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PubMed2000

[Lipodystrophy and hyperglycemia produced by protease inhibitors].

BACKGROUND: HIV-1 protease inhibitors (PI) have been recently associated with a syndrome of anomalous body fat distribution or lipodystrophy (LD), which sometimes is associated to hyperglycemia. Many aspects of this syndrome remain obscure. The objective of the study is to describe the prevalence, clinical patterns, derangement of glucose metabolism associated and follow-up. METHODS: Patients taking at least one PI during January 1998 were asked a questionnaire about any body change, and a physical exam looking for fat changes was performed. In patients found to have LD, basal plasma glucose, cholesterol, triglycerides and cortisol were studied, and an oral glucose tolerance test (OGTT) was performed. In those cases with breast enlargement, prolactin and estradiol were measured. RESULTS: Among 272 patients, five cases (1.8%) of LD were detected. The syndrome appeared associated with all the IP available at the time of the study, a medium of 4.2 months after the introduction of the drug. The most common pattern was fat accumulation in abdomen and breast, and fat loss in arms, legs and face. Basal glycemia was normal in all 5 patients, but OGTT showed carbohydrate intolerance in two (both of them had family antecedents of type 2 diabetes mellitus). Only one patient need treatment withdrawal because of progressive deforming changes. CONCLUSIONS: The LD can appear in patients taking any IP. Body changes are usually self limited and in many patients PI don't need to be stopped.

Adult↗
PubMed2000

Alteration of tumor necrosis factor-alpha T-cell homeostasis following potent antiretroviral therapy: contribution to the development of human immunodeficiency virus-associated lipodystrophy syndrome.

Highly-active antiretroviral therapy (HAART) has lead to a dramatic decrease in the morbidity of patients infected with the human immunodeficiency virus (HIV). However, metabolic side effects, including lipodystrophy-associated (LD-associated) dyslipidemia, have been reported in patients treated with antiretroviral therapy. This study was designed to determine whether successful HAART was responsible for a dysregulation in the homeostasis of tumor necrosis factor-alpha (TNF-alpha), a cytokine involved in lipid metabolism. Cytokine production was assessed at the single cell level by flow cytometry after a short-term stimulation of peripheral blood T cells from HIV-infected (HIV(+)) patients who were followed during 18 months of HAART. A dramatic polarization to TNF-alpha synthesis of both CD4 and CD8 T cells was observed in all patients. Because it was previously shown that TNF-alpha synthesis by T cells was highly controlled by apoptosis, concomitant synthesis of TNF-alpha and priming for apoptosis were also analyzed. The accumulation of T cells primed for TNF-alpha synthesis is related to their escape from activation-induced apoptosis, partly due to the cosynthesis of interleukin-2 (IL-2) and TNF-alpha. Interestingly, we observed that LD is associated with a more dramatic TNF-alpha dysregulation, and positive correlations were found between the absolute number of TNF-alpha CD8 T-cell precursors and lipid parameters usually altered in LD including cholesterol, triglycerides, and the atherogenic ratio apolipoprotein B (apoB)/apoA1. Observations from the study indicate that HAART dysregulates homeostasis of TNF-alpha synthesis and suggest that this proinflammatory response induced by efficient antiretroviral therapy is a risk factor of LD development in HIV(+) patients.

Acquired Immunodeficiency Syndrome↗
PubMed2000

[Lipodystrophy and metabolic disorders in anti-HIV therapy].

For the effective treatment of HIV infection, combinations of antiretroviral drugs that, at various points of attack, prevent viral replication are used. After the introduction of HIV-1 specific protease inhibitors, various metabolic complications and changes in body habitus manifesting as abnormal fat distribution were observed in HIV patients. These side effects, initially assigned class-specifically to the protease inhibitors, have, however, also been frequently seen under other drug combinations. Changes to body habitus as a result of fat redistribution have mostly been designated as lipodystrophy syndrome, but are now increasingly being recognized as highly heterogeneous abnormalities. Furthermore, the disturbances of glucose and fat metabolism may occur completely independently of phenotypic habitus changes. The result is that both the suspected pathophysiological relationships and the therapeutic consequences are becoming even more complex. This paper summarizes the current state of investigations into the side effects of antiretroviral therapy and their clinical consequences.

Anti-HIV Agents↗
PubMed1999

Scoliosis in a patient with lipodystrophy--treatment difficulties and literature review.

A 12 year-old Chinese schoolgirl presented with left-sided scoliosis at the age of 9 years. She has a rare defect in lipid metabolism, which is not known to be associated with spinal deformity. Her scoliotic curve deteriorated despite bracing. We report a rare occurrence of scoliosis in patient with lipodystrophy and the difficulty of using instrumented fusion in treating this condition.

Adolescent↗
PubMed2001

[Acquired partial lipodystrophy. Insulin resistance, hepatic lipase activity and small and dense LDL particles].

Partial lipodystrophy (PLD) is an infrequent condition characterized by symmetric loss of subcutaneous adipose tissue in the upper or lower part of the body, although occasionally it affects only the extremities. In all cases it appears along with acantosis nigricans (AN), insulin resistance and impairment in the metabolism of lipids and carbohydrates. The case depicted pertains to a 49 year old female with no family history involving loss of adipose tissue in face and upper body. No fat in lower part of body was observed. The patient showed facial thinning at age 8, AN at 11 and gestational diabetes during her fourth pregnancy at 33. At present, the patient presents severe hyperglycemia and hyperinsulinemia with a marked insulin resistance. Type IV hyperlipoproteinemia (OMS), declined C-HDL and Apo A1 and low C-LDL but with a high proportion of small and dense LDL particles were present. Non esterified fatty acids were high. Lipoprotein lipase and hepatic lipase activities are in the lower limit and increased respectively. Fraction C3 of the complement was diminished. No mutations were observed either in codons 170, 809 and 972 of the IRS-1 receptor or in codon 276 of the adrenergic beta 2 gene.

Female↗
PubMed2001

[Metabolic disorders and lipodystrophy. Adverse effects of antiretroviral therapy].

Lipodystrophy resp. lipoatrophy and metabolic disorders under antiretroviral therapy are mainly imputed to protease inhibitors. Nucleoside-analogues are suspected to cause lactatea-cidosis as well. The treatment does not pursue standardized concepts. The lipodystrophic alterations which are not endangering the patient but are often cumbersome for him, can be met by PI-saving therapy in a few cases. Against hyperlipidemia cholesterol-synthesis inhibitors are currently debated. Diabetes-therapy follows the conventional concepts. In case of lactate-acidosis antiretroviral therapy must be discontinued temporarily.

Anti-HIV Agents↗
PubMed2001

Abdominal carcinomas mimicking HIV-associated lipodystrophy.

Two cases of abdominal distention and extremity muscle wasting in HIV-infected men who were receiving HAART are reported. In both instances, clinician and patient alike were concerned about the possibility of HIV-associated lipodystrophy. However, further investigation led to a diagnosis of disseminated cancer in both patients.

Aged↗
PubMed2001

Congenital generalized lipodystrophy in a 4-month-old infant.

Congenital generalized lipodystrophy (CGL, Berardinelli-Seip syndrome) is a rare autosomal recessive disorder with a clinical presentation of paucity of adipose tissue, muscular hypertrophy, organomegaly, and insulin-resistant diabetes. A 4-month-old Taiwanese female infant had hepatosplenomegaly and low body weight gain despite a voracious appetite. Hypermetabolism, hyperhidrosis, loss of subcutaneous fat, muscular hypertrophy, acanthosis nigricans, hypertrichosis, and marked hypertriglyceridemia were also noted. Liver histology revealed fatty change and portal-to-portal bridging fibrosis. Clinical features, serum biochemistry, and liver histology were compatible with the diagnosis of CGL. She was given a special diet characterized by calorie restriction and partial substitution of long-chain triglycerides with medium-chain triglycerides. The serum triglyceride concentration subsequently decreased. This present case suggests that extensive fatty infiltration and subsequent cirrhosis of the liver may be the earliest complication of CGL.

Female↗
PubMed2001

Antiretoviral therapy and the lipodystrophy syndrome, part 2: concepts in aetiopathogenesis.

Clinical research has indicated that the use of nucleoside reverse transcriptase inhibitor (NRTI) and HIV protease inhibitor (PI) therapy is associated with a risk of long-term toxicity syndromes, and that the aetiopathogenesis of these adverse effects is independent of the antiretroviral effects of these drugs. In relation to the lipodystrophy syndrome, it appears that the most powerful determinant of subcutaneous fat wasting is an interaction between these two drug classes. In this review, possible mechanisms underlying the contributions of both PI and NRTI drugs are reviewed, with an emphasis on their effects on adipose tissue. On this basis, an 'adipocentric', or minimal model of the syndrome is developed, in which divergent effects at the adipocyte of NRTIs (mitochondrial toxicity) and PIs (insulin resistance and impaired adipocyte maturation) interact to produce a phenotype that is consistent with clinical observations.

Adipocytes↗
PubMed2001

[Membranous lipodystrophy of the bone].

Membranous lipodystrophy is a rare disease in which cyst-like lesions of fat occur in subcutaneous and other sites including bone marrow, together with sudanophilic leukoencephalopathy. The disease has been reported mostly in Finland and in Japan, with sporadic cases from USA, Belgium, Italy, and France. The cyst-like lesions of limb bones progress in early adult life, usually followed by neurological disorders including convulsions and presenile dementia. Histologically, the fat cells of the bone marrow, synovial membrane, and other sites, are replaced by a convoluted, hyaline, eosinophilic membrane that surrounds a large space. The histochemical and ultrastructural characteristics of the membranes are described. In the brain, atrophy of the subcortical white matter of the frontal and temporal lobes with marked astrocytosis and fibrillary gliosis, and a slight or moderate degeneration of myelin sheaths, are the most prominent changes. Genetic studies of the disease have been reported, revealing an autosomal recessive gene, explaining both its sporadic and familial occurrence, with mutations involving the gene encoding a transmembrane protein, key activating signal transduction element in NK cells (TYROBP). The pathogenesis of membranocystic changes is still unknown: result of a metabolic disorder or circulatory disturbances.

Bone Diseases↗
PubMed2002

[HIV-associated lipodystrophy syndrome. Stress for the psyche and heart].

The HIV-associated lipodystrophy syndrome is a new disease entity and a result of the otherwise successful antiretroviral therapy. It consists of metabolic disorders which may in part lead to an increased cardiovascular risk or hyperlactatemia resulting in increased morbidity and mortality. The change in body shape is often disfiguring and diminishes the quality of life of the affected individual substantially. The present paper reviews the current options and limits to treat the various components of the syndrome.

Adaptation, Psychological↗
PubMed2000

"Switch" studies for people with lipodystrophy.

Many people are considering or have already switched to a regimen without protease inhibitors in hopes of reversing fat redistribution, or lipodystrophy syndrome(s), and/or to lower cholesterol and triglyceride levels that have been associated with using anti-HIV therapy. The studies below suggest that this strategy may be somewhat effective in reducing triglyceride and cholesterol levels. But there is conflicting information on whether it is effective in reversing fat redistribution.

Anti-HIV Agents↗
PubMed2002

Clinical, endocrine and metabolic studies in the kindred of familial partial lipodystrophy--a syndrome of insulin resistance.

OBJECTIVE: To study clinical, endocrine and metabolic profiles in the kindred of subjects with familial partial lipodystrophy (FPLD, Dunnigan type). MATERIAL AND METHODS: Twenty two relatives (10 males, 12 females), from an extended family with FPLD, were assessed for the phenotypic features, impaired glucose tolerance (IGT)/diabetes mellitus (DM), dyslipidemia and the presence of insulin resistance. Plasma glucose and serum lipids were measured using glucose oxidase and standard colorimetric methods. Serum insulin was estimated by radioimmunoassay. RESULTS: The age was 12 to 67 years, two being adolescents. Two of the 20 adults were overweight and eight were underweight; BMI (adults) was 15.5 to 28.5. Features of FPLD were evident among eight out of 12 women. This typical phenotype was not obvious in all 10 male members. Varying degree of Hirsuitism was observed in four of 12 women, acanthosis nigricans in 11 out of 22 members and skin tags were present in only eight of 22; hypertension in six members and diabetes in four. Eleven members had either impaired glucose tolerance (IGT) (n=7), or DM (n=4). Ten of 20 members showed hyperinsulinemic response on oral glucose tolerance test (OGTT). Dyslipidemia was present in 13 family members. CONCLUSION: The majority (2/3rd) of female members showed typical phenotypic features of FPLD, with a clustering of cardiovascular risk factors and insulin resistance syndrome. More than half the men without phenotypic features of FPLD had either IGT/DM, dyslipidemia, hypertension or cardiovascular disease.

Adolescent↗
PubMed2002

[Facial lipodystrophy in patients with HIV infections troublesome to treat].

HIV-infection is now a treatable chronic disease. The lipodystrophy syndrome, which is a common complication of treatment, is characterized by peripheral lipoatrophy, central lipohypertrophy, hyperlipidemia and insulin resistance. The underlying mechanisms are still poorly understood, but the combination of protease inhibitors with nucleoside analogs seems to induce complicated metabolic disturbances. From the patient's point of view, facial atrophy is the most stigmatizing aspect of the syndrome and might badly influence treatment adherence, crucial for long term antiviral efficacy. We propose a topographical classification and grading of facial lipoatrophy, and describe local treatment with injectable hyaluronic acid in gel form. The problem with such injections is their high cost. Since hyaluronic acid injections are not covered by the usual government subsidy for prescription medicines, ways of financing such treatments should be sought.

Adult↗
PubMed2003

Evidence of human immunodeficiency virus-associated lipodystrophy syndrome in children treated with protease inhibitors.

We conducted a prospective evaluation for evidence of the HIV-associated lipodystrophy syndrome of 26 children infected with HIV-1. Six children had evidence of body fat redistribution. Nine children showed laboratory evidence of insulin resistance. All children with body fat distribution or insulin resistance had been treated with protease inhibitors. Children treated with protease inhibitors had higher total cholesterol, higher low density lipoprotein-cholesterol and higher triglycerides than untreated children.

Adolescent↗
PubMedDate not supplied

Peripheral motor-sensory neuropathy in membranous lipodystrophy (Nasu's disease): a case report.

A case of membranous lipodystrophy (ML) with peripheral polyneuropathy (PN) is described. A 40-year-old woman presented with dementia, multiple lytic bone lesions with typical membranous material in adipose tissues and neurophysiological and pathological findings of peripheral neuropathy. We describe the first case of ML with PN. It is interesting since nerve involvement might be an additional cause of symptoms usually attributed to bone lesions.

Adipose Tissue↗
PubMed2003

Increased mitochondrial DNA content in peripheral blood lymphocytes from HIV-infected patients with lipodystrophy.

We have evaluated mitochondrial (mt) DNA content in CD4 and CD8 peripheral blood lymphocytes (PBLs) from HIV-infected patients taking highly active antiretroviral therapy (HAART) who display different types of adipose tissue alterations. A cross-sectional study was performed in a total of 23 patients with lipodystrophy (LD): nine patients with fat accumulation, six patients with fat loss, eight patients with combined form, who were compared to 11 individuals infected by HIV without LD (HIV-positive) and 10 seronegative controls (CTRL). PBLs were obtained by standard methods, that is, gradient density centrifugation on Ficoll, and CD4 or CD8 cells were positively isolated by magnetic sorting to eliminate the contamination of platelets. mtDNA content was then measured by an original assay based upon real-time PCR. mtDNA content was significantly increased in CD4 T cells from patients with LD, while no differences were present between CD4 and CD8 cells from HIV-positive and CTRL individuals. Nor were any differences found when comparing LD or HIV-positive patients treated with stavudine or zidovudine, or taking D-drugs or non D-drugs. Patients with fat accumulation had significantly higher mtDNA content compared to HIV-positive and CTRL, this phenomenon regarding both CD4 and CD8 PBLs. Considering all HIV-positive patients (including LD), mtDNA content showed a significant, positive correlation with cholesterolaemia but not with triglyceridaemia and glycaemia. Relatively high mtDNA content in LD patients, as well as the correlation between mtDNA content and cholesterol in all HIV-positive subjects, suggest the involvement of mitochondria in such a pathology. However, further studies are needed to confirm these initial observations and ascertain whether the quantification of mtDNA in PBL is a useful and reliable marker to investigate and monitor HAART-related changes in fat distribution.

Adipose Tissue↗
PubMed2003

Mitochondrial DNA depletion and respiratory chain enzyme deficiencies are present in peripheral blood mononuclear cells of HIV-infected patients with HAART-related lipodystrophy.

The main objective of the present study was to ascertain if mitochondrial DNA (mtDNA) depletion as reported in HIV-infected patients with highly active antiretroviral therapy (HAART)-related lipodystrophy (LD) implies any degree of mitochondrial respiratory chain (MRC) dysfunction. For this purpose, we evaluated HIV patients on different HAART schedules with LD (group A; n=12) and on HAART but without LD (group B; n=12), and untreated HIV-infected patients as controls (group C; n=24). mtDNA content was determined on peripheral blood mononuclear cells (PBMCs) with a real-time PCR method. Complex II, III and IV activities of the MRC were simultaneously measured spectrophotometrically, as were spontaneous and stimulated oxygen consumption by PBMCs. Compared to controls (group C, 100%), patients with LD (group A) showed a decreased mtDNA content (54%, P<0.001), which was associated with a decline in complex III (62%, P<0.05) and IV activity (69%, P<0.05) (both complexes partially encoded by mtDNA), but not in complex II activity (exclusively encoded by nuclear DNA). Patients in group B showed a similar pattern of mitochondrial dysfunction but to a lesser extent and without statistical significance. Respiratory activities in both treated groups (A and B) did not differ in comparison with controls. We conclude that mtDNA depletion occurring during HAART is associated with deficiencies in MRC complexes partially encoded by mtDNA, which are detectable by PBMCs. Presented in 'Late Breakers and Hot Topics' session at 6th International Congress on Drug Therapy in HIV Infection, Glasgow, UK, 17-21 November 2002.

Adult↗