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CARDIOVASCULAR PATHOLOGY IN AIDS

The heart is not a frequent site for opportunistic infectious or neoplastic processes in
patients with AIDS (Table 5). Most AIDS patients are in the third to fifth decades of life, at an
age when cardiovascular complications from atherosclerosis are not as frequent as in older
patients. Atherosclerotic cardiovascular disease leading to ischemia and infarction can and does
occur in some AIDS patients, particularly as the numbers of HIV-infected persons begin to
include older persons and those surviving longer on antiretroviral therapy (ART). However, the
chronic debilitated state with cachexia brought on by AIDS may also lead to regression of
atherosclerotic lesions. Clinical cardiac findings may be present in a fourth to three-fourths of
adult AIDS patients and may be accompanied by findings that include chest pain, tachycardia,
electrocardiographic changes including various arrhythmias, effusions, and congestive heart
failure. There may be mild cardiomegaly on chest roentgenogram and minimal
electrocardiographic findings.[896,897]
Pericardial effusions may be seen in about 40% of persons with HIV infection. In most
of these cases, the effusion is small and clinically insignificant. A specific etiology for the
effusion, which can include a variety of infectious agents, is found in about a fourth of cases.
Persons with AIDS who have a pericardial effusion, regardless of size, tend to have lower CD4
counts and decreased survival, compared to those without effusions. Though pericardial
effusions are seen in the late stages of AIDS, they are rarely the cause of death. The findings of
an elevated jugular venous pulse and pulsus paradoxus with "low pressure tamponade" may be
masked by dehydration, Regardless of the etiology, a large pericardial effusion in AIDS carries
a high mortality, and treatment with a pericardial window is unlikely to prolong survival
significantly.[896]
Cardiac tamponade is usually marked by dyspnea, fever, cough, and chest pain. Cardiac
arrest may be an initial manifestation. Most cases have serosanguineous fluid. The most
common etiology is mycobacterial infection, followed by neoplasms (non-Hodgkin lymphoma or
Kaposi sarcoma) and bacterial infection. Most patients die from cardiac tamponade.[898]
Cardiac manifestations in pediatric AIDS are similar to those in adults. There does not
appear to be an increased risk for congenital heart disease with HIV infection. Cardiac
dysfunction is a manifestation of HIV infection in children, with a prevalence of 18 to 39%, and
mortality is higher when there is decreased left ventricular function.[899]

MALIGNANT LYMPHOMA.-- A high grade non-Hodgkin lymphoma is one of the
most common AIDS diagnostic disease seen in heart, occurring in about one sixth of AIDS cases
when lymphoma is diagnosed at autopsy (Table 5). The serum creatine kinase is unlikely to be
elevated. Grossly, lymphomas may produce a patchy pattern of infiltration with white streaks or
distinct nodules. Despite the often widespread infiltration by malignant lymphoma, cardiac
enlargement and failure are uncommon. Microscopically, the lymphomatous infiltrates extend in
and around myocardial fibers, onto the endocardium, and over the epicardium. There is little
myocardial fiber necrosis or inflammation resulting from such infiltration. These lymphomas
can be classified either high grade (diffuse large cell) or intermediate grade (small noncleaved
cell) types.[900]