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Case Reports and Interesting Cases

Introduction: Atherosclerosis is known to be premature and often widespread in patients with HIV. We describe a case of regression of a significant carotid artery stenosis in a patient with HIV after commencing antiretroviral therapy. Case report: A 58-year-old male inpatient with an ischaemic left great toe developed an acute left hemiparesis, dysarthria and left visual and sensory inattention, the day after admission. CT showed acute right MCA thrombus and right frontal lobe infarction. Carotid ultrasound demonstrated greater than 95% stenosis of the right internal carotid artery with ‘string flow’ appearance. Bilateral occlusive femoral disease was also present. An HIV test, performed to investigate the widespread arterial disease, was positive. CD4 count was 230 and a month post-stroke the antiretroviral combination drug Atripla (tenofovir, emtricitabine and efavirenz) was started. He was seen 2 months after commencing Atripla for consideration of carotid endarterectomy. However repeat ultrasound showed significant plaque regression to 40–50%, therefore no longer requiring surgery by local criteria. Discussion: This is the only case to our knowledge demonstrating significant plaque regression apparently due to antiretroviral therapy. Indeed, patients with HIV appear to have an increase in carotid intimal medial thickening on antiretroviral therapy although this has been attributed to protease inhibitors. The nature of the plaque in HIV patients has been demonstrated to be inflammatory in nature, seeming to have more in common with arteritis than true atherosclerosis. This case highlights the importance of considering and testing for HIV particularly in those with widespread premature atheromatous disease.