JAW Vol. 24, No. 4 Octohct 1Y’J4:103-32

ventricular dysfunction an

although a pathogenic opportunistic infectious agent can rarely be

ide

. All patients had moderate to severe global lef!

ventricular hypokinesia on two-dimensional

Endomyocardial biopsy samples were evalua

histologic studies, immunoperoxidase staining

ization for cytomegalovirus and NIV-I gene sequences.

Resulk Twenty-eight patients presented with New York

Association functional class III or IV congestive heart failure.

Early in the acquired immunodeficiency syndrome (AIDS) epidemic, autopsy series described a varieiy of cardiac abnor- malities in patients infected with the human immunodeficiency virus type 1 (HIV-l). Marantic cndocarditis, mztastatic Kaposi sarcoma and opportunistic infection of the myocardium and pericardium (l-4) were noted. Later studies (5-l 1) confirmed that clinically significant and life-threatening cardiomyopathy was also part of the spectrum of HIV-l-related cardiac disease. Echocardiographic studies (12,13) have further docu-

From lhe Divisions of Cardiology and lnfcctious Diseases. Departments of Medicine, PatholoB, Immunology and Infectious Diseases and Epidemiology, School of Public Health and Hygicnc, Johns Hopkins Medical Institulions, Baltimore, Maryland; and *Department of Pathology. Emory University School of Medicine, Atlanta, Georgia. This work was supported by Grants ROI-41514 and MWRR00722 from the National Heart, Lung, Blood Institntc, National Institutes of Health, Bethe&, M;t@md.

Manuscript received December 20, 1993; revised manuscript received March 24, 1994, accepted May 10, 1994.

Address for corresoondence: Dr. Ahvie Herskowitz, Departments of Medi- cine and Immunology and Infec’:ous Diseases, The Johns Hopkins School of Medicine, Division of Cardiology. 615 North Wolfe Street, Room 5017, Balti- more, Maryland 21205.

01994 by the American College of Cardiology

FQW patients had nly~cardit~s secondary to known et~o~Qgies Gstic infection n = ra~in~~aced ~ny~erse~lsitivity

~~y~c~~~~litis II = 2). sing 33 samples, 17 (51%) showed histologic esi i~~ati~ic active or ~~rder~iae ~ly~c~~rditis.

the cytomegalovirus i All but one @ieat with specific

with congestive heart failure; all patients had myocarditis and 4+ cell counts < ~~~/rn~13.

Co&krsinrrs. This study demonstrates

infection and myocarditis may be importa

symptomatic

(J AW Co11 Cardiol ~994;24:~~~~- 32)

mented clinically silent abnormalities, such as pericardial cffusions and marantic endocardilis in 30% to 40% of patients, as well as clinically significant dilated cardiomyopathy in -10% of adults with HIV-l infection.

Current hypotheses concerning the etiology of cardiomyop- athy related to HIV infection include myocardial infection with HIV-l or coinfection with other cardiotropic viruses (14,15), postviral cardiac autoimmunity (lb), selenium deficiency (IT), autonomic dysfunction and cardiotoxicity from illicit drugs such as cocaine and heroin (18,lY). The possibility of cardiac hypersensitivity or toxicity, or both, from iatrogcnic pharma- cologic agents has been suggested, particularly for nucleoside analogs (20,21) and pentamidine (22,23). The role of myocar- ditis in the developmenr of HIV-i-associated left ventricular dysfunction has not been fully characterized. In earlier studies (8,0), lymphocytic myocarditis was noted to bc a frcqucnt finding at autopsy in HIV-l-infected patients with and without known cardiac disease during life. However, recent studies (24,25), have demonstrated a high prevalence of myocarditis in antemortem endomyocardial biopsy samples in small numbers of HIV-l-seroprxitive patients with left ventricular dysfunc-

1026 HERSKOWITZ ET AL. UYOCARDITIS AND HIV-1 INFECTION

J.4CC Vol. 24, No. 4 October 1901:1025-32

tion. A direct role for HIV-I-mediated cardiac injury has remained difficult to define because the HIV-I genome has been demonstrated within myocytes in cardiac autopsy and biopsy tissue from patients both with and without known cardiac dysfunction during life (14,26,27). Our recent pilot studies (15) have shown that nonpermissive or latent infection of myocytes with cytomegalovirus (CMV) immediate early (IE-2) genes is present in a subgroup of HIV-l-seropositive patients presenting with severe left ventricular dysfunction.

This study characterizes the histologic, immunopathologic and in situ hybridization results in 37 consecutive endomyo- cardial biopsy samples from HIV-!-seropositire patients with moderate to severe global left ventricular dysfunction. Our results sugest that myocardial viral infection with CMV and HIV-! may play a role in tr ring ongoing cardiac inflam- mation and injury.

Patients. From Deccmbcr 1988 to May 1992, a total of 47 HIV-l-seropositive patients were identified with moderate to severe global left ventricular hypokinesia on two-dimensiona! echocardiography. Endomyocardial biopsy was not considered clinically feasible in eight patients because of multiorgan dysfunction associated with end-stage HIV-! infectios. Of the remaining 39 patients, 37 consented to undergo endomyocar- dial biopsy. All HIV-1 diagnoses were made according to criteria from the Centers for Disease Control (28). Of the 37 patients, 32 were referred to the cardiomyopathy service, and 5 were prospecdvely identified through their participation in our longitudinal prospective study of HIV- l-associated car- diomyopathy (29). All prospectively enrolled patients who undetwcnt endomyocardia! biopsy were demonstrated to have progressive deterioration of left ventricular function on serial two-dimensional echocardiograms.

Dota c&&m. The protocol was approved by the Johns Hopkins Committee on Clinical Investigation, and written informed consent was obtained from each patient. A question- n&e was completed, routine vital signs were obtained, and echocardiography was performed. The interview consisted of questions about the patient’s HIV risk factors and cardiovas- cular history and risk factors. Hospital and clinic charts for all patients were reviewed for confirmation of HIV-! status and cardiovascular history, documentation of viral and nonviral opportunistic infections, current and past medications, drug allergies and history of autoimmune disease. Patients were examined by one of two attending cardiologists. For purposes of this study, heart failure was considered to be present if the patient met New York Heart Association criteria for func- tional class III or IV congestive heart failure.

Echocardiography. Quantitative M-mode and two- dimensional echocardiography were performed using a phantom-calibrated Hewlett-Packard ultrasound machine. Each two-dimensional study consisted of parastemal long- and short-axis views (the latter at two cross-sectional leveis) and apical hvo- and four-chamber views. Measurements of left

ventricular size and wall thicknesses were made on M-mode strips from each patient according to standard guidelines. Left ventricular volumes were measured with an application of the biplane Simpson rule, and ejection fractions were subsequently calculated (30,313. Each study was recorded on videotape and later scored by one observer who was unaware of patient identity or of the temporal sequence in which studies were acquired. Regional wall motion scores were developed to complement the cafculated ejection fraction because repeated measures of ejection fraction can vary up to 10%. Each myocardial segment was scored for wall motion by means of semiquantirative visual analysis grading for dyskinesia, akine- sia. hypokinesia and normal motion (dyskinesia = 1: akinesia = 0; severe hypokinesia = 0.5; modcrate hyokinesia = 1; mild hypokincsia = 1.5; normal wall motion = 2). A ltotal score of 12 was considered normal left ventricular funclion, and modcratc to severe left ventricular dysfunction was de- fined as a score ~6 (29).

Histologic and immurohistologlc studies. A minimum of four right ventricular cndomyocardial biopsy specimens were obtained for all patients by way of the right internal jugular vein. Portions of two of the largest specimens were flash-frozen for more extensive immunohistoc! mica1 staining, and the remaining specimens were fixed in formalin. Formalin-fixed biopsy specimens stained with hcmaloxylin and eosin were examined at a minimum of four levels by two cardiac pethol- ogists (32). Slides stained with hemntoxylin and eosin were scrccncd for apparent infiltrates, myocyte necrosis, myofiber hypertrophy and interstitial fibrosis. Special stains were used to identify hncteria, fungi and mycobacteria.

Histologic diagnosis of idiopathically active or borderline myocarditis was made with use of the Dallas criteria (33). To further corroborate the histologic diagnosis, immunoperoxi- dase staining on scria! sections of the same paraffin-embedded tissue used for histology was performed with monoclonal

antibodies for CD45 (common leukocyte antigen) (CLA, Dako). As described previously (252, a lymphocytic infiltrate was defined as ~10 lymphocytes/high power field (400x), using an Olympus BH2 microscope with wide-field 10x eye- pieces (diameter 550 pm, area 2.4 x lo5 pm’). Frozen sections were used for other lymphocyte and antigen markers, including monoclonal antibodies to CD45 (HLel, Becton-Dickinson), CD4 (Leu3A, Becton-Dickinson), CD8 (Leu-2, Becton- Dickinson) and major histocompatibility (MHC) classes I and II (Dako). The immunoperoxidase procedure has been de- scribed in detail elsewhere (25).

To identify possible unique histologiclimmunohistologic features of HIV-l-associated myocarditis, endomyocardial bi- opsy results from 32 consecutive non-HIV-infected patients found to have myocarditis confirmed by immunohistologic staining were selected from a group of 287 patients who underwent endomyocardial biopsy at Johns Hopkins between January 1985 and December 1988 for evaluation of unex- plained cardiomyopa,athy (94%) or unexplained arrhythmias (6%) (32). All oatients had onset of symptoms within the previous 6 months.

JACC Vol. 34, No. 4 October I’J~J4zIK!5-3?

HERSKOWITZ ET AI_, MYOCARDITIS AND NIV-I INFECTION

1327

ously (1534). Recombin

linkrr at fhc 5’ end and

erived from this region arc able to dctcct nonpcrmis- V infection by Northern blot analysis and by in situ

hybridization. Our OWII previous study (35) using a de

(DNA) riboprobe failed to dcmonstratc scripts within nine cndomyocardial biopsy samples from HIV- I-seropositlvc patients with active myocarditis. i’o bcttc~

address the question of whether myocardial cells arc infcctcd with HIV-l in patients with cardiomyopathy, in our current study we used a subgenomic ribonucleic acid (RNA) riboprobe to detect HIV-I in heart tissue using in situ hybridization (kindly provided by Dr. N. B. K. Raj, Thr Johns Hopkins University). We used a 942-bp riboprobe derived from the 5’ end of HIV-I gllg sequences b ecause many HIV-I transcripts share this sequence, suggesting that it may be significantly more sensitive than conventional whole-genomic DNA probes. The riboprobes derived from this region have been shown to be able to detect infection of A3.01 cells infected with HIV-I as well as spleen and kidney tissue from patients infcctcd with HIV-I (37). A modified in situ messenger RNA riboprobc

hybridization method that has been described previously (15.34) was employed using digoxigenin labeling.

Multiple frozen heart sections obtained at autopsy from eight patients with AIDS and no clinical heart disease were used as controls for CMV and HIV-l in situ hybridization studies. Brain tissue from a patient with CMV encephalitis and lymph nodes from HIV-I-seropositive patients with lymphad- enopathy served as positive controls for CMV and HIV-l

hybridization procedures, respectively. Statistics. Categoric data were analyzed with a standard

two-tailed chi-square or Fisher exact test. Continuous data were summarized with standard measures of central tendency and dispersion, using the Student I test or, for skewed distribu- tions, the Mann-Whitney U test to guide interpretation, with

conventional levels of significance.

Clinical features of t atient cohort. Demographic and

clinical characteristics of the patients undergoing endomyocar- dial biopsy are presented in Table 1. There were no relations

between the severity of left ventricular dysfunction and the

. Demographic and Clinical Characteristics of 37 Human lmmunodeficiency Syndrome Uwkrgoing Endumyocardial

pe 1-S :rOpositivc Patients

No. (V) of Patients

Mem (+ SD) age (yr) 38 2 9 Black TXC 2x (76) Male gender 31 (84) Live in Baltimore-Washington area 35 (9-s) HIV risk

Intravenous drug use 19 (51) Homosexual 16 (43) Other 2 (5)

Prior AlDS-defining opportunistic infection 17 (46) Median CD4 T-cell count/mm.’ 28 CD4 T-cell count <XC,mm’ 28 (76) Presenting cardiovascular symptoms

Congestive IWilit failure 28 (76) Asympbmatic global LV dysfunction S(l4j* Ventricular tachycardia 1(-v Sol”‘Lvcnlricul;ir tachyCardi;l 1 (3 Atypical chest p.G ? (5)

- ’ Idcntilicd in il longitudinal prqwlivc hludy inwlving twc)-diili~ii~iull;ll

cchclc;trdioFr;lplly. AIDS = quircd immurwdeficicncy syndrome; HIV =

httmmi ililnlunodeliciericy virus: LV = left ventricular.

presence of alcohol abuse, hypertension or diabetes mellitus.

The mecn presentation ejection fraction as calculated from

two-dimensional echocardiograms was 30%, and 46% of pa-

ticnts had left ventricular end-diastolic dimensions >fj.O cm.

OF the 17 patients with a previous history of AIDS-defining opportunistic infection, 10 had Pmwntocy.~ris pbleumonia; 6 had solid organ CMV infection: 4 had disseminated iI$j~~~bac’~cu~~n~ miurn iramce/Mm: and 4 had cryptococccmia. Thcrc was no

relation between the prcsc!icc of an opportunistic infcclion and the scvcrity of left ventricular dysfunction. Only 23 pa- ticnts (62%) with global left ventricular dysfunction were exposed IO nuclcuside analogues (all 23 to zidovudine, 3 to ddL and 1 to ddC). Of those 23, 13 patients (57%) had a history of noncardiac zidovudine toxicities (severe bone marrow suppres- sion in 7 and skeletal myositis in 6) requiring discontinuation of the drug.

Histologic findings. Two patients had myocarditis associ-

ated with opportunistic infection of the myocardium (CMV

myocarditis wiih class;cal intranuciear inclusion bodies and cryptococcal myocarditis). In addition, two patients being treated with penicillins had eosinophilic infiltrates consistent with hypersensitivity myocarditis. Symptoms of congestive heart failure resolved after discontinuation of the offending drug. Of the remaining 33 samples, according to the Dallas criteria, 9 (27%) of 33 biopsy samples from HIV-I- seropositive patients showed active myocarditis (Fig. 1). In

addition, 8 (24%) of 33 showed borderline myocardilis, and 16 (49%) of 33 showed no myocarditis. The pattern of histologic findings in HIV-l-seropositive patieilts with myocarditis is indistinguishable from typical cases of myocarditis in patients without HI\:-1 risk factors (38). Of the 28 patients presenting with signs and symptoms of co;lgcstive heart failure, 19 were

1028 ljERS,l$OWlTZ ET AL. MYOCARDITIS AND HIV.1 INFECTION

JACC Vol. 24, No. 4 October 1903:1025-32

F@c 1. A, Mcdiumqowcr photomicqraph takca frum an cndw myocardial Vi sp&iicn demonstrating active mywardilis. Note tti inbxstitial r$zction of inlammatory cells surrounding a small group of necrotic myocytes (arrows). Hcmatoxylin and eosin X250,

noperoxidase staining of a frozm section for human lcukoqtc antigen (HLA) ABC in

a myocarditis sample demonstrating intcnsc majw histowmpatibility class I czqmx&n throughout the myocardial intcrstitium (x400, &wed by 24%). This pattern of staining was routinely found in biipsy samples both fmm patients with readily diagnosed histologic myocarditis aad patients with only immunohistologic evidence of increased myocardial inflammatory cells.

found to have either idiopathic active or borderline myocardi- tis (n = 15) or myocarditis secondary to known etiologies (n = 4) compared with 2 of 9 patients without congestive heart failure (p = 0.02). This suggests a relation between the presence of myocarditis on endomyocardial biopsy and the severity of left ventricular dysfunction.

Vimi Qbddization. Co&d subjects. HIV-1 was readily identified by in situ hybridization in lymph node tissue from patients with AIDS with lymphadenopathy. None of the eight control autopsy heart specimens from patients without known heart disease showed specific hybridization within myocytes

and interstitial cells. None of the autopsy control cardiac tissues bad specific hybridization with CMV K-2 or delayed early riboprobes within myocytes. The four control patients with clinical CMV disease (CMV pneumonitis in two, CMV encephalitis ia two) all demonstrated specific bybridizatio~ within microcirculatory endothelial cells only.

Smlypatients: CiUVrihpbes, The presence of CMV viral DNA was examined by use of the sense IE-2 riboprobe under denaturing conditions. This sense riboprobe has previously been demonstrated to produce hybridization of permissively infected cells (36). No specific hybridization was seen with the

sense riboprobe, SM sting that no viral DNA replication was

being detected In dition, only one sample with classical

intranuclear inclusions showed specific hybridization with the antiscnsc riboprobe for the 2.7-kb major delayed early gene. This riboprobe has been dcmonstratcd to produce intense hybridization only in permissively infected cells, morphologi- cally c~ractcrized by the pre.seucc of intranuclear inclusions

(36). Sixteen samples (48%) had myocyte nuclear or nucleolar

hybridization with the antisense CMV IE Parallel in situ hybridization studies usin sense riboprobe were negative (data not s

patients with a history of solid organ (rctinitis in 4, pneumonitis in 2, colitis

in 1). Six patients were intraver,ous drug users. All I6 patients had circulating CD4’ cells <2OO/mm”, and all had positive histologic or immunohistologic evidence of myocarditis and presented with functional class 111 or IV congestive heart failure. The pattern of myocyte nuclear and perinuclear hy- bridization with the I&2 antisense riboprobe was not limited to sites of myocardial inflammation or necrosis but was similar to the diffusely enhanced myocardial expression of MHC class I. All nine biopsies from patients without congestive heart failure failed to show specific hybridization with either the CMV IE-2 or HIV-I and riboprobes.

HIV-1 ribopdm Of the 33 samples tested, specific hybrid- ization within rare, isolated myocytes was demonstrated io 5 samples by use of the antisense HIV-1 riboprobe. In addition, specific hybridization within rare, isolated interstitial mononu- clear cells was also found in three of these five samples. The

precise identification of these interstitial cells awaits future studies. All five samples had histologic evidence of active or borderline myocarditis, although myocytes with specific hybrid- ization with the HIV-l riboprobe were not surrounded by inflammatory cells (Fig. 2). All five samples with specific HIV-l hybridization had concurrent hybridization with the CMV IE-2 riboprobe.

Immunohistolqic studies. Results from idiopathic active and borderline myocarditis were compared, with 32 consecu-

tive endomyocardial biopsy samples showing histologically active and borderline myocarditis in patients without AIDS risk factors (data not shown). Non-HIV myocarditis is charac- terized b:l a mixed inflammatory infiltrate, whereas HIV-l- associated myocarditis is predominantly composed of CD8+ lymphocytes that were increased in 71% of HIV-l-seropositive

JACK Vol. 24, No. 4 October 1YY4: 1025-X HEKStCOWlTZ El‘ AL.

MYOCARDITIS AND NIV-I lNFECFiON 1029

patients with idiopathic rnyocarditis (vs. 40% of the non-HIV group, p = 0.06). In the setting of myocarditis in the control HIV-seronegative group, induced MHC class I and aberrantly expressed MHC class II are commonly found on myocytes (73% and 8f%, respectively). In contrast, in the HIV-1-seropositive group, intense staining is limited to MHC class I, which was found in 65%, and aberrant MHC class II (human leukocyte antigen [HLAJ-DR) staining was observed in only 18% (p = O.OOUl vs. the non-HIV-seropositive cohort) (Fig. IB).

In our current study, all samples with histologic myocarditis had positive immunohistologic criteria for myocarditis as well. Because many patients with HIV-1 infection have markediy depressed circulating leukocyte counts, we considered that myocardbl infiltrates may be diminished and difficult to diag- nose solely on the basis of routine histologic studies. Of 116 HIV-1-seropositive patients with no histologic myocarditis, 8 showed immunohistologic evidence of increased numbers of CD45 (common leukocyte antigen)-positive cells. Clinical characteristics of and biopsy tindings in these patients are presented in Table 2. All eight patients had AIDS and presented with symptoms of congestive heart failure and a markedly depressed left ventricular ejection fraction. These

Pigurc! 2. A, In situ hybridization using the antiscnsc riboprobe for cytomcgalovirus (CMV) innncdiate early (IE-2) gellcs in a control autopsy heart specimen from a patient with a history of CMV pncumonitis and encephalitis but no known cardiac disease during life. Note that the specific hybridization is limited focally to the microvas- cular endothclium. No specific myocyte hybridization is present. In contrast. intense hybridization is present within the nuclear and pcrinuclcar regions throughout tue endomyocardial biopsy sample from two HIV-I-seropositive samples with active myocarditis (R and C, respectively). Tangentially cut myocytcs appear to have subsar- colemmal staining, which is most likely an artifact. D, In situ hybrid- ization using the antisense riboprobe for HIV-I genes demonstrating intense staining within two myocytes and several interstitial mononu- clear cchs

findings suggest that by use of the more sensitive immunohis- tologic method, a subgroup of patie.tts with .AIDS with no myocarditis by the classical Dallas criteria appear to have immunohistologic and clinical findings identical to thos:: of idiopathic myocarditis and may similarly have immunc- mediated heart disease.

Clinical characteristics of patients with and without histologic or immunohistotogic evidence of myocardial in puposes of this comparison, the four patients with myocarditis

HERSKOWITZ ET AL. JACC Vol. 24, No. 4 MYOCARDITIS AND HIV-1 INFECTION Octnber 1994:1025-32

Table 2. Clinical Characteristics of and Biopsy Findings in Human Immunodeficiency Virus Type LSeropositive Patients With and Without Myocardial Inflammation on Endomyocardial Biopsy

No Myocarditis (Dallas criteria [n = 161)

Idiopathic Active or Positive Negative Rordcrlinc Myocarditis Immunohistologie lmmunohistologic

(Dallas criteria [n = 171) Findings (n = 8) Findings (n = 8) V&e

Clinical and Demographic Characteristics

Age Cvr) Race

Black White

Male gender

IVDU

AIDS-detining epportunistie infection

Medien CD4 T-eell count!ntm’

CD4 T-cell cwtt <2tX)/mm’

Congestive heart failure at prwntatitra

Any exposure to zidovudine

Zidovudine-rclatcd noncardiac toxicity

38 z 9 37 z 10 382 11 0.95

Hx 63 63 11.23 12 37 37 0.23

71 luo 113 0.17

5’) I3 50 0.09

53 fi3 25 (I.22

?I 24 272 t1.w2

NY ItIt1 3N w0.l

Y4 lOtI I3 < wtH~I

SY 63 75 0.94

65 so 3N 0.42

LV ejection fraction

Dilated LV cavity

Dilated RV cwity

Pericardial effusion

Echuewdiograpbic Findings

242 I2 292 IS

65 PS

?I NN

ti 75

Immunohisteehcn~icaI Findinns

41 + I3 ll.Nt~7

2s 0.93

13 tt.tlt12

25 tl,Ol

Increased MHC class I staining 05 IOn 0 OSHWI?

CDN-predominant myocardial infiltrate 77 7s 0 tl.wON

III Situ Hyhridiratien Findings

Myucyte CMV IE-2 Nenc transcripts 64 tltl 0 o.tntN

Myueyte HIV-l gene transcripts 7 ntl 0 0.w

Data prc.sentod are viva value L SD or pereeut of patients. CMV = cytcm~rgalovirus: IE-2 = immediate early; IVDU = intravenous drug users: MHC = mater histcwompatibility: KV = right ventricular: other abhreviatiuns as in

Table I.

secondary to known etiologies were excluded. Patients with histologic myocarditis as defined by the Dallas criteria had clinical and biopsy profiles similar to patients with only immu- nohistologic evidence of myocardial inflammation. Both pa- tient groups appeared to bc clearly different from patients with no evidence of either histologic or immunohistologic myocar- ditis.

Discussion This study demonstrates that a large proportion of HIV-I-

infected patients with AIDS presenting with symptomatic severe global left ventricular dysfunction have evidence of idiopathic active or borderline myocarditis. It also demon- strates thut a signilicant subgroup of these patients are found to contain viral transcripts of either the IE-2 gene of CMV or HIV-l within myocytes.

Predisposition for symptomatic cardiac dysfunction in pa- tients with AIDS. Results from prospective echocardiographie studies (lo-13,20,39,40) support the following general consensus:

1) The two most common forms of HIV-associated symptomatic cardiac disease are severe global left ventricular dysfunction with heart failure and pericardial eIIusion with cardiac tamponade. 2) A large proportion of patients appear to have clinically silent abnormalities (e.g., small pericardial effusions, nonbacterial thrombotic endocarditis and mild global left ventricular dysfunc- tion). 3) Mild left ventricular dysfunction appears to be reversible in many patients, but a subgroup of patients progress to symp- tomatic heart failure. 4) Left veniricular dysfunction occurs in all major HIV risk groups and appears to be increased in patients with low CD4 counts, although other clinical mark::rs of suscep tibility have not yet been well defined.

Virus-associated mywarditis as a potential cause of HIV- l-associated cardiomyopathy. The association between myo- carditis and symptomatic cardiomyopathy in HIV-l-infected patients with low circulating CD4 cells may result from an increased predisposition to cardiotropic viral infection. Cyto- megalovirus is prevalent in patients with AIDS, and CMV- induced myocarditis, which is characteristically diagnosed in

(cons&tent with nonpermissive infection specific ~~ybr~dizati~~ with botl 1 antisense riboprobes. Specific

myocytes was not fou:ld in any of the control autopsy cardiac samples from patients with AIDS without cardiac disease during life. This association of CMV with HIV myocarditis is consistent with similar ~I~diIigs in autopsy tissue by Parravicini et al. (42). In our study, all patients whose endomyocardial biopsy samples de~n~~llstratcd specific myocytc viral hybridiza- tion had CD4 COUllts <20O/mnr’, alld idl had histologic or

i~~mu~~o~~istol(~gic cvidcncc of lllyOci\lXli~ll i~l~~l~l~lali~)n and

prescntcd with unexplained congestive heart failure. None of the biopsy samples that failed to show l~ist~~~~~g~c or ~~1~~~~~~~~~~

histologic myocarditis monstrated specific myocyte hybrid- ization with CMV or V-l. Only 6 of the 16 patients who showed specific hybridization of CMV IE-2 in cardiac myo- cytes bad clinical evidence of solid organ infection with CMV at the time of cardiovascular presentation.

The diffuse pattern of CMV IE-2 gene expression within myocytcs and endothelial cells from biopsy samples of patients with myocarditis and congestive heart failure suggests that latent cardiotropic CMV infection may play a signiticant role in the development of myocarditis (Fig. 2). Persistence of the CMV viral genome within large numbers of myocytcs may initiate either a CD8+ T cell response to virally infected myocytes expressing MHC class I imtigens or initiate the clonal expansion of autoreactive CDS’ T cells, which target normal myocytes and produce the myocarditis. Supportive evidence for these possibilities, which probably act in concert in vivo, has been demonstrated in experimental studies of murine CMV and coxsackievirus B3 (CB3)-induced

Does direct myocardial infection wit the development of myocarditis? The possibility that a pri- mary cardiomyopathy may develop as a consequence of direct HIV-l myocardial infection is intriguing, and, indeed, finding HIV-1 transcripts in 15% of endomyocardial biopsy samples is comparable to the proportion of samples found to contain HIV-l transcripts in patients with the AIDS-dementia com- plex, AIDS enteropathy and Iymphoid interstitial pneumonitis (45,46). However, the precise role of HIV-l infection of myocytes in the development of myocarditis and left ventricu- lar dysfunction remains poorly understood. Previous in situ hybridization and polymerase chain reaction studies (14,27,47) have shown the presence of HIV-l transcripts within heart tissue in patients both with and without symptomatic heart disease. The absence of specific HIV-1 hybridization in all but rare myocardial cells suggests either that these cells are not infected or, alternatively, that HIV-1 infection of myocardial cells remains largely in the latent phase, as is seen with CMV,

or

SMC ensitive enough to detect s. Nevertheless, the focal bin myocardial cells may

receptor that has been shown be expressed by this cell

they do not yet support a direct role for development of myocarditis and left ventricular dysfunction.

The concurrent finding of myocyte transcripts of both CMV IV-1 in the same biopsy samples of five patients is

consistent with reports (48) dern ting activation of HIV-1 replication in cells infected with and suggests that in vivo interaction aud coinfection may p!ay a role ic the p of some cases of HIV-1-related myocarditis (42). should be noted that our study does not rule out ;;otential involvement of other cardiotropic viruses, such as coxsackie- virus and echovirus.

nohistologic study is most commonly used to confirm the histologic diagnosis of myocarditis (32), in the present study involving patients with markedly depressed circulating CD4 counts, 50% of the biopsy samples with no myocarditis on routine histologic studies were found to have immunohisto- logic evidence of increased numbers of infiltrating leuko- cytes (predominantly CD8+ T cells). The presence of posi- tive viral hybridization, along with increased myocardial expression of MHC class I in this s&group of biopsy samples, strongly suggest the presence of an active immune process within the myocardium and undcrscorc the potential difficulty in using histologic criteria in severely immunosup- pressed patients.

Gonchkons. Our study demonstrates a high prevalence of myocarditis in HIV-l-infected patients with low circulating CD4 counts. Although the potential cardiotoxic role of co- caine, alcohol, iatrogenic drugs and nutritional factors should be entertained in every case of HIV-1-associated heart dis- ease, our current study results support a direct association among myocardial inflammation, the presence of cardiotropic virus and severe left ventricular dysfunction. Only a minority of

patients (2 of 37) were found to have opportunistic infectious etiologies for their left ventricular dysfunction (lytic CMV

infection with classical intranuclear inclusions and C’~~?UCOC- cm), and no patients were found to have neoplastic invasion of the myocardium. These observations suggest that the preva- lence of severe HIV-l-associated left ventricular dysfunction may increase as therapies to prevent fatal opportunistic infec- tions take effect in this population. Additional studies are needed to identify risk factors for the development of HIV-I- associated left ventricular dysfunction and to clarify the immu- nopathogenesis of this disorder so that effective medical management can be planned.

10X HERSKOWITZ ET AL. MYOCARDITIS AND HIV-I INFECTION

JACC Vol. 24, No. 4 Ootohcr I*)94c IO?%32

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II’.

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