M.Med.(Internal Medicine), Faculty of Health Sciences, University of the Witwatersrand, 2009. / In Africa, infective endocarditis (IE) is still a disease of young adults with underlying
rheumatic heart disease (RHD). As of 2006, almost two-thirds of all persons infected
with human immunodeficiency virus (HIV) are living in sub-Saharan Africa. Southern
Africa thus remains the epicentre of the global HIV epidemic. The HIV sero-prevalence
data reported in Southern Africa are as high as 20% - 30% of the adult population aged
between 15 and 49 years. In South Africa, the prevalence of HIV among adults aged 15 -
49 is 18.8%. Based on a simple extrapolation, there is a higher possibility of encountering
a significant number of patients infected with HIV and underlying RHD with IE in
Southern Africa than in any other part of the world. In Africa because both HIV and
valvular heart disease are relatively common, the co-existence of the two conditions in
individual patients is not rare.
Despite the major advances in diagnosis and management of this classical disease, the
overall mortality rates for both native-valve and prosthetic-valve endocarditis remain as
high as 20 to 25 percent after 1 year and at 50% after 10 years. However, the mortality
rate varies, depending on a number of factors, such as:
• the causative microorganism
• the presence of complications
• the development of perivalvular extension or a myocardial abscess
• neurological events
• the existence of conditions such as congestive heart failure
• renal failure
• severe immunosuppression due to HIV infection in intravenous drug abusers
• the use of combined medical therapy and surgical therapy in appropriate patients.
vi
The clinical outcome of infective endocarditis in HIV patients is poor, severe
immunodeficiency in IVDAs with IE has been reported to be associated with poor
outcome. However, such an association has never been documented in non-IVDAs,
particularly in Africa, where the expected majority patients with HIV and IE are non-
IVDAs.
The clinical profile including bacteriology of infective endocarditis in HIV patients is
different from HIV uninfected patients. The clinical impact of the HIV epidemic on
infective endocarditis in Africa has not been elucidated in the world literature and there
is, moreover, a paucity of literature describing this clinical entity of HIV and IE in Africa.
Objective
The objective of this study was to highlight the co-existence of infective endocarditis in
HIV positive, non-intravenous drug abuse in South Africa and Africa by: reporting three
cases admitted at the researcher’s institution within a period of two months; and
undertaking a literature review.
Methods
This was a retrospective case report and literature review study of IE in HIV infected
patients. Three HIV positive patients with IE and with or without underlying chronic
rheumatic heart disease were reported. The patients were admitted at the researcher’s
institution within a period of two months. All three patients did not report intravenous
drug abuse. However, all patients died within a short period of admission to the hospital.
The systematic review of cases published in the literature was delivered from MEDLINE
SEARCH from January 1985 to December 2006. The following key words were used:
Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome,
Rheumatic Heart Disease, Infective Endocarditis, and Intravenous Drug Abusers
and Non-Intravenous Drug Abusers. Most of the articles were identified in English;
where articles were identified in Spanish and French, only abstracts were used.
vii
Literature emanating from Africa was emphasized. In addition, the references quoted in
this study were reviewed for relevance on the topic.
Results
Three patients with definitive IE and infected with HIV were reported: one patient was
without underlying chronic rheumatic valvular heart disease and two showed underlying
chronic rheumatic valvular heart disease. There are few reported studies of IE not related
to intravenous drug abuse in HIV infected patients in the literature, which is probably
attributable to the reported low prevalence of IE in this sub-group of patients. Most of
these published studies are limited to a series of case reports and very little data or reports
originate from Africa.
Conclusion
The clinical pattern of IE in HIV positive patients who are not IVDAs is not well
described in literature. However, in this anecdotal case report, the three patients studied
retrospectively had a poor outcome. Based on this anecdotal report of three cases
described, if an extrapolation was done from these numbers and a prospective analysis
performed, we would observed a substantial number of non-IVDU cases with infective
endocarditis and HIV/AIDS in Africa. The literature review in its current form may shed
some light on HIV and IE in non-IVDU patients, but doesn’t specifically address the
issue of the potential co-existence of HIV and IE in Africa. Given the high prevalence
both HIV/AIDS and rheumatic valvular heart disease in Africa, in future, we are more
likely to see a significant proportion of patients with IE and underlying rheumatic
valvular heart disease who are coincidentally HIV infected. There is a useful need for
prospective studies describing the prevalence and outcome and for subsequently defining
the management of this condition in Africa.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/7393 |
| Date | 29 October 2009 |
| Creators | Mvungi, Robert Sostenes |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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