Paradoxical Cerebral Fat Embolism in an Adolescent PLHA: A Convergence of Trauma, ART Induced Hypercoagulability, and Septal Heart Defect
,
Abstract
Fat embolism syndrome (FES) is a life-threatening complication following long bone fractures, primarily affecting the pulmonary circulation. However, cerebral fat embolism (CFE) is a rare yet severe variant that can occur when fat emboli bypass the lungs through a right-to-left cardiac shunt, such as an atrial septal defect (ASD). In individuals with HIV on antiretroviral therapy (ART), persistent endothelial dysfunction and
ART-induced hypercoagulability predispose them to an exaggerated thrombo-inflammatory state, amplifying the risk of paradoxical embolism. We describe a 14-year-old male with perinatally acquired HIV on ART who presented after a high-impact road traffic accident. The patient sustained comminuted fractures of the right
femoral shaft, tibia, and femoral condyle. Initially neurologically intact (Glasgow Coma Scale [GCS] 15), he experienced rapid neurological deterioration (GCS dropped to 8), alongside respiratory distress and acute respiratory distress syndrome (ARDS)-like symptoms. Urgent evaluation with a 2D echocardiogram revealed an ASD with a right-to-left shunt, strongly supporting the diagnosis of paradoxical cerebral fat embolism.
This case illustrates how trauma, combined with HIV-related endothelial dysfunction, ARTinduced hypercoagulability, and a congenital cardiac anomaly, can converge to precipitate severe neurological decline through paradoxical embolism.
[2] Meyer JR, Leeflang EJ, Vrijdag HS. Right-to-left shunting as a pathway for cerebral fat embolism in patients with patent foramen ovale. Neurology. 1993;43(7):1331-3.
[3] von Bergmann E. Über Fettembolien. Berl Klin Wochenschr. 1873;10:385-7.
[4] Shaikh N. Emergency management of fat embolism syndrome. J Emerg Trauma Shock. 2009;2(1):29-33. https://doi.
org/10.4103/0974-2700.44680
[5] Kwiatt ME, Seamon MJ. Fat embolism syndrome. Int J Crit Illn Inj Sci. 2013;3(2):64-8. https://doi.org/10.4103/2229-
5151.109426
[6] Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br. 1970;52(4):732-7. https://doi.org/10.1302/0301-
620X.52B4.732
[7] Mellor A, Soni N. Fat embolism. Anaesthesia. 2001;56(2):145-54. https://doi.org/10.1046/j.1365-2044.2001.01724.x
[8] Triant VA. Cardiovascular disease and HIV infection. Curr HIV/AIDS Rep. 2013;10(3):199-206. https://doi.org/10.1007/
s11904-013-0168-6
[9] Friis-Møller N, Reiss P, Sabin CA, Weber R, Monforte AD, El-Sadr W, et al. Class of antiretroviral drugs and the risk of
myocardial infarction. N Engl J Med. 2007;356(17):1723-35. https://doi.org/10.1056/NEJMoa062744
[10] Barbaro G. Cardiovascular manifestations of HIV infection. J R Soc Med. 2001;94(8):384-90.
https://doi. org/10.1177/014107680109400804
[11] Narula N, Zaragoza-Macias E, Nasur A, Khouzam RN, Afonso L. HIV-related cardiovascular disease: role of antiretroviral therapy. Cardiol Rev. 2012;20(4):211-8.
[12] Klein C, Kern R, Etgen T, Brunner F, Ziemann U. Paradoxical cerebral embolism in patients with fat embolism syndrome and right-to-left shunting: a case series. Stroke Res Treat. 2012;2012:697821.
[13] Van Camp G, Franken PR, Melis W, Wouters K, De Sutter J, Clement DL. Diagnosis of patent foramen ovale and
paradoxical embolism: transesophageal versus transthoracic contrast echocardiography. Am Heart J. 1995;129(3):465-71.
| Files | ||
| Issue | Vol 9 No 6 (2024): November-December | |
| Section | Case Report(s) | |
| DOI | https://doi.org/10.18502/crcp.v9i6.18950 | |
| Keywords | ||
| Fat embolism syndrome Cerebral fat embolism People living with HIV/AIDS(PLHA) Antiretroviral therapy | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
