[Cannabis use and untreated HIV-infection: unknown risk factors for premature peripheral artery disease]

A 32-year-old woman presented with a painful leg and a gangrenous big toe. Her medical history included HIV-infection that had remained untreated for 8 years. In addition, she had smoked about 10 cannabis-cigarettes daily during the previous 15 years. Physical examination and angiography confirmed the presence of severe peripheral artery disease in the left lower leg. She received a femorodistal bypass graft but the gangrene was progressive, ultimately necessitating a lower leg amputation. Histopathological examination revealed intimal fibrosis and thrombosis with recanalisation in combination with fragmentation of the internal elastic membrane. Peripheral artery disease is often associated with lower extremity ischaemia, mostly affecting elderly patients and almost always caused by atherosclerosis. When ischaemic symptoms manifest themselves in young individuals (<40 years), rare causes of obliterative arterial disease, such as inflammation or post-traumatic vascular injury, must be excluded. Use of cannabis and untreated HIV infection are both relatively unknown risk factors for the onset of premature non-atherosclerotic arterial disease. Stopping the smoking of cannabis appears to have a favourable effect on the ischaemic symptoms. Whether treatment of HIV-infection can affect the course of premature peripheral vascular disease is unknown. When deciding whether or not to give antiviral therapy, care providers should also consider the increased cardiovascular mortality rates associated with these treatment regimens. In the case described, the HIV-infection was considered the most likely cause of the peripheral artery disease, based on all the histopathological findings.