Download Place: Bellary

Place: Bellary
Date:
From,
Dr. Nandini Devru
Post Graduate Student in M.D.
Dept. of Medicine,
Vijayanagar Institute Of Medical Sciences,
Bellary.
To,
The Principal,
Vijayanagar Institute Of Medical Sciences,
Bellary.
THROUGH PROPER CHANNEL
Respected sir,
Subject: Acceptance of registration and forwarding of dissertation topic,
In accordance with the above cited subject, I undersigned studying Post
Graduate Course in M.D. General Medicine have been allotted the dissertation topic “A
STUDY OF CARDIAC MANIFESTATIONS IN PATIENTS WITH HIV/AIDS IN
VIMS BELLARY”, under the guidance of
Dr.SHASHIBHUSHAN J. Professor
Department of Medicine, VIMS, Bellary.
I request you to kindly forward the dissertation topic in the prescribed form to
the university for approval.
Thanking you,
Signature of the guide
(Dr.SHASHIBHUSHAN J.)
Yours faithfully,
Dr. Nandini Devru.
Place: Bellary
Date:
From,
The Professor & Head of the Department,
Department of Medicine,
VIMS, Bellary.
To,
The Registrar,
Rajiv Gandhi University of Health Sciences,
Bangalore.
THROUGH PROPER CHANNEL
Respected sir,
As per the regulations of the University of registration of Dissertation topic, the
following Post Graduate in M.D. General Medicine has been allotted the dissertation
topic as by the Official Registration Committee of all qualified and eligible guides of the
Department of Medicine.
NAME
Dr. NANDINI
DEVRU
TOPIC
“A STUDY OF CARDIAC
MANIFESTATIONS OF
Post Graduate Student in HIV/AIDS IN VIMS
M.D.
BELLARY”
GUIDE
Dr.Shashibhushan
J.
Dept. of Medicine,
VIMS, Bellary.
Therefore, I kindly request you to communicate the acceptance of the dissertation
topic allotted to the PG student at an early date.
Thanking you,
Yours faithfully,
Dr.GADWALKAR R SRIKANT
Signature of the guide
Professor & Head of the Department,
Department of Medicine,
VIMS, Bellary.
(Dr.SHASHIBHUSHAN J.)
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE .
ANNEXURE—II
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.
NAME OF THE
CANDIDATE AND
ADDRESS (in block letters)
2.
NAME OF THE
INSTITUTION
3.
COURSE OF STUDY AND
SUBJECT
4.
DATE OF ADMISSION TO
30-05-2011
THE COURSE
TITLE OF THE TOPIC:
“A STUDY OF CARDIAC MANIFESTATIONS IN PATIENTS
WITH HIV/AIDS IN VIMS BELLARY”
5.
Dr. NANDINI DEVRU
POST GRADUATE STUDENT IN
M.D.GENERAL MEDICINE.
VIMS,BELLARY-583 104
VIJAYANAGAR INSTITUTE
OF MEDICAL SCIENCES,
BELLARY
MD GENERAL MEDICINE
BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY:
The prevalence of cardiac involvement in AIDS patients has been
reported to range between 28% and 73%2. The cardiac diseases include pericardial
effusion,
myocarditis,
dilated
cardiomyopathy,
endocarditis,
pulmonary
hypertension, malignant neoplasm, coronary artery disease, left ventricular
dysfunction, and drug related cardiotoxicity2. Cardiac involvement in AIDS/HIV
infected persons occurs frequently but may be quiescent clinically and may be a
direct cause of death3 When patients are examined by echocardiography, cardiac
abnormalities are detected more often than would be expected from clinical
symptoms and physical examination
6.2 REVIEW OF LITERATURE:
AIDS17 was first recognized in United States in the summer of
1981,when the U.S. Centers for Disease Control and Prevention(CDC) reported
unexplained occurrence of Pneumocystis jiroveci(formerly P. carnii) pneumonia in
five previously healthy homosexual men in Los Angeles and of Kaposi’s
sarcoma(KS) with or without P. jiroveci pneumonia in 26 previously healthy
homosexual men in New York and Los Angeles. The disease was soon recognized
in male and female drug users; in hemophiliacs aand blood transfusion recepients;
among female sexual partners of men with AIDS; among infants born to mothers
AIDS or with a history of injection drug use. In 1983 human immunodeficiency
virus was isolated (HIV) isolated from a patient with lymphadenopathy, and by
1984 it was demonstrated clearly to be the causative agent of AIDS. In 1985 a
sensitive enzyme linked immunosorbent assay was developed.
HIV infection is a global pandemic, with cases reported from
virtually every country. At the end of 2009,an estimated 33.3 million individuals
were living with HIV infection according to Joint United Nations Programme on
HIV/AIDS. More than 95% of people living with HIV/AIDS reside in low and
middle income countries.
CARDIAC MANIFESTATIONS OF HIV/AIDS
The prevalence of cardiac involvement in AIDS patients has been reported to
range between 28% to 73%. Because of the longer survival in HIV patients, the
more manifestations of late-stage HIV infection will be seen, including HIVrelated cardiac diseases. These cardiac diseases include pericardial efflusion,
myocarditis, dilated cardiomyopathy, endocarditis, pulmonary hypertension,
malignant neoplasms, coronary artery disease and drug-related cardiotoxicity.
a.PERICARDIAL EFFUSION
Pericardial effusion is one of the most common forms of cardiovascular
involvement in HIV infection. There are varieties of clinical manifestations, which
include asymptomatic pericardial effusion, percarditis, cardiac tamponade, and
constrictive pericarditis. Approximately one fifth of AIDS patients have
pericardial effusion. The clinical manifestations of pericarditis are similar between
patients with and without HIV. Numerous1 case reports have shown multiple
unusual organisms associated with pericardial effusion in HIV patients.
Pericardial effusion2 in HIV patients may be a marker of end-stage HIV
infection because it is associated with low CD4 cell count and is often caused by
opportunistic infections and malignant neoplasms seen in the advanced stage of
AIDS.
b.MYOCARDITIS
Anderson et al3 suggested that myocarditis in HIV patients may play a role in
the development of ventricular dysfunction. The autopsy incidence of myocarditis
was approximately one third of all AIDS patients. A specific cause was found in
less than 20% of these patients. Common pathogens in AIDS myocarditis include
Toxoplasma gondii, M tuberculosis, and Cryptococcus neoformans. Other
infectious organisms have been reported to include
Myocobacterium
avium-
intracellulare complex, Aspergillus fumigatus, Candida albacians, Histoplasma
capsulatum, Coccidiodes immitis, cytomegalovirus, and herpes simplex. Recent
data suggested that HIV alone can cause myocarditis.
c.DILATED CARDIOMYOPATHY
Herskowitz et al4 found that patients with severe symptomatic heart
failure usually had a low CD4 cell count, myocarditis, and a persistent elevation
of antiheart antibodies. The postmortem gross findings of dilated cardiomyopathy
in patients with AIDS have included increased heart weight, with either
biventricular or 4 – chamber dilation, and a pale appearing myocardium5.
Echocardiographic findings, included 4 – chamber enlargement, diffuse left
ventricular hypokinesis, and decreased fractional shortening. Coudray and
colleagues6 demonstrated that left ventricular diastolic impairment could occur in
the early stage of HIV infection. Dilated cardiomyopathy occurs late in the course
of HIV infection and is usually associated with a significant reduced CD4 cell
count7, 8, however, there was no association between the progression of left
ventricular dysfunction and the rate of CD4 cell count decline9.
d.ENDOCARDITIS
Infective endocarditis in patients with AIDS usually occurs in parenteral
drug users. Human immunodeficiency virus infection may increase the risk of
infective endocarditis among intravenous drug user. Nahass et al12 studied the
causes of infective endocarditis in 34 HIV patients, and they found that S.aureus
(75%) and Streptococcus viridans (20%) were the major responsible organisms.
Other unusual organisms described as case reports were Salmonella, A fumigatus,
and Pseudallescheria boydii.
Marantic endocarditis or nonbacterial thrombotic endocarditis is
characterized by friable, fibrinous clumps of platelet and red blood cells adherent
to the cardiac valves without an inflammatory reaction. It is estimated that this
condition occurs in 3% to 5% of AIDS patients10. It usually occurs in patients
older than 50 years. Marantic endocarditis is known to be associated with
malignant neoplasms, hypercoagulable states and chronic wasting disease. Mitral
and aortic valves are commonly involved in HIV negative patients11, but the
tricuspid valve is usually involved in AIDS patients. Systemic emoblism can
occur in up to 42% of patients, but most of these events are clinically silent.
Embolisation can involve the brain, lung, spleen, kidney, and coronary arteries.
Systemic emoblization from marantic endocarditis is a rare cause of death in
AIDS patients.
e.PULMONARY HYPERTENSION
Kim and Factor first described human immunodeficiency virus associated
pulmonary hypertension in 1987. By 1998, 88 patients with HIV infection were
described with this entity. The incidence of HIV associated pulmonary
hypertension is 1 in 200 compared with 1 in 200,000 in the general population13.
It is more common in male and young patients (mean age, 32 years). The common
risk factors are intravenous drug use, homosexual contacts, and hemophilia. The
major symptom of this condition is dyspnea. There was no correlation between
either a history of opportunistic infections or CD4 cell count and the development
of pulmonary artery systolic pressure was 68 mm Hg. The major causes of death
were right-sided heart failure and respiratory failure. Half of the patients died in 1
year.
f.CARDIAC NEOPLASMS
Two types of malignant neoplasms affecting the heart have been described
in patients with HIV infection: Kaposi sarcoma and malignant lymphoma.
KAPOSI SARCOMA
In 1983, Autran et14 al first described Kaposi sarcoma of the heart in an
HIV patient. The incidence of Kaposi sarcoma involving the heart ranged from
12% to 28% in retrospective autopsy findings. Most (90%) of the autopsies were
performed on homosexual or bisexual patients. Cardiac involvement with Kaposi
sarcoma in an HIV infected patient usually occurs as a part of disseminated
Kaposi sarcoma. Acquired immunodeficiency syndrome – related metastatic
Kaposi sarcoma involves either the visceral layer of serous pericardium or the
subepicardial fat. Myocardium and endocardium may also be involved.
MALIGNANT LYMPHOMA
In 1985, the Centers for Disease Control and Prevention recognized
the linkage between intermediate and high-grade lymphoma and HIV
seropositivity and included this in the diagnostic criteria for AIDS. Lymphoma is
the second most common tumor that involved the heart. Cardiac involvement with
non- Hodgkin lymphoma; usually derived from B cells, is typically high grade
and is often disseminated early in patients with AIDS. Disseminated cardiac
lymphoma is more common than primary cardiac lymphoma. It has been reported
to account for 15% of all cardiac and peri-cardial metastases in non-AIDS
series15. Primary cardiac lymphoma is extremely rare. Patients may present with
intractable congestive heart failure, pericardial effusion, cardiac arrhythmia, or
cardiac tamponade.
g.CORONARY ARTERY DISEASE
Coronary artery disease has been reported in a patient with HIV infection
at autopsy. Coronary artery disease in HIV-positive patients may be due to
artherogenesis as a result of virus-infected monocytes-macrophages, possibly
through altered adhesion or due to angitis. HIV-infected patients receiving
HAART have an increased risk of ischemic heart disease16. Atherosclerosis and
atherothrombosis from dyslipoproteinemia caused by highly active antiretroviral
therapy, especially protease inhibitors, have been reported.
6.3 OBJECTIVES OF THE STUDY:
 To study the Clinical Profile of Cardiac abnormalities in HIV/AIDS
patients and its correlations with investigations like
1.
Echo
2.
Chest X-ray
3.
ECG and
4.
CD4 count
MATERIALS AND METHODS
SOURCE OF DATA:
The study will be conducted in patients admitted in the Department of General
Medicine of VIMS hospital Bellary and also patients visiting ART Centre
VIMS, BELLARY during the period from 01/01/2011 to 31/05/2012.
METHOD OF COLLECTION OF DATA
Our study is a clinical, prospective, observational and open study .
200 cases of seropositivity of HIV patient diagnosed by Elisa technique will
be selected for the study. A detailed clinical profile including detailed history,
general physical examination and systemic examination will be done for each
patient with special emphasis on cardiovascular system. Routine line of
investigation obtained for all the patients. All patients will be subjected to
cardiovascular investigation like ECG, ECHO, and chest x-ray. All relevant
findings of echocardiography like of LV internal dimension in systole [LVIDs]
LV internal dimension in diastole [LVIDd] interventricular septal thickness in
systole and diastole, fractional shortening [FS] and ejection fraction [EF] will be
studied.
All patients will be evaluated for their CD4 counts and will be analyzed
for various cardiac dysfunctions.
The complete data will be collected in a specially designed Case Recording Form
.
The data collected will be transferred in to a Master Chart, which is then subjected
for statistical analysis. Patients are selected with the following inclusion/exclusion
criteria
1)INCLUSION CRITERIA:
The patients aged > 15years.
 Patients diagnosed to have HIV infection/AIDS after S.D Bioline, Triline and
Tri-spot tests being positive.
2) EXCLUSION CRITERIA:

Patients <15 years are excluded.
Patients with congenital heart disease.
Patients with preexisting valvular heart disease.

Patients with preexisting hypertension.

Patients with preexisting diabetes mellitus
All the patients included in the study will be explained about the procedure in
detail and issued Patient Information Sheet. Informed/written consent will be
taken in each case . All investigations and interventions will be done under direct
supervision and guidance of our guide.
SAMPLE SIZE AND DESIGN:
A total of 200 cases will be studied prospectively.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR
OTHER HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY
YES, our study requires investigations like
1. Routine investigations
2. Blood HIV 1 and 2.
3. CD4 count
4. ECG
5. Chest X-ray P/A view
6. Blood culture and sensitivity
7. Echocardiography
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTION?
-Yes
8.
LIST OF REFERENCES:
1.
Eisenberg MJ, Gordon AS, Schiller NB. HIV associated pericardial
effusions. Chest. 1992; 102:956-958.
2.
Heidenreich PA, Eisenberg MJ, Kee LL, et al. Pericardial effusions in
AIDS: Incidence and survival. Circulation.1995: 92:3229-3234.
3.
Anderson DW, Virmani R, Reilly JM, et al. Prevalent myocarditis at
necropsy
in
Acquired
immunodeficiency syndrome. J
Am Coll
Cardiol. 1988; 11:792-799.
4.
Herskowitz A, Willoughhy SB, Vlahov K, Baughman KL, Ansari AA.
Dilated Heart muscle disease associated with HIV infection. E ur
Heart J. 1995; 16(suppl O):50-55.
5.
Roldan EO, Moskowitz L, Hensley GT. Pathology of the heart in
acquired
Immunodeficiency syndrome.
Arch
Pathol
Lab
Med. 1987;111:943-946.
6.
Coudray N, de Zuttere D, Force D, et al. Left ventricular diastolic function
in Asymptomatic and symptomatic human immunodeficiency virus
carriers :an echocardiographic study. Eur Heart J. 1995;16:61-67.
7.
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.
8.
Jacob AJ, Sutherland GR, Bird AG, et al. Myocardial dysfunction in
patients
Infected with HIV: prevalence and risk factors. Br Heart J.
1992;68: 549-553.
9.
Acierno LJ.Cardiac complications in
acquired
immunodeficiency
syndrome (AIDS):a review. J Am Coll Cardiol. 1989;13:1144-1154.
10.
Currie PF, Sutherland GR, Jacob AJ, Bell JE, Brettle RP, Boon NA. A
review of Endocarditis in acquired immunodeficiency syndrome and
human Immunodeficiency virus infection. Eur Heart J. 1995;16(suppl
B):15-18.
11.
Lopez JA, Ross RS, Fishbein MC, Seigel RJ. Nonbacterial thrombotic
Endocarditis. Am Heart J. 1987; 113:773-784.
12.
Nahass RG, Weinstein MP,. Infective endocarditis in intravenous drug
users: a comparison of human immunodeficiency virus type 1–negative
and –positive patients. J Infect Dis. 1990;162:967-970
13.
Mesa RA,
Edell ES,
immunodeficiency
virus
Dunn WF,
infection
and
Edwards
pulmonary
WD.
Human
hypertensions.
Mayo Clin Proc.1998;73:37-44.
14.
Autran B, Gorin I, Leibowitch M, et al. AIDS in a Haitian woman with
cardiac Kaposi’ssarcomaand Whipple’s disease. Lancet. 1983;1:767-768.
15.
Peterson CD, Robinson QA, Kurnich JE. Involvement of the heart and
pericardium in the malignant lymphoma[letter]. Am J Med Sci.1976;
272:161.
16.
Niels Obel et al. Ischemic Heart Disease in HIV-Infected
and HIV-
Uninfected Individuals: A Population-Based Cohort Study, Clinical
Infectious Diseases 2007; 44:1625–31
17.
Fauci A, Clifford Lane H. Human immunodeficiency virus disease: AIDS
and related disorders. Harrison’s principle of internal medicine.2011;18th
edn:1506.
9.
SIGNATURE
CANDIDATE:
OF
THE
(Dr. NANDINI DEVRU)
10. REMARKS
GUIDE:
OF
THE
11. 11.1NAME
AND Dr. SHASHIBHUSHAN J.
DESIGNATION OF GUIDE Professor, Dept. of Medicine.
(in block letters)
VIMS, BELLARY.
11.2 SIGNATURE
11.3 CO.GUIDE (if any)
11.4 SIGNATURE
11.5
HEAD
OF
DEPARTMENT:
THE Dr. GADWALKAR R SRIKANT
Prof. & Head Of The Department,
Department of Medicine,
VIMS, Bellary.
11.6 SIGNATURE
12. 12.1 REMARKS OF THE
CHAIRMAN & PRINCIPAL
12.2 SIGNATURE