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Editor,—Atrial myxoma has not previously been reported in HIV infection. We describe a patient with advanced HIV disease who underwent surgery for this condition.
The patient was diagnosed with asymptomatic HIV infection in February 1987 when she was aged 50 years. Her CD4 count was 690 ×106/l at this time. HIV infection was acquired through sexual intercourse with a bisexual male partner. In December 1990 the CD4 lymphocyte count had fallen to 190 ×106/l and zidovudine monotherapy was started. This was continued until 1996 when she was prescribed a combination regimen. Co-trimoxazole was given for Pneumocystis carinii prophylaxis, but the patient deferred starting this until December 1992.
In February 1992 the patient was admitted to another hospital with an acute myocardial infarction which was successfully thrombolysed. Fasting lipids were within the normal range. There were no cardiac risk factors apart from smoking.
In September 1995 the patient experienced a syncopal episode. An echocardiogram revealed a mass in the left atrium consistent with a left atrial myxoma. A coronary angiogram showed normal coronary arteries. Surgical resection of the myxoma was recommended.
In December 1995 the patient's CD4 count was 64 ×106/l, but apart from oral candidiasis there had been no HIV related problems since diagnosis. Two leading UK HIV physicians were asked if they considered surgery to be advisable. They estimated the patient's likely survival from HIV disease to be 1–4 years. The risks of major heart surgery had to be balanced against the likelihood of recurrent symptoms from the myxoma in the next 1–4 years. The patient and her physician agreed to proceed with surgery.
On 4 December 1995 the patient underwent surgical resection of a pedunculated left atrial mass. Histological examination confirmed a benign atrial myxoma. The procedure was uncomplicated and she was discharged from hospital 4 days later. Annual cardiac review including an echocardiogram has shown no evidence of recurrence up to the present time. She remains free from cardiovascular symptoms. Her HIV disease is managed with combination therapy that consists of stavudine, lamivudine, and efavirenz. Current CD4 count is 564 ×106/l and viral load less than 50 copies/ml (Chiron bDNA v3.0)
Atrial myxoma is a rare tumour that is considered to be benign although recurrence and metastases have been described.1 The myocardial infarction suffered by our patient may have been an embolic manifestation of the myxoma, and the normal serum lipids and normal coronary angiogram almost 4 years later would support this.
In 1995 expert opinion provided a very guarded prognosis for someone with a CD4 count of 60 ×106/l who had been exposed to a single antiretroviral agent, zidovudine. Today there would be less debate over the merits of such a surgical procedure in this scenario, and this case demonstrates the excellent outcome that can be achieved with major surgery despite profound immunosuppression. The proved benefits of HAART (highly active antiretroviral therapy) have made it unacceptable to deny major surgical interventions to individuals with HIV.