Aorto-femoral bypass in the HIV infected patient

We describe a 49-year old male Nigerian with HIV infection who presented in our institution with aorto-iliac arterial occlusive disease and progressive severe ischaemic changes of the lower extremity. His preoperative CD4 count was 43 cells / microlitre. He underwent a successful intra-peritoneal aorto-femoral bypass. This report illustrates that vascular reconstruction in an HIV infected patient can be successfully performed with minimal morbidity despite a high risk factor for major infection. The histological finding was in keeping with an accelerated atherosclerosis resulting from HIV infection.

Vascular disease in HIV/AIDS patients

OBJECTIVES

An ongoing prospective clinical survey to determine the spectrum of vascular disease in HIV/AIDS patients and the risk factors affecting clinical outcome in order to formulate a management protocol for future use.

METHODS

Comprehensive screening for risk factors for vascular disease as well as HIV/AIDS-related conditions. Disease pattern and presentation are noted and patients treated accordingly. Vascular emergencies are managed regardless of HIV status because this information is usually not available at the time of presentation. Elective management is based on immune status and risk stratification.

RESULTS

42 patients tested positive for HIV. The majority of patients presented with occlusive disease (57%), followed by aneurysms (21%) and vascular trauma (19%). A variety of vascular surgical procedures were performed on 36 patients. There was no surgical mortality and 10 patients developed complications, including 2 amputations and 7 cases of minor wound sepsis. The 3 patients who received preoperative antiretroviral therapy showed a marked reduction in viral count and a significant improvement in CD4 T-cell count.

CONCLUSION

Surgery can be safe and effective in HIV-positive patients provided the necessary precautions are taken to reduce surgical morbidity.

New imaging findings in a patient with central nervous system dysfunction after bone marrow transplantation

Central nervous system disorders are an important complication of bone marrow transplantation (BMT). We have recently performed cerebral angiography to examine central nervous system dysfunction in a 22-year-old woman with acute lymphoblastic leukaemia who had undergone BMT. Angiography demonstrated multiple stenoses and occlusions in the peripheral branches of the anterior and middle cerebral arteries, a pattern similar to that seen in vasculitis. She was thought to most likely have cytomegalovirus (CMV) vasculitis, but other forms of vasculitis, such as angiitis-like-syndrome-associated graft-versus-host disease could not be excluded. This case suggests that CMV vasculitis may cause central nervous system dysfunction after BMT and that imaging studies may provide useful information about central nervous system disorders in these patients.

Increased incidence of cardiac complications in kidney transplant recipients with cytomegalovirus disease

BACKGROUND

The transplant literature has not shown cytomegalovirus (CMV) disease to be a significant risk factor for posttransplant cardiac complications. A large number of nontransplant studies have, however, reported an association between coronary heart disease (CHD) and CMV disease. Pathology studies have demonstrated a high incidence of CMV in atheromatous plaques from the coronary circulation.

METHODS

We performed multivariate analysis to determine if posttransplant CMV disease was a significant risk factor for cardiac complications in kidney transplant recipients. We also performed univariate analysis to determine which cardiac complications were more common in the recipients with CMV disease.

RESULTS

Between January 1, 1984 and June 30, 1997, 1859 adults underwent kidney transplants at our institution. Of these, 377 developed one of the following cardiac complications posttransplant: myocardial infarction, angina, arrhythmia, congestive heart failure, and angiographic vessel occlusion. By multivariate analysis, significant risk factors for one of the above cardiac complications were recipient age >50 years [odds ratio (OR)=2.5, P=0.0001], diabetes (OR=1.99, P=0.0001), a history of cardiac disease pretransplant (OR= 1.34, P=0.04), and CMV disease (OR=1.5, P=0.01). Univariate analysis demonstrated that recipients with CMV disease had a higher overall incidence of cardiac complications. Arrhythmias, congestive heart failure, and vessel occlusion were more common in those with CMV disease. The incidence of myocardial infarction, angina, and cardiac arrest did not differ between the two groups (recipients with versus without CMV disease).

CONCLUSIONS

CMV disease is associated with an increased risk of cardiac complications in kidney transplant recipients. In our series, angiographic vessel occlusion was more common in recipients with CMV disease. This interesting finding may support the theory that CMV plays some role in the pathogenesis of CHD.

Severe digital arterial occlusive disease and acute parvovirus B19 infection

We report a case of arterial occlusive disease and digital ischaemia associated with acute parvovirus B19 infection. Treatment with intravenous epoprostanol improved her symptoms.

[Obliterative arteriopathy in chronic rejection after hepatic transplantation. Search of cytomegalovirus genome by in situ hybridization and viral antigens by immunohistochemistry]

OBJECTIVES

This study was performed to assess the role of cytomegalovirus in the parietal infection of intrahepatic arteries in the pathogenesis of obliterative arteriopathy from chronic rejection after orthotopic liver transplantation.

METHODS

We studied two groups of liver transplants by in situ hybridization and immunohistochemistry: group 1, including 10 liver grafts with obliterating arteriopathy, and group 2 including 7 liver grafts without any arterial disorders. The results were correlated with clinical data (cytomegalovirus infection and acute rejection).

RESULTS

By in situ hybridization, cytomegalovirus DNA was identified in the media in 70% of transplants in group 1 and 42% in group 2. Detection of immediate early and late antigens by immunohistochemistry was negative. Cytomegalovirus infections were often associated with acute rejection.

CONCLUSION

These results suggest that cytomegalovirus detected in arteries is latent, and that cytomegalovirus probably does not play a role in the pathogenesis of chronic rejection obliterative arteriopathy.