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\begin{document}

\title{Extensive Myocardial Infarction complicated with Stroke as First
Presentation of HIV in A young Sudanese Male: Case Report}



\author[1]{ Moh. Eljack}%
\author[1]{Najla  Fouad Nassir Mohammedali}%
\author[1]{Omer Idris Ahmed}%
\author[2]{Alshareef  B. Nour}%
\author[3]{Mazin S. Hassan Haroun}%
\author[3]{Khabab  Mohamed Ahmed}%
\author[4]{Abdallah  M. Abdallah}%
\author[3]{Mustafa Mohamed Ibrahim Ali}%
\affil[1]{Medani Heart Centre}%
\affil[2]{Wad Medani College of Medical Science and Technology}%
\affil[3]{University of Khartoum Faculty of Medicine}%
\affil[4]{University of Bahri, Faculty of medicine}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
HIV can be associated with cardiovascular complications. We highlight
unusual presentation of HIV patient with MI and stroke. 30 year old HIV
male presented with MI complicated by stroke. Recovered within 5 days
with anti-ischemic and diuretics. Screening tests for unusual
presentations prevent fatal complications of common diseases.%
\end{abstract}%



\sloppy


\textbf{Extensive Myocardial Infarction complicated with Stroke as First
Presentation of HIV in A young Sudanese Male: Case Report}

Moh.Mah.Fadelallah Eljack\textsuperscript{1}, Najla Fouad Nassir
Mohammedali\textsuperscript{2}, Omer Idris Ahmed\textsuperscript{3},
Alshareef B. Nour\textsuperscript{4}, Mazin S.
Haroun\textsuperscript{5}, Khabab Abbasher Hussien Mohamed
Ahmed\textsuperscript{6\textbf{*}} , Abdallah M.
Abdallah\textsuperscript{7}, Mustafa Mohamed Ibrahim
Ali\textsuperscript{8}

\begin{enumerate}
\tightlist
\item
  University of Bakht Alruda, Faculty of Medicine, Medani Heart Centre,
  Sudan, m.mahmmoud96@gmail.com
\item
  Cardiology Consultant, Medani Heart Centre, Sudan,
  najlafouad5@gmail.com
\item
  Medical Doctor at Medani Heart Centre, Sudan, Idrisomer697@gmail.com
\item
  Wad Madani college of Medical science and technology, Sudan,
  Alsharifnour@hotmail.com
\item
  University of Khartoum, Faculty of Medicine, Sudan,
  mazinsalaheldien@gmail.com
\item
  University of Khartoum, Faculty of Medicine, Sudan,
  Khabab9722@gmail.com
\item
  University of Bahri, Faculty of Medicine, Sudan,
  abdallah.mustafa1738@gmail.com
\item
  University of Khartoum, Faculty of Medicine, Sudan,
  triplex960@gmail.com\textbf{Correspondence Author:}Khabab Abbasher
  Hussien Mohamed Ahmed Email: Khabab9722@gmail.com ORCID ID:
  0000-0003-4608-5321 Khartoum State, Postal code: 11111, Sudan, Mobile:
  00249907712134
\end{enumerate}

\textbf{Abstract}

HIV can be associated with cardiovascular complications. We highlight
unusual presentation of HIV patient with MI and stroke. 30 year old HIV
male presented with MI complicated by stroke. Recovered within 5 days
with anti-ischemic and diuretics. Screening tests for unusual
presentations prevent fatal complications of common diseases.

\textbf{Key Words:}

HIV, Myocardial Infarction, Stroke, Sudan

\textbf{Introduction:}

A Patient with Human Immunodeficiency Virus (HIV) has an increased risk
of developing coronary artery diseases (CAD) either through traditional
CAD risk factors, antiretroviral drug effects or HIV-related parameters
including inflammatory and immunologic changes (1). Also an increased
risk of stroke either including HIV-related intra- and extra-cranial
vasculopathy, HIV induced cardiomyopathy, HIV-induced coagulopathy and
opportunistic infection-associated vasculitis; However, this is mostly
significant~among those younger than 50, but not among older patients
(2,3). The most significant early manifestation of HIV infection among
Africans was marked by slim disease (diarrhea and wasting),
tuberculosis, variety of Opportunistic Infections (OI), weight loss,
fever, and dermatological symptoms(4). Here, we report a young Sudanese
male patient whom was diagnosed with Extensive ST segment Elevation
Myocardial Infarction (STEMI) complicated later with Ischemic Stroke who
was found to have a high HIV viral load with exclusion of other possible
causes of his underlying condition.

\textbf{Case Report:}

A 30 years old thin male with a clear medical background presented to
the emergency department at Medani Heart Centre (MHC) with central
crushing chest pain with maximum intensity radiated to the left shoulder
and jaw aggravated by movement and improved by rest not associated with
cough or shortness of breath and not improved by ingestion of food or
Antacids. The patient denied fever, change in appetite, diarrhea,
vomiting, change in urine, headache or any other form of neurological
symptoms.

However there was no past history of a similar condition or cardiac
problems. The patient mentioned that he is a heavy smoker and has had
unprotected sexual intercourse many times. The patient denied drinking
alcohol.

On examination the patient looked ill, thin and not pale or jaundiced,
pulse 110 regular good volume, Bp100/60 bilaterally, normal pericardium
findings, clear chest and soft abdomen. ECG showed Significant ST
segment elevation from v1 to v6 and mild elevation in leads 2, 3 and avF
confirmed later by positive serum troponin as Late Extensive ST segment
elevation Myocardial Infarction crushed by aspirin 300mg, clopidogrel
300 mg, bisoprolol 2,5 mg, Enoxaparin inj. weight~ 1 kg 12 hourly and
the patient was scheduled for urgent Coronary Angiography but during
preparation the ICT for HIV tested positively necessitating confirmation
with ELISA which showed a high viral load of 22.4 AU/ml (normal up to 1
AU/ml). Other tests revealed normal fasting lipid profile, complete
blood count and normal renal function tests with electrolytes.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Echocardiography showed anterior, septal, apical and anterolateral wall
hypokinesia with two apical thrombus measures 1110 cm ,1012 cm
subsequently with moderately impaired left ventricular systolic function
(Ejection Fraction=34) favoring the decision of adding furosemide 40 mg
tabs once daily and spironolactone tabs 25 mg once daily. See
\textbf{Figure 1}

The patient was followed up closely symptomatically with serial ECGs on
the subsequent days showing significant improvement until day 4 of
Admission in the evening follow up when he was found to have slurred
speech and he mentioned that he was unable to move his right side,
without mouth deviation, headache or blurring of vision. On examination
he was afebrile, conscious, oriented in time, place and person. There
was bulbar cranial nerves affection (without fascial palsy), right side
hypotonia, power grade 3 and hyporeflexia. The patient was sent for
urgent brain CT scan which showed left parietal area infarction. See

\textbf{Figure 2}

The patient was followed up for the following 5 days showing complete
recovery and returned speech fluency with normal tone, power grade 5 and
normal reflexes. He was discharged after being counseled perfectly on
full anti-ischemic and diuretics with enoxaparin shifted to rivaroxaban
15 mg 12 hourly sent to HIV program for proper management to be seen
after two weeks in the Cardiology Referral Clinic.

\textbf{Discussion:}

HIV-infected patients have an increased risk of developing coronary
artery disease (CAD), yet short-term prognosis after cardiovascular
events remains unclear (5). HIV-related Coronary heart disease risk
factors were described in literature, including Antiretroviral therapy,
HIV disease parameters, female gender and HCV co-infection (6). CAD
etiology in HIV-infected patients is the result of a number of
interactions causing inflammation, endothelial dysfunction, and
coagulation disorders, ultimately leading to atherosclerosis (7). The
severity of HIV-related immunosuppression is correlated with some
abnormalities which account for the observed hypercoagulability in
HIV-infected patients. This correlation is measured by CD4+ cell counts
and the presence of concurrent infectious or neoplastic diseases. These
abnormalities include the presence of decreased levels of natural
anticoagulants/heparin co-factor dimer, antiphospholipid
antibodies/lupus anticoagulant, elevated factor VIII coagulant activity,
activated protein C resistance, increased platelet activation and
hyperhomocysteinemia (8,9). In our patient, ECG showed Significant ST
segment elevation from v1 to v6 and mild elevation in lead 2, 3 and aVF
which was confirmed by positive serum troponin as Late Extensive ST
segment elevation Myocardial infarction. Myocardial infarction was our
initial working hypothesis, yet we included many possible underlying
pathologies. At first we excluded HIV opportunistic infections, because
myocardial infarction in HIV patients is usually a presentation of the
elderly, 50 years of age and more according to studies, unlike our 30
years old previously healthy patient(7). But on our routine out-patient
HIV testing program in the emergency department that was done before the
urgent coronary Angiography, ICT result for HIV turned out positive and
was confirmed with ELISA, which showed a high viral load of 22.4 AU/ml
(10-12). After management of myocardial infarction and stabilization of
the patient, he suddenly developed stroke. In addition to the
traditional risk factors, HIV is associated with other factors that
increase the risk of stroke, including immunosuppression and high
viremia, as in our patient. The etiology of stroke in people living with
HIV is multifactorial, including Atherosclerosis of the large arteries,
small vessel disease, cardio embolism, central nervous system (CNS)
infections, coagulation disorders, and non-atherosclerotic vasculopathy,
yet the triggering mechanism for stroke remains unclear (13). A possible
explanation of the presentation at this age is that the myocardial
infarction was directly related to HIV chronic inflammation and immune
activation independent of other risk factors (6). Two cohort studies
found a strong association of HIV with a 44\% to 48\% increased risk of
Myocardial Infarction, independent of traditional risk factors, such as
age, race, socioeconomic status, and substance abuse (14,15). To our
knowledge and available literature, this is the first case ever to
present with atypical HIV presentation as an ST-elevation Myocardial
Infarction complicated by stroke in such young age.

\textbf{Conclusion:}

This presentation of a young HIV-infected patient is unusual and very
uncommon. It points out the risk of subclinical HIV infection, and the
increased risk of CAD and stroke in this young HIV-infected population.
It also highlights the importance of routine out-patient HIV testing in
such emergency cases, in that it reduces the chances of debilitating
diseases to go undiagnosed, only to be discovered by its severe
complications at a very late age, as in a case of a patient who was
diagnosed with HIV for the first time at the age of 74 (16).

\textbf{Declarations:}

\textbf{Ethical Approval and Patient's consent:}

Ethical approval was obtained from research and ethics committee at
Medani Heart Centre (MHC). Both written and verbal consents were
obtained from the patient.

\textbf{Conflict of interest:}

The Author Report No Conflict of Interest

\textbf{Funding:}

The Study was funded by authors themselves.

\textbf{Acknowledgments:}

Not applicable.

\textbf{Authors' contribution:}

All authors contributed equally in the study.

\textbf{References}

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Ανασκόπηση \selectlanguage{english}( Systematic Review ). J Psychiatr Res. 2017;94(3):36--46.

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\textbf{Hosted file}

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