Abstract Title

An Unusual Case of Viral Cardiomyopathy Presenting as Acute Ischemic CVA

Presenter Name

Shaista Walji

RAD Assignment Number

411

Is your abstract a case presentation?

1

Abstract

Background/Abstract: HIV

HIV-associated cardiomyopathy (HIVAC) is a significant cause of morbidity and mortality among HIV-infected individuals.1 The HIV virus is increasingly becoming recognized as an important cause of cardiomyopathy. While the exact mechanism remains unclear, effects from direct viral burden as well as opportunistic infections are thought to play a key role.2 Here we present a case of severe cardiomyopathy in a patient previously undiagnosed with HIV.

Case Report: A 21yo Hispanic male with PMH significant for fatty liver disease and recent Tylenol toxicity presented to the ER for evaluation of sudden onset of left sided weakness and left facial droop. He was found down and noted to be shaking, thus there was also a concern for seizure activity. NIHSS upon arrival was 16, with early changes on CT and visualized clot in M1 distribution of the right MCA with poor collateral flow on CTA. Right MCA syndrome was diagnosed and patient was given tPA. Patient recovered well with rapid resolution of the focal deficits. Prothrombotic workup revealed low protein C activity. Transthoracic echo performed as part of evaluation of ischemic CVA demonstrated a LVEF of 15% and moderately dilated left ventricle.. The etiology of CVA was felt to be thromboembolic secondary to this severe cardiomyopathy. Patient denied any personal or family history of prior cardiac problems as well as cardiac arrhythmias. Due to noted recurrent fevers and pancytopenia throughout the course of his admission, HIV reactivity was checked and revealed him to not only have HIV but also AIDS with a CD4 count of 84 and RNA PCR of 121,000. With this finding, viral cardiomyopathy was felt to be the most reasonable explanation for heart failure in this young patient. He was started on oral anticoagulation to prevent further thromboembolic events and was fitted for a LifeVest.

Discussion/Conclusion:

HIV- associated cardiomyopathy is a known chronic complication in patients living with HIV/ AIDS, especially in uncontrolled infection as was seen in the patient who presented to our hospital. Uncontrolled infection can lead to both direct and indirect cardiotoxicity from infections associated with low CD4 counts as well as HIV itself. The pathogenesis of HIV- induced cardiomyopathy is often multifactorial including myocarditis, cardiac autoimmunity, micronutrient deficiency, and even antiretroviral therapy (ART) induced.1 Patients living with HIV are at a higher risk than the general population for developing HF. Studies have shown that in HIV-infected individuals, the prevalence of HF was highest among those with CD4 counts

References:

  1. Lumsden RH, Bloomfield GS. The Causes of HIV-Associated Cardiomyopathy: A Tale of Two Worlds. Biomed Res Int. 2016;2016:8196560.

  2. Al-kindi SG, Elamm C, Ginwalla M, et al. Heart failure in patients with human immunodeficiency virus infection: Epidemiology and management disparities. Int J Cardiol. 2016;218:43-46.

  3. Ntsekhe M, Mayosi BM Cardiac manifestations of HIV infection: an African perspective. Nat Clin Pract Cardiovasc Med. 2009;6:120–127.

  4. Gopal M, Bhaskaran A, Khalife WI, Barbagelata A. Heart Disease in Patients with HIV/AIDS-An Emerging Clinical Problem. Curr Cardiol Rev. 2009;5(2):149-54.

  5. Currie PF, Jacob AJ, Foreman AR, Elton RA, Brettle RP, Boon NA. Heart muscle disease related to HIV infection: prognostic implications. BMJ. 1994;309:1605–1607.

  6. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, KasperEK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy.N Engl J Med. 2000;342:1077–1084

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An Unusual Case of Viral Cardiomyopathy Presenting as Acute Ischemic CVA

Background/Abstract: HIV

HIV-associated cardiomyopathy (HIVAC) is a significant cause of morbidity and mortality among HIV-infected individuals.1 The HIV virus is increasingly becoming recognized as an important cause of cardiomyopathy. While the exact mechanism remains unclear, effects from direct viral burden as well as opportunistic infections are thought to play a key role.2 Here we present a case of severe cardiomyopathy in a patient previously undiagnosed with HIV.

Case Report: A 21yo Hispanic male with PMH significant for fatty liver disease and recent Tylenol toxicity presented to the ER for evaluation of sudden onset of left sided weakness and left facial droop. He was found down and noted to be shaking, thus there was also a concern for seizure activity. NIHSS upon arrival was 16, with early changes on CT and visualized clot in M1 distribution of the right MCA with poor collateral flow on CTA. Right MCA syndrome was diagnosed and patient was given tPA. Patient recovered well with rapid resolution of the focal deficits. Prothrombotic workup revealed low protein C activity. Transthoracic echo performed as part of evaluation of ischemic CVA demonstrated a LVEF of 15% and moderately dilated left ventricle.. The etiology of CVA was felt to be thromboembolic secondary to this severe cardiomyopathy. Patient denied any personal or family history of prior cardiac problems as well as cardiac arrhythmias. Due to noted recurrent fevers and pancytopenia throughout the course of his admission, HIV reactivity was checked and revealed him to not only have HIV but also AIDS with a CD4 count of 84 and RNA PCR of 121,000. With this finding, viral cardiomyopathy was felt to be the most reasonable explanation for heart failure in this young patient. He was started on oral anticoagulation to prevent further thromboembolic events and was fitted for a LifeVest.

Discussion/Conclusion:

HIV- associated cardiomyopathy is a known chronic complication in patients living with HIV/ AIDS, especially in uncontrolled infection as was seen in the patient who presented to our hospital. Uncontrolled infection can lead to both direct and indirect cardiotoxicity from infections associated with low CD4 counts as well as HIV itself. The pathogenesis of HIV- induced cardiomyopathy is often multifactorial including myocarditis, cardiac autoimmunity, micronutrient deficiency, and even antiretroviral therapy (ART) induced.1 Patients living with HIV are at a higher risk than the general population for developing HF. Studies have shown that in HIV-infected individuals, the prevalence of HF was highest among those with CD4 counts

References:

  1. Lumsden RH, Bloomfield GS. The Causes of HIV-Associated Cardiomyopathy: A Tale of Two Worlds. Biomed Res Int. 2016;2016:8196560.

  2. Al-kindi SG, Elamm C, Ginwalla M, et al. Heart failure in patients with human immunodeficiency virus infection: Epidemiology and management disparities. Int J Cardiol. 2016;218:43-46.

  3. Ntsekhe M, Mayosi BM Cardiac manifestations of HIV infection: an African perspective. Nat Clin Pract Cardiovasc Med. 2009;6:120–127.

  4. Gopal M, Bhaskaran A, Khalife WI, Barbagelata A. Heart Disease in Patients with HIV/AIDS-An Emerging Clinical Problem. Curr Cardiol Rev. 2009;5(2):149-54.

  5. Currie PF, Jacob AJ, Foreman AR, Elton RA, Brettle RP, Boon NA. Heart muscle disease related to HIV infection: prognostic implications. BMJ. 1994;309:1605–1607.

  6. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, KasperEK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy.N Engl J Med. 2000;342:1077–1084