**2.3 Clinical manifestation**

Clinical presentation of HIV associated myocarditis in symptomatic patients is generally similar to myocarditis due to other causes. The absence of symptoms and signs of heart disease does not however exclude cardiac involvement, as occurrence of sub-clinical cardiac abnormalities with possible fatal consequences in this population has been described [Kaminski et al., 1990]. Diagnosis requires the possibility of cardiac involvement to be constantly in mind and symptoms associated with myocarditis are varied, and relate either to the actual inflammation of the myocardium, or the weakness of the heart muscle that is secondary to the inflammation. Signs and symptoms of myocarditis include: **chest pain** (often described as "stabbing" in character); **congestive heart failure** (leading to edema, breathlessness and hepatic congestion); **palpitations** (due to arrhythmias); **sudden death** (in young adults, myocarditis causes up to 20% of all cases of sudden death); **fever** (especially when infectious); symptoms in infants and toddlers tend to be more non-specific with generalized malaise, poor appetite, abdominal pain, chronic cough. Later stages of the illness will present with respiratory symptoms with increased work of breathing and is often mistaken for asthma.

Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent with a recent viral infection, including fever, rash, diarrhea, joint pains, and frequent fatigue.

Myocarditis in HIV Positive Patients 157

**Cardiac angiography:** This is often indicated to rule out coronary ischemia as a cause of new-onset heart failure, especially when clinical presentation mimics acute myocardial infarction. It usually shows high filling pressures and reduced cardiac outputs [Tang et al.,

The gold standard is still **biopsy of the myocardium**, generally done in the setting of angiography. A small tissue sample of the endocardium and myocardium is taken, and investigated by a pathologist by light microscopy and—if necessary—immunochemistry and special staining methods [Cunningham et al., 2006]. Histopathological features are: a myocardial interstitium with abundant edema and inflammatory infiltrate, rich in lymphocytes and macrophages. Focal destruction of myocytes explains the myocardial pump failure. The need for routine myocardial biopsy in patients with HIV is controversial and associated risks are significant – sensitivity is low, especially in patchy lesions, and beyond research protocols, its use is limited to patients with extensive cardiac damage with

Myocarditis identified at autopsy or on endomyocardial biopsy in HIV-infected patients is most often nonspecific and manifested as focal, inflammatory lymphocytic infiltrates without myocyte necrosis. Other reported histopathologic findings include lymphocytic infiltration with myocyte necrosis fulfilling the Dallas criteria or myocyte damage without associated cellular inflammatory infiltrate [Anderson et al., 1988, Barbaro et al., 1998]. The autopsy finding of focal myocarditis in many patients who die of AIDS-related complications, but have no known premortem heart disease, suggests that focal lymphocytic infiltration may have no clinical significance. By comparison, diffuse lymphocytic

The prevalence of nonspecific myocarditis is related to the stage of HIV infection and the presence of structural heart disease. In one study of HIV-infected patients with a premortem diagnosis of dilated cardiomyopathy*,* histologic findings consistent with lymphocytic myocarditis by the Dallas criteria were identified in 63 of 76 patients (83%)

**Electrocardiography** (ECG) is a useful screening tool in patients with HIV infection, and ECG changes may precede echocardiographic abnormalities. Patients with abnormal ECG

Electrocardiography is often nonspecific (eg, sinus tachycardia, nonspecific ST or T-wave changes). Occasionally, heart block (atrioventricular block or intraventricular conduction delay), ventricular arrhythmia, or injury patterns with ST- or T-wave changes mimicking myocardial ischemia or pericarditis (pseudoinfarction pattern) may indicate poorer

**A chest X- ray** can offer data about the size and shape of hart, as well as identification of

**Echocardiography** has been shown to be extremely useful for the diagnosis and monitoring of HIV associated myocardial disease. Echocardiography is performed to exclude other causes of heart failure (eg, valvular, amyloidosis, congenital) and to evaluate the degree of cardiac dysfunction (usually diffuse hypokinesis and diastolic dysfunction). It also may allow gross localization of the extent of inflammation (ie, wall motion abnormalities, wall thickening, and pericardial effusion). In addition, echocardiography may distinguish

fluid in or around the heart that might indicate heart failure [Round 2007].

myocarditis meeting the Dallas criteria appears rare [Anderson et al., 1988].

**2.4.2 Invasive techniques** 

no identifiable cause [Wu et al., 1990].

[Barbaro et al., 1998].

**2.4.3 Non-invasive techniques** 

prognosis [Gorgels 2007].

patterns should be further investigated [Tang et al., 2009].

2009].

Myocarditis is often associated with pericarditis, and many patients present with signs (pericardial friction rub) and symptoms that suggest concurrent myocarditis and pericarditis.
