|Year : 2014 | Volume
| Issue : 2 | Page : 127-129
Abdominal aortic thrombosis in a young male patient living with human immuno deficiency virus/acquired immune deficiency syndrome
Ajay Pal Singh1, Sandeep Singh2, Manish Kishore Multani1, Shilpi Sikarwar3
1 Department of Medicine, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
2 Department of Post Internal, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
3 Department of Pathology, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
|Date of Web Publication||3-Oct-2014|
Ajay Pal Singh
Olyai Hospital Campus, Hospital Road, Gwalior - 474 009, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Thrombotic event in Acquired Immune Deficiency Syndrome (AIDS) patients was a rare clinical entity prior to Highly Active Anti Retro Viral Therapy (HAART) era, but it is increasing. Aortic thrombosis, a rare fatal event, leads to arterial embolic events often due to thrombi associated with extensive underlying atherosclerosis. Case Presentation: We report a case of young male suffering from AIDS, presented with chronic diarrhea and abdominal pain. Patient was diagnosed as a case of partial abdominal aortic thrombosis. No familial predisposition or any other risk factor for thrombosis was identified. Treatment following intravenous heparin was started and later on switched to oral warfarin. After 10 days, he was devoid of symptoms and discharged on oral warfarin and Anti-Retro Viral Therapy (ART). Discussion: The current case report reinforces that similar situations are bound to arise again in the future. Clinicians should also consider etiologies other than infectious as cause of abdominal pain to prevent any catastrophe. Clinicians should be aware and alert of unprovoked thrombosis to promote timely treatment and prophylaxis.
Keywords: Abdominal pain, acquired immune deficiency syndrome, aortic thrombosis, arterial occlusive disease, human immuno deficiency virus
|How to cite this article:|
Singh AP, Singh S, Multani MK, Sikarwar S. Abdominal aortic thrombosis in a young male patient living with human immuno deficiency virus/acquired immune deficiency syndrome. Nig J Cardiol 2014;11:127-9
|How to cite this URL:|
Singh AP, Singh S, Multani MK, Sikarwar S. Abdominal aortic thrombosis in a young male patient living with human immuno deficiency virus/acquired immune deficiency syndrome. Nig J Cardiol [serial online] 2014 [cited 2019 Dec 7];11:127-9. Available from: http://www.nigjcardiol.org/text.asp?2014/11/2/127/142113
| Introduction|| |
Acquired Immune Deficiency Syndrome (AIDS)-associated arterial occlusive disease is being recognized as special clinical entity.  Thrombotic event in AIDS patients was a rare clinical entity prior to Highly Active Anti Retro Viral Therapy (HAART) era, but is increasing.  Arterial lesions commonly involving small arteries, could also involve large arterial trunk in AIDS patients.  We report a case of young AIDS male presented with chronic diarrhea and abdominal pain. Patient was diagnosed as a case of partial abdominal aortic thrombosis, an uncommon presentation in AIDS patients.
| Case report|| |
A 33-year-old male suffering from AIDS presented on 8 th September 2012 to the outdoor patient department with acute abdominal pain since 2 days with history of abdominal pain and diarrhea on and off since 4 months.
The results of physical examination included reduced body weight, 36 kg; Body Mass Index (BMI) 11.14 kg/m 2 ; feeble left dorsalis pedis artery; infra axillary crepitation on auscultation; liver span 17 cm; and bilateral femoral artery bruit. Otherwise, the patient was in a stable condition with a normal examination status. His laboratory data revealed a white blood cell (WBC) count of 6900 cells/μL; hemoglobin, 11.2 g/dl; platelets, 0.17 million/μL; serum glutamic oxaloacetic transaminase (SGOT), 104 IU/L; serum glutamic pyruvic transaminase (SGPT), 96 IU/L; uric acid lactate 4mg/dl; total cholesterol, 145 mg/dl; triglyceride, 109mg/dl; high-density lipoprotein (HDL), 58.1 mg/dl; low-density lipoprotein (LDL_, 65.1 mg/dl; very-low-density lipoprotein (VLDL), 21.8 mg/dl. Stool studies for bacteria, ova, and parasites were found to be negative.
Ultrasonography (USG) abdomen with high frequency probe was advised to look in the cause of abdominal pain. USG reported a very uncommon finding with partial thrombosis in aorta, extending from origin of left renal artery to proximal part of left common iliac artery. Both kidney showed mildly raised echotexture. No thrombosis of left lower limb was reported. A diagnosis of abdominal aortic thrombosis was made.
His family history was negative for malignancy and thromboembolic disease; his psychosocial background revealed a chronic cigarette smoker and no drug abuse. He was married, laborer by occupation, compelling him to work outside the home alone for work for more than 6 months.
A thorough workup of his past medical history revealed that the patient was admitted previously 22 nd August 2012, prior to current admission. He had complaints of abdominal pain and diarrhea on and off since 4 months with occasional episodes of bloody stool. He narrated a past history of intermittent claudicating pain in left lower limb since 2 years. He was diagnosed as Human Immuno Deficiency Virus (HIV) seropositive on 22 nd august 2012 with CD4+ cell count of 129/μL, World Health Organization (WHO) stage II, and not on Anti-Retro Viral Therapy (ART). Weight, 40 kg; BMI, 12.38 kg/m 2 ; Direct serum bilirubin, 0.64 mg/dl; SGPT 109 IU/L; Hb, 9.4 mg/dl. USG report was suggestive of gastroenteritis and mildly raised bilateral renal echotexture. He was treated on the line of gastroenteritis then was relived and was discharged. He encountered sudden onset of left lower limb weakness with no sensation on 2 nd September 2012. He took warm compressions and sensation regained.
Patient was given intravenous Heparin 80 IU/kg bolus followed by 18 IU/kg for 24 hours to achieve an activated partial thromboplastin time (aPTT) of 62 seconds, simultaneously tablet Warfarin was started at an initial dose of 2.5 mg. Patient's International Normalized Ratio (INR) was 1.2 and prothrombin time was 16 seconds prior to the commencement of Warfarin. Target INR was kept at 2.0-3.0 and was achieved as 2.3 at the time of discharge. He was registered in ART center for ART and was given three drug regimens of zidovudine (AZT) + lamivudine (3-TC) + nevirapine (NVP) along with trimethoprime sulphamethoxazole (TMP-SMZ) coverage. After 6 days, a repeat color doppler with high frequency probe of abdominal aorta was obtained. Partial thrombosis of aorta, extending from origin of left renal artery with no thrombosis in proximal part of left common iliac artery was seen [Figure 1] and [Figure 2]. After 10 days, he was devoid of symptoms and discharged on oral Warfarin 2.5 mg and ART (AZT, 3-TC, NVP + TMP-SMZ) and was counseled to report to ART center for follow-up after a month.
|Figure 1: Image showing common iliac vessels with forward diastolic flow suggestive of decreased arterial flow distally|
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|Figure 2: Increased ecogenicity seen in abdominal aorta with decreased flow suggestive of arterial thrombosis (percentage stenosis 60.14%)|
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| Discussion|| |
Patient living with AIDS are always prone for an uncommon complication that is vascular thrombosis. , Venous thrombosis is more frequently prevailing condition then the rare arterial thrombosis (AT) with no large cohort studies in the literature for the latter.  Arterial lesions commonly involve small arteries; however large arterial trunks could also get thrombosed.  Studies reported clinical thrombosis in 2% of HIV-infected patients with venous thrombosis in 10% and arterial involvement in 6% cases.  Arterial aneurysm even aortic aneurysm has been described by number of studies but partial aortic thrombosis has been described by few studies to the best of our knowledge. 
Median age for venous and AT onset has been found to be 45 (22-56) years and 53 (44-59) years, respectively. age at diagnosis of HIV infection to be 34 (16-73) years.  Age related annual incidences of AT in men aged <45 years were 0.07% with threefold higher risk in HIV patients.  Development of aortic thrombosis in our case in such a young age of 33 years then the defined median age of 53 (44-59) years in studies suggests that the case might have encountered the infection in very early of his life. 
Aortic thrombosis, a rare fatal event leads to arterial emboli often due to thrombi associated with extensive underlying atherosclerosis. This arterial emboli might had lead to mesenteric ischemia, leading to acute exacerbation of chronic pain and the sudden onset of lower limb weakness in the case. Mesenteric ischemia has been seen as one of the several reported culprit in causation of abdominal pain in AIDS patients. , The idea of development of some arterial emboli in this patient is also supported by the notion that the arterial thrombotic event leads to peripheral arterial disease mostly presented as claudicating pains as in present case. 
In this patient the suspected causes for AT have been cited in various studies which include higher levels of immune activation, risk of specific complications, smoking, and treatments that may contribute to a hypercoagulable state. ,, But the normal lipid profile and absence of HAART rules out the possibility of treatment induced thrombosis in our patient. ,,, Very low CD4 counts (129 cells/μL) at the time of first presentation could be a possible culprit for the aortic thrombosis in this patient as described by other studies. ,,
This case suggests that a changing trend of the disease may lead to deviation from the predefined pathway of presentation of the disease. Therefore, clinicians should be aware and alert for unprovoked thrombosis to promote a timely treatment and prophylaxis. Precise diagnosis based on symptoms alone is very difficult in these patients and studies have shown that imaging facilities have provided the first clue in suspecting the possibility of an underlying HIV infection. , Imaging facilities like color doppler can be used feasibly in regular screening of these patients' with CD4 cells count <200 cells/μL in resource poor settings. 
These patients are having increased risk of cardiovascular complication leading to mortality and morbidity thus, a thorough evaluation for coronary artery disease should always be considered in such patients according to the available guidelines, despite of being asymptomatic. ,
| Conclusion|| |
Abdominal symptoms are amongst the most frequent complaints of patients with AIDS. In developing world AIDS patients presents with abdominal pain, infectious etiologies are often considered as culprit. As the silent thrombosis which was not diagnosed on first visit lead to embolism causing severe pain and left lower limb weakness. The graveness of the situation could be imagined from the notion that once missed it might lead to catastrophic complications if missed on the second visit. Present case justifies that vascular thrombosis should also be considered in differential diagnosis and a timely workup to be done to prevent any catastrophe.
| References|| |
|1.||Mulaudzi TV. HIV associated vasculopathy. Available from http://www.ajol.info/index.php/cme/article/viewfile/50313/39000 [Last accessed on 2014 Jun 14]. |
|2.||Jacobson MC, Dezube BJ, Aboulafia DM. Thrombotic complications in patients infected with HIV in the era of highly active antiretroviral therapy: A case series. Clin Infect Dis 2004;39:1214-22. |
|3.||Konin , Anzouan-Kacou JB, Essam N′loo A. Arterial thrombosis in patients with human immunodeficiency virus: Two-case reports and review of the literature. Case Rep Vasc Med 2011;2011:847241. |
|4.||Majluf-Cruz A, Silva-Estrada M, Sánchez-Barboza R, Montiel-Manzano G, Treviño-Pérez S, Santoscoy-Gómez M, et al. Venous thrombosis among patients with AIDS. Clin Appl Thromb Hemost 2004;10:19-25. |
|5.||Lijfering WM, Sprenger HG, Georg RR, van der Meulen PA, van der Meer J. Relationship between progression to AIDS and thrombophilic abnormalities in HIV infection. Clin Chem 2008;54:1226-33. |
|6.||Ando T, Makuuchi H, Kitanaka Y, Koizumi H. Rupture of a pseudo aneurysm of the abdominal aorta in a patient with human immunodeficiency virus infection. Ann Thorac Cardiovasc Surg 2011;17:198-200. |
|7.||Thom TJ, Kannel WB, Silbershatz H, D′Agostino RB. Incidence, prevalence, and mortality of cardiovascular diseases in the United States. In: Alexander RW, Schlant RC, Fuster V, editors. Hurst′s the Heart. 9 th ed. New York: McGraw-Hill; 1998. p. 3-17. |
|8.||Munirathnam D, Raj R. Unusual Presentation of HIV Vasculopathy in a Child. Indian J Hematol Blood Transfus 2011;27:169-71. |
|9.||Mulaudzi TV, Robbs JV, Pillay W, Pillay B, Moodley J, Magagula T, et al. Thrombectomy in HIV related peripheral arterial thrombosis: A preliminary report. Eur J Vasc Endovasc Surg 2005;30:102-6. |
|10.||Guaraldi G, Ventura P, Garlassi E, Orlando G, Squillace N, Nardini G, et al. Hyperhomocysteinemia in HIV-infected patients: Determinants of variability and correlations with predictors of cardiovascular disease. HIV Med 2009;10:28-34. |
|11.||Baker JV, Neuhaus J, Duprez D, Kuller LH, Tracy R, Belloso WH, et al. INSIGHT SMART Study Group. Changes in inflammatory and coagulation biomarkers: A randomized comparison of immediate versus deferred antiretroviral therapy in patients with HIV infection. J Acquir Immune Defic Syndr 2011;56:36-43. |
|12.||Chakraborty PP, Bandyopadhyay D. Utility of abdominal ultrasonography in HIV patients. Singapore Med J 2009;50:710-4. |
|13.||Corr P. Imaging of acquired immunodeficiency syndrome (AIDS). Ann Acad Med Singapore 2003;32:477-82. |
[Figure 1], [Figure 2]