CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 8, September 2012
e4
AFRICA
effusion. Pericardial disease is the most frequent cardiovascular
manifestation of HIV infection
24,25
and it is often associated
with shortened survival, independent of CD
4
count and serum
albumin values.
23,26,27
The prevalence of pericardial disease on
echocardiography in Prendergast’s study ranged from 10 to 59%,
2
although the majority of these patients were asymptomatic. This
was confirmed by our findings, where pericardial effusion was
found in almost half of the patients, while only one patient had
overt symptoms. With the increasing incidence of HIV infection,
pericardial effusion and its attendant complications may become
a major cardiac abnormality to contend with in future.
No definitive cause was determined for any pericardial
effusion in this study. Determination of the aetiology of pericardial
effusions in HIV-infected patients is often difficult.
22,23,26
Pericardiocentesis is not feasible in the majority of these patients
because most pericardial effusions are small,
22,23,28
and even when
indicated for the relief of tamponade, its diagnostic accuracy is
said to be low.
29
Various causative factors involved in the development of
pericardial disease have been described. Tuberculosis is the
commonest cause of pericardial disease in Africa,
26,27
accounting
for 86 to 100% of cases.
29
Other reported causative factors include
the human immunodeficiency virus itself,
2,30
opportunistic
infections such as cytomegalovirus,
31
mycobacterium,
32
cryptococcus,
33
bacterial infections,
34
malignancies such as
Kaposi’s sarcoma,
35
and non-Hodgkin lymphoma.
22,36
It can also
be part of a generalised effusive serous process involving pleural
and peritoneal surfaces, which is probably a consequence of
enhanced cytokine expression.
4,22
The findings in this study also confirm that HIV infection
was associated with left ventricular dysfunction and increased
ventricular dimensions. Similar trends have been noted in other
studies.
9,18,34-36
The presence of ventricular dysfunction in the
absence of chamber enlargement, as found in about half of those
with ventricular dysfunction in our study, has also been reported
in other studies.
10,24,28
This has been posited to represent an early
phase of heart muscle disease/cardiomyopathy, from which the
patients eventually progress to left ventricular dilatation and
dilated cardiomyopathy.
20,24,28
Systolic dysfunction, which is a frequently documented
finding in echocardiography of HIV-infected patients,
9,10,28,37,38
was
noted in about a third of our cases, signifying reduced myocardial
contractility. The dysfunction was more frequent with disease
progression, paralleling the reports by other workers.
9,10,28,37
Systolic dysfunction is said to be an important cause of
morbidity and mortality in AIDS patients.
38
It is also posited
that symptomatic heart failure will occur in approximately 6%
of these patients, especially at the end stage of the disease.
26,35,39
With this in mind, early recognition of dysfunction and institution
of management may impact on the overall outcome of these
patients.
9
Diastolic dysfunction was also noted in our patients, signifying
ventricular filling abnormalities due to a non-compliant
ventricle.
21
Diastolic dysfunction was also observed to be more
frequent and worsening with disease progression. The findings in
our study compare with the 30% prevalence noted by Danbauchi
et al
.
25
in their work. Diastolic dysfunction has also been reported
in other studies.
16,37
DCM is a well-documented cardiac abnormality in HIV/
AIDS,
9,34,40,41
and was found in 5% of our cases, with none in the
control group (Fig. 2). All patients with DCM had more advanced
immunosuppression with a mean CD
4
count of 80/
µ
l. This result
correlates well with several reports that dilated cardiomyopathy
in HIV is associated with advanced immunosuppression and
lower CD
4
lymphocyte counts
<
100/
µ
l.
3,9,18,28,29
Nzuobotane
et
al
.
9
demonstrated a similar relationship between the degree
of immunosuppression and the likelihood of cardiomyopathy.
Interestingly, a CD
4
count of 100/
µ
l proved to be the important
threshold in that study as well. Currie
et al
.
18
in a similar study,
reported DCM in 4% of cases, a result which parallels that of
Fig. 1. Massive pericardial effusion in a patient with HIV/
AIDS, shown from the pasternal long-axis view.
Fig. 2. Apical four-chamber view showing dilated cardio-
myopathy.
