A Comparison of HIV-Positive Patients with and without Infective Endocarditis: An Echocardiographic Study—The Emory Endocarditis Group Experience

An echocardiographic study of infective endocarditis, with special reference to patients with HIV

OBJECTIVE

The aim was to describe the echocardiographic features of patients with infective endocarditis (IE), and to compare the manifestations of IE in HIV-positive versus HIV-negative patients.

METHODS

The study was prospective in nature and screened patients referred to Inkosi Albert Luthuli Hospital (IALCH) with suspected IE between 2004 and 2007. Only patients with a definite diagnosis of IE according to the modified Duke criteria were enrolled for the purpose of the study. Inkosi Albert Luthuli hospital is an 842-bed tertiary referral centre, serving a KwaZulu-Natal population of 10 million people, who are of various races.

RESULTS

During this period, 91 patients were screened for IE. Seventy-seven (HIV infected, n = 17) satisfied the criteria for a definite diagnosis of IE. Blood cultures were positive in 46% of cases. The commonest organism was S aureus. Most patients had advanced valve disruption with heart failure and high peri-operative mortality. The clinical profile in the HIV-infected patients was similar to the that of the non-infected patients. The prevalence of echocardiographic complications (abscesses, aneurysms, perforations, fistulae and chordal ruptures) was 50.6% in the whole group. Except for the presence of leaflet aneurysms and root abscesses in four advanced (CD4 counts > 250 /mm(3)) HIV-infected cases, complications were not more frequent in the HIV-infected group.

CONCLUSION

There was a high rate of culture-negative cases in this study, probably related to prior antibiotic usage; in this setting the modified Duke criteria have diagnostic limitations. No significant differences in the clinical presentation of infective endocarditis were noted between HIV-infected and HIV-negative patients.

Valvular manifestations of human immunodeficiency virus infection--results from the prospective, multicenter HIV-HEART study

BACKGROUND AND AIMS

HIV infection is associated with an elevated rate of cardiac diseases. The aim of the current study was to assess the prevalence of valvular disorders in a large population of HIV-infected patients.

METHODS

We enrolled 803 adults (age 44 ± 10 years, 16.6% women) in this prospective, multicenter cohort study. All patients underwent a comprehensive two-dimensional transthoracic echocardiography examination including Doppler evaluation of valvular function. Statistical analyses were performed in respect of severity of HIV infection.

RESULTS

Overall, the rate of patients with pathologic function of cardiac valves was 77.6% (N = 623). Most of these patients had signs of valvular regurgitation (N = 620; 77.2%), whereas stenoses were rare (N = 23; 2.9%). Clinically relevant valvular disorders (excluding mild stages) were seen in only 4.7% (N = 38; regurgitation: N = 36, 4.5%; stenosis: N = 3, 0.4%). Clinical stages of HIV infection, defined by the Centers for Disease Control and Prevention (CDC) classification, were associated with higher rates of valvular diseases (CDC-stage B/C versus A: 6.2 versus 2.3%, P = 0.015). However, there was no association between current CD4 cell count or virus load and the prevalence of valvular disorders (both P > 0.2). None of the patients had signs of active endocarditis in the present study.

CONCLUSION

Valvular heart diseases are common in HIV-infected patients. Fortunately, most of these disorders are mild today. We found an association between the onset of valvular heart disease and clinical stages of HIV infection.

Incidence of, risk factors for, clinical presentation, and 1-year outcomes of infective endocarditis in an urban HIV cohort

BACKGROUND

Previous studies described infective endocarditis (IE) in the era before highly active antiretroviral therapy (HAART); however, IE has not been well studied in the current HAART era. We evaluated the incidence of, risk factors for, clinical presentation, and 1-year outcomes of IE in HIV-infected patients.

METHODS

We evaluated all cases of IE diagnosed between 1990 and 2002 in patients followed at the Johns Hopkins Hospital outpatient HIV clinic. To identify factors associated with IE in the current era of HAART, a nested case-control analysis was employed for all initial episodes of IE occurring between 1996 and 2002. Logistic regression analyses were used to assess risk factors for IE and factors associated with 1-year mortality.

RESULTS

IE incidence decreased from 20.5 to 6.6 per 1000 person-years (PY) between 1990 and 1995 and 1996 and 2002. The majority of IE cases were male (66%), African American (90%), and injection drug users (IDUs) (85%). In multivariate regression, an increased risk of IE occurred in IDUs (AOR, 8.71), those with CD4 counts <50 cells/mm, and those with HIV-1 RNA >100,000 copies/mL (AOR, 3.88). Common presenting symptoms included fever (62%), chills (31%), and shortness of breath (26%). The most common etiologic organism was Staphylococcus aureus (69%; of these 11 [28%] were methicillin resistant). Within 1 year, 16% had IE recurrence, and 52% died. Age over 40 years was associated with increased mortality.

CONCLUSIONS

IE rates have decreased in the current HAART era. IDUs and those with advanced immunosuppression are more likely to develop IE. In addition, there is significant morbidity and 1-year mortality in HIV-infected patients with IE, indicating the need for more aggressive follow-up, especially in those over 40 years of age. Future studies investigating the utility of IE prophylaxis in HIV patients with a history of IE may be warranted.