Correspondence

HIV-Associated Coronary Arteritis in a Patient with Fatal Myocardial Infarction

N Engl J Med 2001; 344:1799-1800June 7, 2001

Article

To the Editor:

Coronary disease has been reported previously in patients infected with the human immunodeficiency virus (HIV) who are receiving protease inhibitors1 or who are also infected with cytomegalovirus.2,3 Dilated cardiomyopathy has also been described in patients with AIDS.4 We report a case of fatal myocardial infarction caused by acute coronary arteritis in a patient infected with HIV.

A 32-year-old homosexual man was admitted to the hospital with an anterior Q-wave infarction. The patient had been known to be positive for HIV type 1 (HIV-1) since 1994 and had not received reverse-transcriptase inhibitors or protease inhibitors since 1998. His CD4 count four months before admission was 230 cells per cubic millimeter. He had never had an AIDS-defining opportunistic infection and had no known cardiovascular risk factors. One week before presentation, he had influenza-like symptoms that were treated with acetaminophen and began to experience worsening left-sided chest pain. On admission, he had evidence of congestive heart failure. Cardiac arrest associated with electromechanical dissociation occurred soon after presentation. The patient died 45 minutes later.

Autopsy revealed a myocardial infarction involving 75 percent of the left ventricular wall. The inner surface of 80 percent of the anterior descending artery and 70 percent of the circumflex artery appeared eroded, with several fissures. There were no thrombi. There was no histologic evidence of myocarditis. In situ hybridization of the myocardium was negative for HIV-1 and cardiotropic viruses (cytomegalovirus, coxsackievirus B3, and adenovirus). Histologic analysis of both the anterior descending and the circumflex arteries showed a dense infiltration of lymphocytes with necrosis of the intima. In situ hybridization performed on serial sections of these arteries showed sparse, intense staining (under the intima and in the media), indicating the presence of HIV-1 sequences within the arterial wall (Figure 1Figure 1In Situ Hybridization of an HIV-1 RNA Probe in a Transverse Section of a Branch of the Left Anterior Descending Coronary Artery.); staining was negative for other viruses. In situ hybridization of uninvolved arteries was negative for HIV-1 and other viruses. Immunohistochemical analysis of both involved and uninvolved arteries was negative for immune complexes.

It is possible that HIV might be incidentally detected in an eroded atherosclerotic plaque; however, the presence of atherosclerotic coronary disease was unlikely, given the age of the patient and the lack of coronary risk factors. Potential mechanisms through which HIV-1 may cause coronary arteritis are activation of cytokines and cell-adhesion molecules and alteration of major-histocompatibility-complex class I molecules on the surface of smooth-muscle cells.5 Infected cells may also generate reactive oxygen species with the activation of factors that induce apoptosis.5

Giuseppe Barbaro, M.D.
University La Sapienza, 00161 Rome, Italy

Giorgio Barbarini, M.D.
Policlinico San Matteo, 27100 Pavia, Italy

Adriano M. Pellicelli, M.D.
Lazzaro Spallanzani Hospital, 00149 Rome, Italy

5 References

1. 1

   Sullivan AK, Nelson MR, Moyle GJ, Newell AM, Feher MD, Gazzard BG. Coronary artery disease occurring with protease inhibitor therapy. Int J STD AIDS 1998;9:711-712
   CrossRef | Web of Science | Medline

2. 2

   Paton P, Tabib A, Loire R, Tete R. Coronary artery lesions and human immunodeficiency virus infection. Res Virol 1993;144:225-231
   CrossRef | Medline

3. 3

   Epstein SE, Speir E, Zhou YF, Guetta E, Leon M, Finkel T. The role of infection in restenosis and atherosclerosis: focus on cytomegalovirus. Lancet 1996;348:Suppl 1:S13-S17
   CrossRef | Web of Science | Medline

4. 4

   Barbaro G, Di Lorenzo G, Grisorio B, Barbarini G. Incidence of dilated cardiomyopathy and detection of HIV in myocardial cells of HIV-positive patients. N Engl J Med 1998;339:1093-1099
   Full Text | Web of Science | Medline

5. 5

   Ellis RW. Infection and coronary heart disease. J Med Microbiol 1997;46:535-539
   CrossRef | Web of Science | Medline

Citing Articles (15)

Citing Articles

1. 1

   J. Jiang, W. Fu, X. Wang, P. H. Lin, Q. Yao, C. Chen. (2010) HIV gp120 induces endothelial dysfunction in tumour necrosis factor- -activated porcine and human endothelial cells. Cardiovascular Research 87:2, 366-374
   CrossRef

2. 2

   Jean-Jacques Monsuez, Jean-Christophe Charniot, Lelia Escaut, Elina Teicher, Benjamin Wyplosz, Carine Couzigou, Noëlle Vignat, Daniel Vittecoq. (2009) HIV-associated vascular diseases: Structural and functional changes, clinical implications. International Journal of Cardiology 133:3, 293-306
   CrossRef

3. 3

   Nirupa Patel, Neej Patel, Luis R. Espinoza. (2009) HIV Infection and Rheumatic Diseases: The Changing Spectrum of Clinical Enigma. Rheumatic Disease Clinics of North America 35:1, 139-161
   CrossRef

4. 4

   U. A. Walker, A. Tyndall, T. Daikeler. (2008) Rheumatic conditions in human immunodeficiency virus infection. Rheumatology 47:7, 952-959
   CrossRef

5. 5

   Eliseo A. Eugenin, Susan Morgello, Mary E. Klotman, Arevik Mosoian, Patrick A. Lento, Joan W. Berman, Alison D. Schecter. (2008) Human Immunodeficiency Virus (HIV) Infects Human Arterial Smooth Muscle Cells in Vivo and in Vitro. The American Journal of Pathology 172:4, 1100-1111
   CrossRef

6. 6

   Mahmoud Umar Sani. (2008) Myocardial disease in human immunodeficiency virus (HIV) infection: a review. Wiener klinische Wochenschrift 120:3-4, 77-87
   CrossRef

7. 7

   F Boccara, S Ederhy, S Janower, N Benyounes, G Odi, A Cohen. (2005) Clinical characteristics and mid-term prognosis of acute coronary syndrome in HIV-infected patients on antiretroviral therapy. HIV Medicine 6:4, 240-244
   CrossRef

8. 8

   F. Saporito, A. Micari, S. Raffa, M. Cerrito, G. Micari, R. Grassi. (2005) Acute myocardial infarction and rescue percutaneous transluminal coronary angioplasty in a young HIV-infected patient. International Journal of Clinical Practice 59:3, 376-378
   CrossRef

9. 9

   Raymond M Johnson, Giorgio Barbarini, Giuseppe Barbaro. (2003) Kawasaki-like syndromes and other vasculitic syndromes in HIV-infected patients. AIDS 17, S77-S82
   CrossRef

10. 10

    Daniel Vittecoq, Lelia Escaut, Gilles Chironi, Elina Teicher, Jean Jacques Monsuez, Michel Andrejak, Alain Simon. (2003) Coronary heart disease in HIV-infected patients in the highly active antiretroviral treatment era. AIDS 17, S70-S76
    CrossRef

11. 11

    Robert L Murphy, Giuseppe Barbaro. (2003) Clinical and biological insights in HIV-associated cardiovascular disease in the era of highly active antiretroviral therapy. AIDS 17, S1-S3
    CrossRef

12. 12

    Gisele Zandman-Goddard, Yehuda Shoenfeld. (2002) HIV and autoimmunity. Autoimmunity Reviews 1:6, 329-337
    CrossRef

13. 13

    Giuseppe Barbaro. (2002) Journal of Cardiovascular Risk 9:5, 295-300
    CrossRef

14. 14

    Daniel Klein, Leo B. Hurley, Charles P. Quesenberry, Stephen Sidney. (2002) Do Protease Inhibitors Increase the Risk for Coronary Heart Disease in Patients With HIV-1 Infection?. JAIDS Journal of Acquired Immune Deficiency Syndromes 30:5, 471-477
    CrossRef

15. 15

    Giuseppe Barbaro, Stacy D Fisher, Steven E Lipshultz. (2001) Pathogenesis of HIV-associated cardiovascular complications. The Lancet Infectious Diseases 1:2, 115-124
    CrossRef