CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
AFRICA
197
Case Reports
Progressive human immunodeficiency virus-associated
vasculopathy: time to revise antiretroviral therapy
guidelines?
NBA NTUSI, D TAYLOR, NG NAIDOO, M MENDELSON
Abstract
Cardiovascular abnormalities were appreciated early in
the epidemic of the acquired immunodeficiency syndrome
(AIDS), even before the aetiological agent, human immuno-
deficiency virus (HIV) was isolated and characterised. The
aetiology and pathogenesis of cardiovascular disease in HIV
infection is still the subject of intense speculation, and is
likely multi-factorial. HIV affects every aspect of the cardiac
axis, causing pericarditis, myocarditis, cardiomyopathy, coro-
nary artery disease and microvascular dysfunction, valvu-
lar heart disease, pulmonary vascular disease and pulmo-
nary hypertension, stroke and peripheral vascular disease.
HIV-associated vasculopathy is an increasingly recognised
clinical entity, causing high morbidity and increasing mortal-
ity in southern Africa, particularly from stroke and cardio-
vascular disease. HIV causes disease of the vascular tree,
either by a direct effect on vascular or perivascular tissue, or
indirectly via immune complex-mediated mechanisms, asso-
ciated opportunistic infections and malignancies. As a result,
highly active antiretroviral therapy (HAART) may have an
important role in controlling disease progression. We report
a case of histologically defined primary HIV vasculopathy in
which the chance to start HAART was initially missed and
in which the patient progressed to require bilateral amputa-
tions, but obtained disease quiescence upon commencement
of HAART.
Keywords:
human immunodeficiency virus, HIV-associated
cardiovascular disease, HIV vasculopathy, highly active antiret-
roviral therapy
Submitted 14/3/10, accepted 12/5/10
Cardiovasc J Afr
2010;
21
: 197–200
DOI: 10.5830/CVJA–2010–048
Human immunodeficiency virus (HIV)-associated vasculopa-
thy is an increasingly recognised, distinct clinico-pathological
entity associated with significant morbidity and mortality in
southern Africa. HIV itself causes vascular disease, either by a
direct effect on vascular or perivascular tissue, or indirectly via
immune complex-mediated mechanisms.
1
As a result, highly
active antiretroviral therapy (ART) may have an important role
in controlling disease progression. We report on a case of histo-
logically defined primary HIV-associated vasculopathy in which
the opportunity to commence ART was missed and in which the
patient progressed to bilateral lower limb amputations.
Case report
A 24-year-old woman was referred to the vascular surgical unit
at Groote Schuur Hospital, with critical limb ischaemia (CLI)
involving the left lower limb. She presented with a five-week
history of ischaemic rest pain and early tissue necrosis involving
the left first toe. Approximately six months previously, she had
had a right below-the-knee amputation, performed at the refer-
ring hospital for CLI, associated with major tissue necrosis, at
which time the surgical specimen was not submitted for histo-
logical assessment.
She had had pulmonary tuberculosis in childhood, subse-
quently complicated by bronchiectasis and pulmonary hyperten-
sion. She remained well until her pregnancy two years earlier,
when she was diagnosed with HIV infection with a CD
4
T-cell
count of 529 cells/
μ
l. She received a single dose of nevirapine at
the onset of labour for prevention of mother-to-child transmis-
sion of HIV. Her alcohol intake was 16 units/day on weekends,
and she had smoked 15 to 30 cigarettes/day for six years.
Examination revealed absent pulses in the left lower limb,
consistent with left femoro-popliteal disease. This was confirmed
on duplex arteriography, which revealed occluded left distal
superficial femoral artery, popliteal artery, popliteal trifurcation
and all three crural arteries. Peripheral angiography demonstrat-
ed similar findings with reconstitution of the left retromaleolar
posterior tibial artery and tarsal arteries. An exhaustive search
for alternative causes of vasculopathy, including autoimmune
and infectious causes of vasculitis, hypercoagulable states and
treatable causes of accelerated atherosclerosis were negative.
Cardiac Clinic, Department of Medicine, Groote Schuur
Hospital and University of Cape Town, South Africa
NBA NTUSI, FCP (SA),
National Health Laboratory Service, Division of Anatomical
Pathology, Groote Schuur Hospital and University of Cape
Town, South Africa
D TAYLOR, MMed
Division of Vascular Surgery, Department of Surgery, Groote
Schuur Hospital and University of Cape Town, South Africa
NG NAIDOO, FCS (SA)
Division of Infectious Diseases and HIV Medicine,
Department of Medicine, Groote Schuur Hospital and
University of Cape Town, South Africa
M MENDELSON, FRCP (UK), PhD
