A 43-year-old man with human immunodeficiency virus (HIV) infection for at least ten years, on antiretroviral treatment.

History, current illness and physical examination
Hepatitis C 1b RNA+ virus infection with hypertransaminasemia. Probable clinically resolved cerebral toxoplasmosis with stable residual lesions in radiological controls. Secondary comic crisis, without recurrence. Ex-smoker. No other history of interest.
As usual treatment for his HIV infection the patient had a regimen based on two protease inhibitors (atazanavir + ritonavir) together with a combination of nucleoside analogue antiretrovirals (emtricitabine + tenofovir). The patient was brought to the emergency department after starting a week earlier with symptoms of respiratory infection, followed by rapidly progressive dyspnoea. On arrival, he presented with severe respiratory distress, arterial oxygen desaturation and bronchospasm, so 400 mg of hydrocortisone were administered together with nebulisations of salbutamol and ipratropium bromide. Despite this, he presented a poor clinical evolution, with progressive arterial desaturation (83% despite high-flow oxygen therapy) and marked hypertension (200/100 mmHg).
Auscultation showed bilateral crackles up to midfield. Chest X-ray showed severe cardiomegaly and bilateral alveolar oedema compatible with acute pulmonary oedema. An urgent echocardiogram showed a dilated left ventricle with very severe global systolic dysfunction (estimated LVEF of 15%), with severe generalised hypokinesia, and severe mitral insufficiency of functional origin.
He was admitted to the ICU where high-dose intravenous diuretic treatment and non-invasive mechanical ventilation were started, stabilising the patient and initiating progressive clinical improvement over the following hours. Serial analyses showed elevated markers of myocardial damage, with a CPK peak of 3,300 and troponin I of 6. He presented two febrile peaks of 38.4oC, with several negative blood cultures.

Complementary tests
- ECG: On arrival at the ED, sinus tachycardia at 156 bpm. Left axis. Signs of left ventricular hypertrophy. Anterior and inferior Q, with 1 mm ST supradelevation from V1 to V4.
- Echocardiogram: severely dilated left ventricle, with severely reduced systolic function (ejection fraction by Simpson biplane of 15%), due to severe generalised hypokinesia. Severe functional mitral insufficiency. Moderately dilated left atrium. Right ventricle of borderline size with reduced TAPSE (14 mm). Inferior cava not dilated with inspiratory collapse present. Absence of tricuspid insufficiency to estimate pulmonary artery pressure. Minimal detachment of pericardial leaflets.
- Coronography: Left common trunk of good calibre with no notable lesions. Anterior descending artery (LAD) with segment with severe atheromatosis that includes its ostium, the proximal-medial LAD and the ostium of the first diagonal. Critical lesion in the middle LAD. Small second ramaseptal with severe disease and very thin calibre. Circumflex of medium calibre and good development with severe lesion (90%) in the proximal third, of complex appearance. Dominant right coronary artery, with diffuse atheromatosis, multisegment. More severe lesion in distal third (60%). Moderate lesion in posterolateral branch (50%), with distal bed of fine calibre.
- Lipid profile: cholesterol 241 mg/dl, HDL-cholesterol 41 mg/dl, LDL-cholesterol 179 mg/dl, triglycerides 104 mg/dl (0.0-150.0).

Clinical course
With non-invasive mechanical ventilation and treatment with diuretics and vasodilators, the patient's clinical evolution was favourable over the following days. Once the heart failure was resolved, a study of dilated cardiomyopathy was performed, suspecting, after elevation of markers of myocardial damage, ischaemic origin of the same. Coronary angiography showed diffuse three-vessel coronary artery disease, with severe lesions on the LAD and CX, which were treated by angioplasty and implantation of drug-eluting stents. There were no subsequent complications, and he was finally discharged with medical treatment.

Diagnosis
Ischaemic dilated cardiomyopathy in a patient with chronic HIV infection.
