CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 2, March/April 2014
52
AFRICA
infected. The remaining 17 patients had normal valves (nine
HIV negative and eight HIV infected). Congenital defects were
found in five patients [patent ductus arteriosus (one), bicuspid
aortic valve (one), and ventricular septal defect (three) (one HIV
infected and two HIV negative).
Fifty-four (70.1%) patients underwent TEE. Of these, 51
had features suggesting IE. The remaining three patients with
negative findings on TEE had thickened calcified valves (one),
thickened leaflets with chordal rupture (one), and the last one
had a normal valve.
Vegetations were the predominant finding in 68 (88%)
patients at echocardiography (Table 5). They were present in
11/17 (64.7%) of the HIV-infected patients, and in 57/61 (95%)
of the HIV-uninfected patients. The remaining nine patients
(six HIV-infected and three HIV-uninfected patients) did not
have vegetations, but did show other echocardiographic features
suggestive of IE. These were leaflet aneurysms in four and aortic
root abscesses in four cases; one patient had a disrupted aortic
valve without the presence of vegetations (Figs 1–3).
In comparison with adjacent valvular tissue, vegetations
appeared echogenic or homogenous in appearance, with an
irregular shape. Single and multiple vegetations were seen with
the same frequency in each group. Vegetation size was similar (11
mm) in each group (
p
=
ns). There was no relationship between
the size of the vegetation and the presence of complications such
as abscess formation, aneurysm, stroke or fistula development.
Complications occurred in four of the 13 HIV-negative
patients with vegetations larger than 10 mm. These were aortic
root abscess (one), fistula (one) (Fig. 4), and two had strokes.
None of the four HIV-infected patients with vegetations
>
10
mm (11, 11, 11 and 11.6 mm) had complications associated with
large vegetations (
p
=
ns) .
Extensive valve disruption was present in both groups, since
patients presented at an advanced stage of infection. Except for
the leaflet aneurysms and root abscesses, which were present in
four and three HIV-infected patients, respectively, (two had both
aneurysm and abscess, one had an abscess, one had an aneurysm),
there did not appear to be any difference in the prevalence of
valve-related complications between the two groups. Of the five
aneurysms in the study, two were cuspal aneurysms of the aortic
valve, (both HIV infected) and the remaining three aneurysms
were located on the mitral valve (two HIV infected).
Therefore, among the HIV-infected patients, leaflet aneurysms
were found in the mitral (two) and aortic (two) position, and one
HIV-negative patient had a leaflet aneurysm associated with
a vegetation
<
10 mm, affecting the mitral valve. One leaflet
aneurysm was found along the annulus of a mitral prosthesis in
an HIV-negative patient, confirmed at TEE (Fig. 2b)
Aortic root abscesses were present in three patients in each
group, and were of a larger size in the HIV-infected (0.73
×
1.2
cm) than the HIV-uninfected patients (0.3
×
0.45 cm), but this
difference was not significant (
p
=
0.118) and was not related
to a very low CD
4
count in two patients (15, 150, 249 /mm
3
).
There was no evidence of myocardial abscess formation. Like
the aortic root abscesses, the leaflet aneurysms were larger in
the HIV-infected patients (0.86
×
0.85 cm vs 0.21
×
0.3 cm) (
p
=
0.008).
The mean ejection fraction (EF) in the HIV-uninfected
patients was 59%, and in the HIV-infected patients, 62.9% (
p
=
ns). Pericardial effusion was common and associated with heart
failure and fluid overload in both groups (
p
=
ns). Twenty-two
of the 26 HIV-uninfected patients with pericardial effusions
had severe valvular regurgitation; 12 (46.2%) showed signs of
heart failure with fluid overload, and two of the remaining 10
patients had impaired systolic function (EF
=
35% in both). All
Table 4. Echocardiographic findings in HIV-positive and
HIV-negative patients with infective endocarditis
HIV+
n
=
17 (%)
HIV–
n
=
60 (%)
Total
n
=
77 (%)
p
-value
Vegetations
11 (64.7) 57 (95) 68 (88.3) 0.447
Leaflet aneurysm
4 (23.5) 1 (1.7)
5 (6.5) 0.008
Abscess
3 (17.6) 3 (5)
6 (7.8) 0.118
Regurgitation
16 (94.1) 59 (98.3) 75 (97.4)
Pericardial effusion
6 (35.3) 26 (43.3) 28 (36.4) 1.000
Chordal rupture/leaflet prolapse 6 (35.3) 20 (33.3) 26 (33.8)
Table 5. Vegetation characteristics in HIV-positive and
HIV-negative subjects
HIV+
n
=
17
HIV–
n
=
60
Total
p
-value
Site
Aortic
2 (11.8) 21 (35)
23 (29.9)
0.189
Mitral
4 (23.6) 21 (35)
25 (32.5)
0.001
Tricuspid
2 (11.8)
1 (1.7)
3 (3.9)
Other site***
0 (0)
4 (6.7)
4 (5.2)
Mixed (aortic + mitral) 3 (17.6) 10 (16.7)** 13 (16.9)
Mean size (mm)
11 (4–24)* 10 (3–30)* 10 (3–30)* 0.447
Vegetation number
Single
6 (35.3) 32 (51.7)
38 (49.4)
Multiple
5 (29.4) 25 (41.7)
30 (38.9)
Total,
n
(%)
11 (64.7) 57 (95)
68 (88.3)
Values expressed in brackets indicate percentages.
*Mean values with the ranges bracketed
**Includes one patient with a VSD who had mitral and tricuspid valve
vegetations
***Other site refers to central line, pulmonary and prosthesis valves. The
left atrial mural endocarditis is included with the mitral valve.
Table 3. Comparison of laboratory features of HIV-positive and
HIV-negative patients with infective endocarditis
Laboratory findings
HIV+
n
=
17 (%)
HIV–
n
=
60 (%)
p
-value
White blood count (/l)
7.7 (2.46–23.14)
9 (4–29.4)
0.387
Lymphocyte (/l)
2.76 (0.44–18.2)
2.93 (0.26–6)
0.548
Platelets (/l)
273 (123–449)
229 (40–432)
0.675
Haemoglobin (mg/dl)
8.92 (5–11.2)
10.76 (6–14.2) 0.119
Sedimentation rate
(mm/h)
110.8 (65–142)
62.5 (6–160)
0.024
C-reactive protein (mg/dl) 95.19 (0.17–265.3) 68 (0.02–336.4) 0.018
Urea (mmol/l)
7.6 (3–192)
13.87 (1.4–28.3) 0.091
Creatinine (mmol/l)
131.6 (57–770) 201.42 (43–851) 0.301
Serum albumin (g/dl)
26.94 (18–36)
33.6 (0.57–49) 0.031
Complement C3 (g/l)
1.48 (1.1–1.77)
1.09 (0.15–1.8) 0.001
Complement C4 (g/l)
0.308 (0.13–0.46) 0.25 ( 0.01–0.52) 0.120
Rheumatoid factor (+)
4 (23.6)
33 (55)
0.052
Haematuria
3 (17.6)
19 (31.7)
Mean values with the ranges bracketed, except rheumatoid factor and
haematuria.
