The impact of HIV co-infection on presentation and outcome in adults with tuberculous pericarditis: Findings from the IMPI trial

Background. Little is known about the impact of HIV infection on clinical presentation, complications, and morbid pericarditis-related outcomes of tuberculous pericarditis and its predictors. Objective. To assess the impact of HIV infection on presentation and outcomes in the multicountry Investigation of the Management of Pericarditis (IMPI) randomised controlled trial of immunotherapy in tuberculous pericarditis conducted in sub-Saharan Africa. Methods. We compared clinical features and outcomes of 1 370 adult patients treated for tuberculous pericarditis (939 and 431 HIV-infected and uninfected, respectively) enrolled in the IMPI trial. Cox proportional hazards models were used to determine independent predictors of outcomes of HIV-associated tuberculous pericarditis. Results. At presentation, HIV-infected (v. uninfected) patients were younger (median age 34.0 years v. 47.7 years), had lower body mass (mean weight 56 kg v. 60 kg), higher prevalence of tachycardia (58.5% v. 51.9%), hypotension (9.4% v. 3.9%), anaemia (65.9% v. 26.8%), and radiographic pulmonary infiltrates compatible with tuberculosis (35.4% v. 27.4%), but had lower rates of peripheral oedema (37.1% v. 48.3%). HIV-infected (v. uninfected) patients were less likely to develop constrictive pericarditis (4.1% v. 10.0% at 1 year, p<0.0001 (hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.27 - 0.63, p<0.0001)). However, there was no difference in case fatality rate at 1 year (14.9% v. 12.2%, respectively, p=0.09; (HR 1.20, 95%CI 0.90 - 1.59, p=0.22)). Among HIV-infected patients, heart failure New York Heart Association (NYHA) class III - IV, low body mass, hypotension, and peripheral oedema were independently associated with death. Conclusion. HIV infection alters the cardiovascular presentation and reduces the incidence of constrictive pericarditis, but does not increase case fatality. Mortality in HIV-infected patients is independently predicted by markers of pericardial and tuberculosis disease severity.