Clinical Presentation and Echocardiography Findings

To determine the clinical features in HIV-positive patients with and without infective endocarditis Smith et al. [39] retrospectively reviewed all bacteremic, HIV-positive patients with suspected infective endocarditis admitted over a four-year period that underwent either transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE). Ten (11.5%) of 87 HIV-positive patients had a clinical diagnosis of infective endocarditis based on the Duke criteria. The mean age of patients with endocarditis was 37.8 years—similar to those without endocarditis, i.e., 39.9 years (p = NS).

Both patient groups were similar with respect to gender, race, IVDU, renal failure requiring hemodialysis, history of predisposing heart disease, origin of infection and causative organism. The mean CD4 count (cells/^L) was 200.7 in patients with infective endocarditis and 95.9 in patients without infective endocarditis (P = NS).

Of ten HIV-positive patients with infective endocarditis, seven had left-sided heart involvement, two had complications related to infective endocarditis, three required cardiothoracic surgery and three died.

Abraham et al. [40] retrospectively reviewed the records of patients with suspected infective endocarditis who were referred to the echocar-diography laboratory for evaluation and had > 2 positive blood cultures for the same microorganism.

One hundred seventy-seven cases of bac-teremia involving 169 patients were evaluated. Fifty-two patients were HIV positive and 125 were HIV negative. One hundred sixty-eight of the patients (95%) underwent TEE. HIV-positive patients were on average 12 years younger than HIV-negative patients (p < 0.0001). HIV-negative patients were more likely to have a cardiac predisposition to endocarditis (P < 0.003). There was a higher rate of diabetes in HIV-negative patients (p < 0.002), which likely corresponded to their older age. There was also a higher incidence of renal failure requiring hemodialysis in HIVnegative patients (p < 0.03), which was likely due to their older age and higher rate of diabetes. More men comprised the HIV-negative group (P < 0.017) (for unknown reasons). There was no difference in the rates of active IVDU between the two groups and the percentage of patients with documented sources of infection that would explain bacteremia, including line infections, was similar.

Staphylococcus aureus was the causative organism for bacteremia in almost half of all patients in both groups. There was no sta

Figure 3.4. Changing characteristics from 1993 to 1999 of 329 patients with infective endocarditis: The increase in nosocomial infective endocarditis [43].

tistically significant difference in the microorganisms between the HIV-positive and HIVnegative patients, although most involved small numbers of patients. When considering all organisms, the rate of endocarditis in HIV-positive patients was lower than in HIVnegative patients (12% vs. 42%, P <0.0001). There was no correlation between the CD4 count and the presence or absence of endocarditis in the HIV-positive group. Multiple logistic regression analysis revealed five clinical factors that were predictive of infective endocarditis: HIV status, presence of IVDA, predisposing heart disease, S. aureus bacteremia and bacteremia caused by modified Duke criteria 1A organisms. In conclusion, the bacteremic HIV-positive patients in this study had less infective endocarditis than bacteremic HIVnegative patients.

Robinson et al. [41] attempted to determine if HIV seropositivity alters the maximum temperature and WBC count of febrile IVDU users with infective endocarditis. In their review of 158 episodes of infective endocarditis among 126 patients HIV infections were not associated with lower maximal temperature. Mean WBC counts were significantly lower in the HIV-positive patients.

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