapy in neurologically symptomatic subjects. Second, potential roles of cytokines and their receptors for CNS disease will be updated. The impact of cytokine receptors on modes of invasion of endothelial cells, monocytes, microglia, and neurons will be discussed. Finally, recently reported controlled therapeutic trials will be reviewed including the impact of antiretroviral therapy and hypothesis-driven neuroprotective strategy studies.     

Central neurologic complications of HIV infection

Human immunodeficiency virus enters the brain at the time of infection and remains in the central nervous system (CNS) throughout the infection. Three currently active topics of clinical importance will be reviewed. First, the role of cerebrospinal fluid (CSF) viral loads as a function of brain infection and performance will be assessed. Evidence is building that CSF viral load is a useful measure in assessing CNS infection in clinical trial settings with possible application to monitoring the effect of therapy in neurologically symptomatic subjects. Second, potential roles of cytokines and their receptors for CNS disease will be updated. The impact of cytokine receptors on modes of invasion of endothelial cells, monocytes, microglia, and neurons will be discussed. Finally, recently reported controlled therapeutic trials will be reviewed including the impact of antiretroviral therapy and hypothesis-driven neuroprotective strategy studies.     

Counseling patients with HIV infection

With the human immunodeficiency virus (HIV) still spreading rapidly throughout the nation, all health care professionals must be skilled not only in the technical aspects of management, but also in patient counseling. Patients are concerned about deteriorating health and the prospect of death, but also about treatment options and financial problems related to the disease. Clinicians who provide counseling must be familiar with these concerns as they explain the medical options to patients and help patients work through the stages of adjustment.