Patient handout

Cardiac tamponade — HIV-related pericardial effusion

PRODUCTION

1. Your condition

This handout is for cardiac tamponade — hiv-related pericardial effusion. Your care team identified this based on: 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).

Other reasons your team may use this plan: echo: pericardial effusion (often large >2 cm) ± fibrin strands ± masses (ks/lymphoma) + rv diastolic collapse + ivc plethora in hiv+ patient (esc 2015); new hiv diagnosis (positive hiv antibody/pcr) prompted by pericardial effusion workup — universal hiv testing in any unexplained effusion (esc 2015 class i); known aids-defining illness (ks, lymphoma, disseminated mac, pcp) + new pericardial effusion — multi-etiology evaluation including malignant invasion (currier).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
normal saline	500-1000 mL bolus	IV	rapid bolus then reassess	Bridge preload to drainage (ESC 2015)
norepinephrine	0.05-0.1 µg/kg/min titrate to MAP ≥65	IV	continuous	Bridge only — does not address obstruction (Roy JAMA 2007)
rifampin	10 mg/kg PO daily (max 600 mg)	PO	daily × 6 mo if TB	WHO 2024 — first-line; major CYP induction → ART regimen change required (efavirenz-based or DTG dose-doubled per WHO HIV/TB)
isoniazid	5 mg/kg PO daily + pyridoxine	PO	daily × 6 mo if TB	WHO 2024 — first-line; pyridoxine prevents neuropathy
pyrazinamide	25 mg/kg PO daily	PO	daily × 2 mo intensive if TB	WHO 2024 — intensive phase only
ethambutol	15-25 mg/kg PO daily	PO	daily × 2 mo intensive if TB	WHO 2024 — intensive phase; visual acuity monthly
liposomal doxorubicin	20 mg/m² IV q3 wk × 4-8 cycles	IV	q3 wk	AIDS-related KS — first-line per NCCN; coordinate with ART optimization (cardiotoxicity surveillance with serial echo)
amphotericin B liposomal	3-4 mg/kg IV daily	IV	daily × 2 wk induction	IDSA 2024 cryptococcal disease guidelines — induction with flucytosine then fluconazole consolidation/maintenance
ganciclovir	5 mg/kg IV q12h × 14-21 d induction	IV	q12h induction then valganciclovir maintenance	DHHS 2024 — CMV end-organ disease in AIDS
trimethoprim-sulfamethoxazole	160/800 mg PO daily	PO	daily	DHHS 2024 — universal PJP prophylaxis if CD4 <200; continue until CD4 >200 × 3 mo on ART
azithromycin	1200 mg PO weekly	PO	weekly	DHHS 2024 — MAC prophylaxis if CD4 <50; discontinue once CD4 >100 × 3 mo on ART
fluconazole	400 mg PO daily induction → 200 mg maintenance	PO	daily	IDSA 2024 cryptococcal — consolidation 8 wk then maintenance until CD4 >100 sustained
pyridoxine	25-50 mg PO daily	PO	daily concurrent with INH	Standard INH co-administration — peripheral neuropathy prevention (WHO 2024)

Plan: HIV-related pericardial effusion — pericardiocentesis + etiology-specific therapy (TB/KS/lymphoma/OI/HIV-CMP) + ART optimization with IRIS-aware timing + selective OI prophylaxis (no steroids per IMPI HIV+ subgroup)

3. When to call your provider

Contact your care team if any of the following happen:

Symptomatic constrictive pericarditis (NYHA II-IV) → cardiothoracic surgery for pericardiectomy (ESC 2015 Class IIa)
Recurrent effusion → re-drainage + diagnostic reconsideration (treatment failure? new OI? KS recurrence?)
TB recurrence → ID + repeat workup + DOT re-engagement
Late IRIS in HIV+ → ID + HIV team
KS or lymphoma recurrence/progression → oncology emergent
ART regimen failure (rising VL) → resistance testing + regimen switch per HIV team

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Paradoxical worsening of pericardial disease 2-12 wk after ART initiation in HIV+ patient — IRIS reaction (WHO HIV 2024)
Kaposi sarcoma flare/reactivation on steroids or immunosuppressive therapy in HIV+ patient (Mayosi IMPI subgroup PMID 25199187)
Xpert MTB/RIF or culture susceptibility shows resistance to rifampin (RR-TB) or rifampin + INH (MDR-TB) in HIV+ TB pericarditis patient (WHO 2024 MDR-TB)(life-threatening)
Cryptococcal antigen positive in pericardial fluid OR fungal culture positive (Candida, Cryptococcus, Aspergillus) — opportunistic fungal pericarditis in advanced HIV (CD4 <100) (IDSA 2024)(life-threatening)
AIDS-related lymphoma (DLBCL, primary effusion lymphoma, plasmablastic) with pericardial invasion confirmed on cytology/flow cytometry/biopsy (NCCN AIDS-related lymphoma)(life-threatening)

6. Sources

Guideline: 2015 ESC Guidelines for the diagnosis and management of pericardial diseases (Adler EHJ 2015 PMID 26320112) anchors drainage + workup baseline; IMPI trial (Mayosi NEJM 2014 PMID 25199187) anchors steroid AVOIDANCE in HIV+ TB pericarditis subgroup (KS reactivation risk); WHO Global TB Report 2024 + WHO TB treatment guidelines 2024 anchor RIPE regimen for TB etiology; WHO Consolidated HIV ART guidelines 2024 + DHHS HIV ART guidelines 2024 anchor ART optimization with IRIS-aware timing + OI prophylaxis; IDSA 2024 cryptococcal disease guidelines + DHHS OI guidelines 2024 anchor opportunistic infection management; NCCN AIDS-related KS + lymphoma anchor oncology pathway. Currier HIV cardiac complications and Sliwa HIV cardiac/Mayosi Heart 2017 anchor HIV-context epidemiology and multidisciplinary co-management.