Challenges in the detection of drug-induced dyslipidaemia in HIV-positive patients treated with protease inhibitors

• Published in: Acta clinica belgica (English ed. Online) 2016-01, Vol.71 (S1), p.33
• Main Authors: Mugabo, Pierre, Madsen, Richard
• Format: Article
• Language: English
• Subjects: Abdomen; Blood clots; Cardiac arrhythmia; Patients; Ultrasonic imaging
• ISSN: 1784-3286; 2295-3337

In a significant number of patients presenting with stroke or peripheral embolization, no cause is found despite extensive diagnostic evaluation. We present a case of multiple bilateral renal infarctions and emphasize the possible diagnostic yield of TEE in such cases. A 52 year old female with history of arterial hypertension, reflux esophagitis and smoking presented to the emergencies complaining of acute abdominal and flank pain, radiating from both lumbar areas to the right and left iliac fossa. Other complaints were nausea as well as rectal and vesical tenesmus. Palpation revealed deep tenderness of the right iliac fossa as well as local guarding and rebound tenderness. Costovertebral angle tenderness was present on the right. The patient was afebrile. Urinalysis and abdominal ultrasound were normal. Contrast enhanced abdominal CT scan revealed bilateral multifocal renal infarctions. Laboratory testing was remarkable for leukocytosis, increased CRP, increased LDH and reduced kidney function. As part of the diagnostic workup, the patient underwent 24-h holter monitoring, coagulation screening, transthoracic echocardiography and eventually transesophageal echocardiography. On the latter, free-floating endo-luminal thrombus material arising from a thick, calcified, ruptured atherosclerotic plaque was seen in the descending thoracic aortic artery and was considered the embolic focus. The patients was initiated on long term low dose aspirine and potent lipid lowering therapy. Low molecular weight heparine was administered for one month, until follow up TEE showed the disappearance of intraluminal thrombus material. She was also urged to quit smoking and take up physical exercise and dietary measures in the light of secondary cardiac prevention. Kidney infarction is rare and probably underdiagnosed, and the exact cause remains unknown in a substantial number of cases. Atrial fibrillation is by far the most common cause and needs to be sought after. With our case, we want to stress the possible diagnostic yield of transesophageal echocardiography in patients with peripheral embolus when a previous extensive diagnostic workup (contrast enhanced CT of the abdomen, 24-h holter monitoring, coagulation screening, doppler ultrasound of the renal arteries and transthoracic echocardiography) was unable to identify an underlying cause. Determination of the exact cause is important for a correct treatment (i.e. antiplatelet therapy and lipid lowering therapy, but no l