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cardio.cardiac-tamponade.hiv-related.v1

Cardiac tamponade — HIV-related pericardial effusion

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to HIV-related pericardial effusion + tamponade in HIV+ patient (typically AIDS-stage CD4 <200 or endemic-region HIV-TB coinfection). Inherits drainage + bridge regimen from parent via routing; specializes for broad etiology differential (TB pericarditis is leading global cause especially sub-Saharan Africa per Mayosi NEJM 2014 IMPI PMID 25199187 + Sliwa cohorts; AIDS-defining malignancies KS + lymphoma; opportunistic infections cryptococcus + candida + CMV + atypical mycobacteria; HIV cardiomyopathy with uremic-like effusion; drug reaction from HAART components; chyle effusion from thoracic duct invasion). Comprehensive pericardial fluid panel essential: cell count + cytology + AFB/Xpert MTB/RIF + ADA + IGRA + fungal smear/culture + cryptococcal antigen + gram + bacterial culture + CMV PCR + flow cytometry + chyle triglyceride; pericardial biopsy if non-diagnostic. Etiology-specific therapy: TB → 4-drug RIPE × 6 mo per WHO 2024; KS → liposomal doxorubicin per NCCN; lymphoma → CHOP-R per NCCN; cryptococcal → L-AmB + flucytosine then fluconazole per IDSA 2024; CMV → ganciclovir/valganciclovir per DHHS 2024. ART optimization with IRIS-aware timing (defer 2-8 wk post-OI Rx if CD4 ≥50; sooner if CD4 <50 due to OI risk per WHO 2024). OI prophylaxis: TMP-SMX if CD4 <200 (PJP); azithromycin if CD4 <50 (MAC). STEROIDS GENERALLY AVOIDED in HIV+ per IMPI HIV+ subgroup (KS reactivation risk). Severity triggers cover IRIS paradoxical worsening, KS reactivation on steroids, MDR-TB resistance, opportunistic fungal pericarditis (cryptococcal/candida), AIDS-defining lymphoma pericardial invasion. Multidisciplinary care: ID + cardiology + HIV care + oncology if KS/lymphoma + pulmonology + public health TB program + cardiothoracic surgery; surveillance for chronic constrictive pericarditis (~25% if TB etiology). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (HIV-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (4)

  • symptom
    Subacute (days-weeks) dyspnea + Beck triad in known HIV+ patient (especially CD4 <200, endemic region) → HIV-related tamponade with broad etiology differential (Mayosi Heart 2017; Currier)
    subacute_dyspnea_in_known_hiv_patient
  • imaging
    Echo: pericardial effusion (often large >2 cm) ± fibrin strands ± masses (KS/lymphoma) + RV diastolic collapse + IVC plethora in HIV+ patient (ESC 2015)
    echo_large_effusion_in_hiv_pt
  • history
    New HIV diagnosis (positive HIV antibody/PCR) prompted by pericardial effusion workup — universal HIV testing in any unexplained effusion (ESC 2015 Class I)
    newly_diagnosed_hiv_with_pericardial_effusion
  • symptom
    Known AIDS-defining illness (KS, lymphoma, disseminated MAC, PCP) + new pericardial effusion — multi-etiology evaluation including malignant invasion (Currier)
    aids_defining_illness_with_pericardial_disease

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Modifies HIV care complexity, ART tolerance, drug interaction profile (DHHS 2024)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad; pulsus paradoxus measurement (Roy JAMA 2007 PMID 17456823)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology (ESC 2015)
  • temperaturerequired
    vital • used at INITIAL_WORKUP
    Fever pattern informs differential — TB (subacute fever + night sweats), opportunistic infection, lymphoma (B-symptoms), HIV-related drug reaction (DHHS 2024)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Definitive bedside dx — chamber collapse, IVC, swinging heart; characterize effusion size + masses suggesting KS/lymphoma + fibrin strands suggesting TB (ESC 2015 Class I)
  • cd4_count_and_viral_loadrequired
    lab • used at CONTEXT
    CD4 stratifies opportunistic infection risk + drives steroid-avoidance decision (KS risk per IMPI HIV+ subgroup PMID 25199187); viral load drives ART urgency + IRIS risk (WHO 2024)
  • art_history_and_adherencerequired
    history • used at CONTEXT
    ART-naive vs experienced changes IRIS risk, regimen choice (rifampin requires efavirenz-based or DTG dose-adjusted ART), and treatment-failure suspicion (DHHS 2024)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline for nephrotoxic ART (TDF), RIPE drug dose-adjustment if TB, contrast use for chest CT (KDIGO 2024)
  • altrequired
    lab • used at INITIAL_WORKUP
    Baseline for ART hepatotoxicity (NVP), RIPE-induced hepatitis if TB, viral hepatitis co-infection screening (DHHS 2024)
  • chest_ct_for_adenopathy_and_massesrequired
    imaging • used at INITIAL_WORKUP
    Mediastinal lymphadenopathy + cavitary disease suggests TB; intrathoracic masses suggest KS/lymphoma; pulmonary consolidation suggests opportunistic pneumonia (DHHS 2024)

12-phase flow (9)

  1. 1FRAME
    HIV-related tamponade — broad etiology differential (TB, malignancy, opportunistic infection, HIV cardiomyopathy, drug reaction); pericardiocentesis for both diagnosis (full panel) + tamponade relief; ART optimization with IRIS-aware timing if ART-naive; STEROIDS AVOIDED in HIV+ per IMPI subgroup (KS reactivation risk)
    inputs: sbp
    advance: HIV-context tamponade physiology suspected
  2. 2ENTRY
    Recognize HIV+ context; capture CD4/VL/ART history; route immediately to drainage if hemodynamic compromise (ESC 2015 Class I)
    inputs: age, cd4_count_and_viral_load
    advance: HIV status + AIDS-staging captured
  3. 3CONTEXT
    CD4 + viral load + ART regimen + adherence history + opportunistic infection prophylaxis status + AIDS-defining illness history + endemic-region exposure (TB) + KS/lymphoma history (DHHS 2024)
    inputs: cd4_count_and_viral_load, art_history_and_adherence
    advance: HIV-context fully captured
  4. 4RED_FLAGS
    Tamponade obstructive shock (Beck triad) + concurrent disseminated TB / opportunistic infection / lymphoma B-symptoms; AVOID positive-pressure ventilation pre-drain (ESC 2015)
    inputs: sbp, hr
    actions: cardiac_tamponade
    advance: shock recognized + concurrent severe illness screened
  5. 5INITIAL_WORKUP
    STAT echo, ECG, CXR + chest CT, troponin, BMP, CBC, CD4/VL, IGRA, cryptococcal antigen, syphilis, viral hepatitis serologies, baseline ALT/Cr (DHHS 2024; ESC 2015)
    inputs: echo, creatinine, alt, chest_ct_for_adenopathy_and_masses, temperature
    actions: panel.cardiac, panel.renal, panel.coag
    advance: echo confirms tamponade + HIV-related workup initiated
  6. 6DIFFERENTIAL
    Pericardial fluid panel: cell count + diff (lymphocytic = TB; neutrophilic = bacterial; eosinophilic = fungal/drug); cytology (KS spindle cells, lymphoma cells); AFB stain + Xpert MTB/RIF + ADA + IGRA (TB); fungal smear + culture + cryptococcal antigen (cryptococcosis, candidiasis); gram stain + bacterial culture; CMV PCR; chylomicron triglyceride (chyle); flow cytometry for lymphoma; pericardial biopsy if non-diagnostic fluid (ESC 2015; Currier)
    advance: comprehensive fluid + biopsy specimens sent
  7. 7TREATMENT
    Step 1 echo-guided pericardiocentesis (diagnostic + therapeutic); Step 2 etiology-specific therapy: TB → 4-drug RIPE × 6 mo per WHO 2024; KS → liposomal doxorubicin + ART; lymphoma → CHOP-based chemotherapy + ART; cryptococcal → amphotericin B + flucytosine then fluconazole; CMV → ganciclovir/valganciclovir; Step 3 ART optimization with IRIS-aware timing (defer 2-8 wk post-OI Rx if CD4 ≥50, sooner if CD4 <50); Step 4 OI prophylaxis (TMP-SMX if CD4 <200, azithromycin if CD4 <50); Step 5 AVOID steroids for pericardial inflammation in HIV+ (KS risk per IMPI subgroup); Step 6 pericardiectomy if chronic constrictive pericarditis develops
    inputs: sbp
    advance: pericardiocentesis + etiology-specific therapy + ART optimization initiated
  8. 8DISPOSITION
    CCU/ICU if hemodynamic compromise; airborne isolation if pulmonary TB suspected; multidisciplinary care: cardiology + ID + HIV care + oncology if KS/lymphoma + pulmonology + public health TB program (DHHS 2024)
    advance: multidisciplinary disposition + isolation status confirmed
  9. 9MONITORING
    Re-accumulation surveillance (echo q24-48h initially then weekly); ART adherence + virologic response (q4-12 wk VL); CD4 trend; IRIS surveillance 2-12 wk post-ART; etiology-specific therapy response; constriction surveillance (~25% in TB cases); drug toxicity (ART, RIPE, chemo) (DHHS 2024)
    actions: panel.cardiac
    advance: etiology-specific therapy response + IRIS surveillance ongoing