A 40 year old young thin lady presented with
left flank pain and lower urinary tract symptoms and on an off fever.She was
retro-positive and was on HAART. On evaluation; she was fit for anaesthesia and
CD- 4 count was also good.
Imaging wise she had left staghorn calculus
with normally excreting kidney and left lower ureteric calculus.We attributed
her LUTS to the lower ureteric calculus as her urine culture and sensitivity
reports were normal.
During the procedure(URS AND PCNL); while starting
the case only she had signsof cornoary syndrome in the form of elevated ST
segment.The procdure was abandoned and the patient was shifted to higher centre
with Cardiac ICU under the care of our cardiologist.
The patient was treated conservatively with
thrombolysis and is presnetly stable except for mild hematuria resulting
because of cystoscopy and aggravated by
the heparinisation.
The patient was not a known case of cardiac
disease and didnot have pre-existing hypertension.
After searching for the literature we came
across the entity called Acute Coronary Syndrome in HIV infected people.
HIV-1 virions appear to infect myocardial cells
in patchy distributions without
a clear direct association between HIV-1 and cardiac myocyte dysfunction.Retrovirus
also causes inflammatory vascular diseases.
Cardiovascular manifestations of HIV have been
altered by the introduction of highly active antiretroviral therapy (HAART)
regimens. On one hand, HAART has significantly modified the course of HIV
disease, lengthened survival, and improved the quality of life of HIV-infected
patients. On the other hand, the early data have raised concerns that HAART is
associated with an increase in both peripheral and coronary arterial diseases.
Acute coronary syndromes may be observed with
increasing frequency among HIV patients receiving therapy with protease
inhibitors as part of HAART regimens.
This syndrome can happen in an apprently young
individuals with HIV without any preexisting factors.The ECG changes also may
be nonspecific and the manifestation also can be vague.
As depicted in the above figure in the women ; there can be atypical symptoms and absence of biochemical markers.This is a dangerous situtation especially for
invasive urological procedures because the patients can be apparently young and healthy. Perioperatively if they get ACS... the management of ACS will lead to
aggravation of hematuria, clot retention , repeated clot evcautaion, repeated
blood transfusion etc.
The retrovirus and also the HAART can lead to
premature atherogenesis and lead to cardiac catastrophe.The urologist can be
caugth off guard and may need to face an embarrassing situation explaining the turn
of the events postoperatively to the
patient and the attendnats.Therefeore pre-operative cardiac consulattaion and
screening and proper counselling of such patinets forms an essential part of
managing such patients operatively. There no conclusive protocoals or guidelines
about cardiac screening of young HIV
positive patients before any surgical
procedures.
A careful cardiological screening is needed for
patients who are being evaluated for or who are receiving HAART regimens. A
tight collaboration between cardiologists and urologists may be useful in such
situation.
Thanks for sharing the information about the BEWARE OF A PHENOMENON -ACUTE CORONARY SYNDROME IN APPARENTLY YOUNG AND HEALTHY RETROPOSITIVE PATIENTS: UROLOGICAL PERSPECTIVE.
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