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More About... HIV-Related Surgery More about... HIV-related surgery Vascular disease in HIV/AIDS The Pavia consensus statement3 brought the Henoch-Schönlein purpura, drug-related RG BOTHA, MB ChB, DA (SA), following important aspects to attention: hypersensitivity vasculitis, temporal MMed (Surg), CVS (SA) • HIV infection may directly cause arteritis/polymyalgia rheumatic and Consultant Vascular Surgeon, Department of cardiovascular disease nonspecific unclassified vasculitis) and Surgery, Faculty of Health Sciences, University of • HIV therapy may cause cardiovascular • microvascular changes (thrombocytic the Free State disease thrombotic purpura (TTP) and haemolytic • HIV therapies may interact with drugs uraemic syndrome).1 Correspondence to: [email protected] used for cardiovascular complications • Primary prevention of coronary Prothrombotic state heart disease in patients receiving An increased prothrombotic state is observed The well-documented relationship between antiretroviral therapy includes exercise, in HIV patients with active opportunistic vascular disease and HIV infection has diet and treatment of hyperlipidaemia, infections or malignancy and in patients with evolved from infectious and inflammatory hypertension and glucose intolerance. AIDS. The potential mechanisms proposed vasculitides to: are the presence of antiphospholipid • premature atherosclerosis Peripheral arterial occlusive disease antibodies, such as anticardiolipin antibodies • its related contributing conditions (PAOD) in HIV-infected patients and lupus anticoagulants, and also increased (metabolic syndrome, dyslipidaemia, Van Marle reported the classic risk factors levels of von Willebrand factor, fibrinogen and insulin resistance syndrome) and for PAOD to be less prevalent in their studied D-dimers as well as deficiencies of protein C, • complications (acute coronary and HIV population. Patients were also of protein S, antithrombin III, heparin cofactor cerebrovascular syndromes).1 younger age than expected at presentation.4 II and increased platelet activation. Three clinical syndromes may present: Triple antiretroviral therapy ensures adequate Thus, the multifactorial pathogenesis viral suppression, which is paramount to Atherosclerotic disease may explain the peculiar characteristics the successful clinical management of HIV- Contributing risk factors are: and features of HIV-associated occlusive infected patients. The associated metabolic • disease specific (metabolic syndrome, vasculopathy (Table I). effects as well as the increased longevity dyslipidaemia, insulin resistance syndrome, associated with these drugs increase the antiretroviral therapy, i.e. protease in- Aneurysms in HIV-infected patients cardiovascular manifestations, which should hibitors) or (Fig. 1) be prevented and treated. • due to a high prevalence of the traditional The pathogenesis is uncertain. It is commonly risk factors for atherosclerosis in this associated with, but not exclusively due to, Perioperative risk assessment and population. a leucocytoclastic vasculitis. This process reduction results in obliteration of the vasa vasorum and The American Heart Association (AHA) Future research has to determine whether transmural necrosis. Infective aetiologies are ‘Initiative to Decrease Cardiovascular Risk HIV infection and antiretroviral therapy a sporadic rather than a consistent finding. and Increase Quality of Care for Patients contribute independently to increased Living with HIV/AIDS’2 concluded that cardiovascular disease.1,2 Unlike degenerative aneurysms, these are metabolic and anthropometric abnormalities found in atypical sites (common carotid and contribute to cardiovascular disease risk. Non-atherosclerotic disease superficial femoral artery) with a saccular/ These abnormalities may be due to HIV • Infectious arteritis (CMV, varicella multi-loculated morphology and tend to or its therapy and may be affected by zoster virus, mycobacterium and fungal be multiple. Low CD4 counts as well as environmental and immunological factors infections) hypoalbuminaemia are consistent findings with the net effect of being pro-atherogenic. • inflammatory vasculitis (leucocytoclastic with prognostic implications.11,12 vasculitis),5 polyarteritis nodosa (PAN), Table I. Characteristics and features of HIV-associated occlusive vasculopathy Young age at onset of disease (mean age 40 yrs)6,7 Most patients present with advanced vascular disease (>50% critical limb ischaemia)2 Smoking is a common traditional risk factor4 CD4+ T cell count <200 cells/µl7 Hypo-albuminaemia is a reliable predictor of increased perioperative complications and poor long-term survival4 Infra-inguinal disease more often than aorto-iliac occlusive disease4 Macroscopic findings Normal arteries proximal,8 and the occlusion is of a fibro-obliterative nature with cords/strings of fibrous tissue which can be removed from the arterial lumen4 Arteriographic findings Pristine proximal arteries with extensive disease extending into the small and medium-sized arteries with poor run-off5,8,9 Duplex ultrasonographic findings Hyperechoic ‘spotting’ in the arterial wall, the ‘string of pearls sign’10 Prognosis Limb salvage rate 27%8 Wound sepsis Graft sepsis Perioperative mortality 6.95% Late mortality 28.75% 376 CME AUGUST 2010 Vol.28 No.8 More about... HIV therapies may The 2008 American College of Chest Table I. Anal disorders in HIV- interact with drugs Physicians guidelines make no reference to positive patients (most often found the HIV-infected patient suffering from VTE. used for cardiovascular Veller and Eyal recommend prophylaxis along in combination) complications. the same guidelines as those for a patient Disorder Average suffering from cancer and standard treatment incidence (%) protocols for patients with proven VTE.14 Proctitis/skin involvement 40 Condylomata acuminata 43 References available at www.cmej.org.za Fissure-in-ano 30 Anal ulcer 29 Haemorrhoids 15 HIV-related anal disease Chlamydia/gonorrhoea 2 E J THERON, FRCS (Edin) Kaposi’s sarcoma 2 Emeritus Professor of Surgery/Consultant/Reader/ Squamous cell carcinoma 1 Training Co-ordinator, Department of Surgery, University of the Free State, Bloemfontein Anal incontinence and soiling is a socially Correspondence to: E J Theron (mwetron@mweb. unacceptable and often devastating problem Fig. 1. Histology of an aorta aneurysm in an co.za) associated with anal disease in AIDS. HIV-infected 40-year-old woman. The slide reveals granuloma formation as well as a TB The higher prevalence of malignant disease bacillus in the wall of the aneurysm. Anal disorders are very common in HIV- in these patients should also be kept in mind, infected patients. It is estimated that at least i.e. Kaposi’s sarcoma of the anal canal skin, As for management, the same principles as in one-third of HIV-positive patients suffer Hodgkin’s lymphoma and possibly squamous the case of other infected aneurysms apply, from an anal disorder and that anorectal cell carcinoma.4 although aneurysm as well as patient factors disease is the most common reason for may influence the definitive therapy of each. surgical referral and intervention in these Clinical approach patients.1 History Venous thromboembolism A careful history of the main complaint, all In addition to classic risk factors, HIV-infected It is therefore imperative that all patients symptoms associated with the anal area, and persons have additional predictors for the presenting with anal disorders should function and anatomy of the anus should development of venous thromboembolic be tested for HIV, and conversely that all be obtained in an objective, formal yet events (VTEs). VTEs are 2 - 10 times more seropositive patients be questioned and sympathetic fashion. Patients are reluctant common among HIV-infected persons if necessary examined for the presence of to divulge details and may have to be gently compared with the general population, with anorectal disease.2 prompted to obtain an adequate picture incidence rates of 1.9 - 7.6 per 1 000 person- of the pathology and altered function years and a median age of 37 years.13 Clinical presentation involved. Questions on sexual practices and The primary care physician should be particularly anal intercourse can sometimes Additional risk factors for VTE in HIV- acutely aware of the symptoms and signs be embarrassing to both patient and infected patients are listed in Table II. that may become apparent; these should be physician. Matter-of-fact queries with regard kept in mind and actively looked for. Pain to pain during anal intercourse will afford Table II. Additional risk factors for (proctalgia) or severe discomfort is the most the patient the opportunity to deny or admit VTE in HIV-infected patients common presenting symptom (55 - 60%), to such practice; subsequent response to followed by a mass or swelling (>28%).1 questioning may then follow spontaneously. Infection by HIV itself – low CD4 cell Blood or bloodstained discharge is often counts and high HIV viral loads13 associated with these symptoms or could be Keeping in mind the possible pathology, Thrombophilic abnormalities: antiphos- the single presenting symptom in up to ≥20% sensitively formulated leading questions will pholipid and anticardiolipin antibodies, of cases. Other presenting complaints include often clear doubts regarding the problem to decreased activities of natural anticoagu- pruritus, painful defecation, incontinence and be managed and its intensity. lants, especially protein S, and increased diarrhoea. Any symptom with regard
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