Abstract

A 45-year-old woman presented with a 6-month history of progressively worsening leg swelling. The patient was otherwise previously healthy. On physical examination, jugular venous pressure was elevated to the angle of the jaw. There were fine crackles at her lung bases. Precordial examination demonstrated a parasternal heave and a loud second heart sound. A Grade 2/6 holosystolic murmur was detected along the left sternal border. There was bilateral pitting edema up to her proximal thighs. An echocardiogram revealed functional tricuspid valvular regurgitation secondary to severe right ventricular dilation and hypokinesis. Right ventricular pressure was elevated at approximately 75 mm Hg, consistent with pulmonary hypertension (PH). Subsequent tests were ordered to elucidate the etiology of her PH, including a connective tissue workup, pulmonary function tests, coronary angiogram, and CT scans for pulmonary embolism, all of which were negative. Surprisingly, a HIV test was performed and found to be positive on confirmatory Western blot. CD4 lymphocyte count was approximately 500 mm³. She denied exposure to HIV risk factors. The patient was subsequently placed on a diuretic, β-blocker, and an ACE inhibitor with good response. She was also referred to the outpatient HIV clinic for close follow up and consideration for highly active antiretroviral therapy (HAART).