CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 196 AFRICA There was no difference in the mean haemoglobin levels (9.7 vs 9.9 g/dl, p = 0.079), C-reactive protein values (61.7 vs 93.8 mg/l, p = 0.188), white cell count (8.2 x 109 vs 11.9 × 109 cells/l, p = 0.060) and erythrocyte sedimentation rate (67.6 vs 54.6 mm/h, p = 0.296) between the HIV-positive and HIV-negative groups, respectively. The mean serum albumin levels were low in both groups [30.6 (HIV+) vs 32.6 g/l (HIV–), p = 0.337). The mean CD4 count was 386.5 ± 262.3 × 106 cells/l in the HIV-positive group. Three subjects had an AIDS-defining CD4 count of less than 200 × 106 cells/l. Of the 97 subjects, positive blood cultures were observed in 63 cases (64.9%). Fifty-four of these cases were from the HIV-negative group and the remaining nine cases from the HIV-positive group. The most common pathogens isolated in the HIV-negative population were Staphylococcus aureus (n = 17, 20.0%) and Streptococcus viridans (n = 12, 14.1%). In contrast, organisms not typically associated with IE were cultured in seven (58.3%) HIV-positive subjects, compared to 24.7% in the HIV-negative group (p = 0.021) (Table 3). The atypical organisms cultured in the HIV-positive group included two cases of Bacillus cereus and one case of Klebsiella pneumonia, Micrococcus, Streptococcus pneumonia, Staphylococcus epidermidis and Staphylococcus species, respectively. Brucella abortus was cultured in one subject with prosthetic valve endocarditis who was HIV negative. Negative blood cultures were observed in 34 cases (35.1%), 31 cases in the HIV-negative and three cases in the HIV-positive subgroup. The transthoracic echocardiogram results were as follows. The mean ejection fraction (EF) was 55.9 ± 6.6%. There was no significant difference in the EF between the HIV-positive and HIV-negative subgroups (57.8 ± 6.7 vs 55.6 ± 6.4%, p = 0.479). The mitral valve was the most common site of infection [41.7 (HIV+) vs 40.0% (HIV–), p = 0.589]. Right-sided involvement (tricuspid valve, n = 8; pulmonary valve, n = 3 and pacemaker lead) was present in 12 cases (12.4%) (Table 4). A vegetation was present in 85 (87.6%) cases. There was no significant difference in the presence of vegetations in the HIV-positive and HIV-negative groups (91.7 vs 87.1%, p = 0.654). A vegetation size of > 15 mm was observed in 16 (16.5%) patients, of which three (25.0%) were HIV positive. Chordal rupture was the most frequent finding in both the HIV-positive and HIV-negative subjects, occurring in eight (66.7%) and 33 (33.8%) cases, respectively. Abscess cavities were noted in 11 patients. This included an aortic root abscess in nine HIV-negative patients (10.6%) and in one HIV-positive case (8.3%) who had a CD4 count of 87 × 106 cells/l. There was one case of a mitral annular abscess and four cases of prosthetic valve dehiscence. All 97 subjects with suspected IE were treated with antibiotic therapy as per the European Society of Cardiology infective endocarditis guidelines.15 Twenty-four patients received medical management only; 18 of these presented in extremis in cardiogenic shock and 17 of these patients died. Of the 24 patients, there was one who was lost to follow up and presumed dead. The remaining 73 subjects received antibiotic therapy and underwent surgery (HIV positive, n = 8; HIV negative, n = 65). Table 2. Clinical presentation of IE stratified by HIV status Parameters HIV (+) n = 12 (%) HIV (–) n = 85 (%) Total n = 97 (%) p-value Dyspnoea class 0.242 NYHA class 1 0 (0.0) 8 (9.4) 8 (8.3) NYHA class 2 5 (41.7) 19 (22.4) 24 (24.7) NYHA class 3* 6 (50.0) 31 (36.5) 37 (38.1) NYHA class 4* 1 (8.3) 27 (31.7) 28 (28.9) Clinical examination Fever 6 (50.0) 31 (36.5) 37 (38.1) 0.366 Osler nodes 0 (0.0) 0 (0.0) 0 (0.0) Clubbing** 9 (75.0) 30 (35.3) 39 (40.2) 0.009 Pallor 10 (83.3) 68 (80.0) 78 (80.4) 0.785 Janeway lesions 0 (0.0) 0 (0.0) 0 (0.0) Roth spots 0 (0.0) 0 (0.0) 0 (0.0) Cutaneous vasculitis 1 (8.3) 7 (8.2) 8 (8.2) 0.991 Splenomegaly** 4 (33.3) 8 (9.4) 12 (12.4) 0.018 Haematuria** 7 (58.3) 25 (29.4) 32 (33.0) 0.046 Clinical complications Heart failure 8 (66.7) 52 (61.2) 60 (61.9) 0.714 Acute kidney injury 4 (33.3) 24 (28.2) 28 (28.9) 0.280 Embolic events 4 (33.3) 37 (45.5) 41 (42.3) 0.503 Embolic CVA 1 (8.3) 15 (17.7) 16 (16.5) 0.416 Cerebral haemorrhage 0 (0.0) 1 (1.2) 1 (1.0) 0.706 Mycotic cerebral aneurysm 0 (0.0) 2 (2.4) 2 (2.1) 0.591 Digital infarcts 3 (25.0) 9 (10.6) 12 (12.4) 0.354 Limb arterial occlusion 0 (0.0) 6 (7.1) 6 (6.2) 0.342 Pulmonary emboli 0 (0.0) 4 (4.7) 4 (4.1) 0.443 Conduction abnormalities 0 (0.0) 4 (4.7) 4 (4.1) 0.443 Persistent fever 1 (8.3) 8 (9.4) 9 (9.3) 0.904 Re-infection 0 (0.0) 4 (4.7) 4 (4.1) 0.443 Mortality 4 (33.3) 19 (22.4) 23 (23.7) 0.402 Died (medical) 3 (25.0) 14 (16.5) 17 (17.5) Died (surgical) 1 (8.3) 5 (5.9) 6 (6.2) *High-grade dyspnoea (NYHA grade III and IV) was present in 65 subjects (67%). **There was no difference in the clinical presentation between HIV + and HIV– groups except for clubbing, haematuria and splenomegaly, which were more common in HIV+ subjects. Table 3. Causative organism stratified by HIV status Microorganisms HIV (+) n = 12 (%) HIV (–) n = 85 (%) Total n = 97 (%) Staphylococcus aureus 1 (8.3) 17 (20.0) 18 (18.6) Streptococcus viridans 1 (8.3) 12 (14.1) 13 (13.4) Enterococcus 0 (0.0) 4 (4.7) 4 (4.1) HACEK* 0 (0.0) 0 (0.0) 0 (0.0) Culture negative 3 (25.0) 31 (36.5) 34 (35.1) Other organisms** 7 (58.3) 21 (24.7) 28 (28.9) Staphylococcus species 1 (8.3) 2 (2.4) 3 (3.1) Staphylococcus haemolyticus 0 (0.0) 2 (2.4) 2 (2.1) Staphylococcus epidermidis 1 (8.3) 3 (3.5) 4 (4.1) Streptococcus pneumonia 1 (8.3) 0 (0.0) 1 (1.0) Group A Streptococcus 0 (0.0) 1 (1.2) 1 (1.0) Group C Streptococcus 0 (0.0) 1 (1.2) 1 (1.0) Streptococcus nutritional variant 0 (0.0) 2 (2.4) 2 (2.1) Streptococcus species 0 (0.0) 1 (1.2) 1 (1.0) Micrococcus 1 (8.3) 0 (0.0) 1 (1.0) Klebsiella pneumonia 1 (8.3) 1 (1.2) 2 (2.1) Corynebacterium 0 (0.0) 2 (2.4) 2 (2.1) Stenotrophomonas 0 (0.0) 2 (2.4) 2 (2.1) Proteus mirabilis 0 (0.0) 2 (2.4) 2 (2.1) Brucella abortus 0 (0.0) 1 (1.2) 1 (1.0) Bacillus cereus 2 (16.7) 1 (1.2) 3 (3.1) *HACEK, Haemophilus spp, Actinobacillus, Cardiobacterium, Eikenella corrodens, Kingella kingae **Other organisms were more common in the HIV-positive group (p = 0.021).
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