CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 3, April 2012
AFRICA
e17
On admission to our hospital, the patient had features of acute,
severe heart failure; the heart shadow had increased markedly in
size on chest radiograph and he was in cardiogenic shock. He had
a good response to inotropes, anti-failure treatment, high-dose
prednisone and temporary interruption of ART. There was no
cause other than HIV found for his DCMO. We hypothesise that
he had an underlying subclinical HIV-associated DCMO, and the
development of TB-IRIS with the associated hypercytokinaemia
resulted in rapid and severe deterioration in cardiac function.
The precipitation of heart failure during IRIS seems to be a
rare event. One explanation for this is that the diagnosis may
be missed. We would therefore encourage clinicians to at least
entertain the diagnosis in patients who present with features
of heart failure soon after starting ART, and especially if they
present with other features of IRIS. The optimal management of
such patients is not determined and will depend on the severity
and co-morbidities. In severe cases, consideration should
be given to ART interruption and corticosteroid therapy in
addition to anti-failure therapy. Given the rarity of this event,
however, there is no prospective evidence on which to base
management decisions. Prospective studies of changes in cardiac
function using echocardiography in patients starting on ART are
warranted. So too are autopsy studies that include examination
of the myocardium of patients who die during periods of IRIS.
Graeme Meintjes is supported by the Wellcome Trust and received SATBAT
research training that was Fogarty International Center and NIH-funded
(NIH/FIC 1U2RTW007373 and 5U2RTW007370).
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