Toxoplasmosis presenting as panhypopituitarism in a patient with the acquired immune deficiency syndrome

Lymphocytic hypophysitis in dogs infected with Leishmania spp

Background

Morphological involvement of endocrine glands, such as the pituitary gland, remain uninvestigated in dogs with canine visceral leishmaniasis. Therefore, this study investigated the presence of amastigotes of Leishmania spp. and characterized inflammatory changes, highlighting the involvement of TCD3+ lymphocytes in different regions of the pituitary gland of dogs.

Methods

Samples were collected from 21 naturally infected dogs and 5 control, uninfected dogs. The different pituitary regions were analyzed in histological sections stained with hematoxylin and eosin (HE) under light microscopy. Inflammation was classified by intensity in a score from 0 to 3, absent (0), mild (1), moderate (2), and marked (3). The immunohistochemical (IHC) evaluation was performed in five high-power fields (hot spot) in a 40x objective of each region with manual counting (Image J1.52ª) of the TCD3+ lymphocytes and for amastigotes analyzed in 40x and 100x objectives. The Shapiro-Wilk test was used to assess the normality of the data. Differences between groups were determined by the Mann Whitney test. The correlation between variables was assessed by Sperman's correlation test. p < 0.05 were considered statistically significant.

Results

Amastigotes from the pituitary glands of two infected dogs were identified using IHC. The histopathological evaluation stained with hematoxylin and eosin showed greater intensity of inflammation in the pars distalis and pars intermedia regions of infected dogs. IHC for TCD3+ lymphocytes showed a higher median number of immunolabeled cells in pars nervosa in the infected group than in the control group (p < 0.05); and expecting a variation in the distribution and number of these cells in naturally infected dogs, the median of the control group was considered a cut-off point, an increase in T lymphocytes (p < 0.05) was also observed in the pars intermedia and pars distalis of an infected subgroup (n = 10). A moderate significant correlation between the intensity of inflammation and the number of immunolabeled TCD3+ lymphocytes was established in the analyzed pituitary regions, characterizing the occurrence of hypophysitis.

Conclusion

These findings presuppose that inflammation and/or the parasite in the pituitary region can result in gland dysfunction, worsening the clinical condition of the patient and compromising the efficiency of treatment and prognosis.

Pituitary abscess: a case report and systematic review of 488 cases

BACKGROUND

Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality.

AIM

To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA.

METHODS

We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted.

RESULTS

We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95% CI 1.0001-1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95% CI 2.80-17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%).

CONCLUSION

PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.

Panhypopituitarism In HIV Patient Receiving Antiretroviral Therapy

The article is dedicated to a clinical case of the panhypopituitarism development in a patient with HIV infection receiving antiretroviral therapy. The number of HIV-infected patients worldwide has increased significantly over the past decades. The introduction of highly active antiretroviral therapy into practice has significantly improved the prognosis for these patients. At the same time, the use of this therapy type is associated with a number of complications – in particular, with the development of the immune restoration syndrome. In addition, cases of endocrine dysfunction are described in many publications. Timely diagnosis and treatment of endocrine disorders would help avoiding complications caused by excess or deficiency of hormones.

Sellar Toxoplasmosis and Nonfunctioning Pituitary Adenoma

BACKGROUND

Sellar toxoplasmosis is associated with congenital infections or immunodeficiency. The finding of Toxoplasma bradycysts in a pituitary adenoma is very unusual.

CASE DESCRIPTION

An otherwise healthy 27-year-old woman presented with secondary amenorrhea and moderately elevated prolactin levels. A macroprolactinoma was suspected on magnetic resonance imaging, and cabergoline was initiated. Although dopamine levels decreased, the tumor did not show significant shrinkage; after 2 years, transsphenoidal resection was indicated to clarify the diagnosis and to cure hyperprolactinemia. Histology showed an inactive pituitary adenoma and Toxoplasma bradycysts. Seropositivity for Toxoplasma gondii, but neither immunodeficiency nor intracerebral spread, was found. During a postoperative follow-up period of 15 months, the patient did not show any recurrence.

CONCLUSIONS

Sellar toxoplasmosis in conjunction with pituitary adenoma is extremely rare. Nonfunctioning lesions should be suspected in cases of sellar masses and moderate hyperprolactinemia.

Multisystemic toxoplasmosis associated with a type II-like Toxoplasma gondii strain in a New Zealand fur seal (Arctocephalus forsteri) from New South Wales, Australia

We report the first confirmed case of toxoplasmosis in an Australian pinniped. Presence of Toxoplasma gondii DNA was detected in the brain of a free-ranging subadult New Zealand fur seal (Arctocephalus forsteri) with nonsuppurative meningoencephalitis, hypophysitis, posterior uveitis, retrobulbar cellulitis, and myocarditis associated with protozoan cysts and tachyzoites. The emaciated seal stranded moribund on a beach in northern Sydney in New South Wales. Histopathology coupled with specific immunohistochemistry and PCR assays confirmed the presence of T. gondii. The T. gondii sample (NZfs8825) identified in this study has an identical genotype as the type II (ToxoDB PCR-RFLP genotype #1) based on the direct sequencing and virtual RFLP of multilocus DNA markers including SAG1, 5'- and 3'-SAG2, alt.SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1, and Apico. Direct sequencing of T. gondii B1 DNA marker from the T. gondii sample (NZfs8825) identified a type II-like strain, based on presence of non-archetypal B1 gene polymorphisms previously reported as unique to Australia. This study suggests that T. gondii oocysts originating from mainland Australia, which has a large population of feral cats, may act as a disease threat to native marine fauna. Therefore, emerging toxoplasmosis in the Arctic has a relevant parallel in the Southern Ocean within Australian waters with yet unknown relevance to Antarctica.

Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections

Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.

Neurosyphilis manifesting with unilateral visual loss and hyponatremia: a case report

Background

Syphilis is called the chameleon of the diseases due to its variety of its clinical presentations, potentially affecting every organ of the body. Incidence of this ancient disease is once again on the increase worldwide.

Case presentation

We here report an unusual case of neurosyphilis manifesting with unilateral visual loss and hyponatremia. The patient also had primary syphilitic lesions and was concomitantly diagnosed with Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection. Treatment with ceftriaxone and prednisolone, completely resolved the hyponatremia and visual acuity was partially restored.

Conclusion

Awareness of syphilis as a differential diagnosis is important as previously unreported presentations of neurosyphilis can arise, especially in HIV infected patients.

Solitary hypothalamopituitary toxoplasmosis abscess in a patient with AIDS

Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite, Toxoplasma gondii. It is the most common cause of focal brain lesions in patients with AIDS. The imaging features and endocrine disorders of CNS toxoplasmosis in patients with AIDS are reviewed.

Toxoplasma gondii: reproductive parameters in experimentally infected male rats

Toxoplasma gondii is a protozoan parasite that is globally widespread and infects man and animals. With the aim of studying the influence of toxoplasmosis on male reproductive parameters, we investigated sperm motility, concentration and morphology of male rats experimentally infected by T. gondii. The GT F1 strain of T. gondii tissue cysts were fed at a dose of 5 x 10(3) tissue cysts per rat by oral gavage in an experimental group of 42 healthy adult male Wistar rats, while 42 male rats were used as controls. On days 10, 20, 30, 40, 50 and 60 post-inoculation (p.i.) 7 rats from each group were anesthetized. The body weight of each animal was recorded, then epididymis and testes were immediately removed, weighed and semen evaluation was undertaken. Weight of the right epididymis was significantly decreased on day 30 p.i., sperm motility was significantly decreased on days 10, 20, 30, 40, 50 and 60 p.i. and sperm concentration was significantly decreased on days 10, 30, 40 and 60 p.i. A marked increase of sperm abnormalities was noticed on days 30 and 40 p.i. No pathological lesions were detected either in the pituitary gland or the testes. In this study it was found that toxoplasmosis can affect main reproductive parameters in male rats, which are the most predictive of their fertilizing capacity.

Imaging of sellar and parasellar lesions

The sellar and parasellar region is an anatomically complex area where a number of neoplastic, infectious, inflammatory, developmental and vascular pathologies can occur. Differentiation among various etiologies may not always be easy, since many of these lesions may mimic the clinical, endocrinologic and radiologic presentations of pituitary adenomas. The diagnosis of sellar lesions involves a multidisciplinary effort, and detailed endocrinologic, ophthalmologic and neurologic testing are essential. CT and, mainly, MRI are the imaging modalities to study and characterise normal anatomy and the majority of pathologic processes in this region. We here provide an overview of the most relevant MRI and CT characteristics together with clinical findings of pituitary tumors, vascular, inflammatory and infectious lesions found in the sellar/parasellar region in order to propose an appropriate differential diagnosis.

A review of hypogonadism and erectile dysfunction among HIV-infected men during the pre- and post-HAART eras: diagnosis, pathogenesis, and management

Hypogonadism and erectile dysfunction (ED) appear to be more common among men infected with HIV compared to age-matched men within the general U.S. population. HIV providers should consider these conditions and utilize standardized evaluation and diagnostic criteria. Treatment of both hypogonadism and ED increases sexual function and quality of life; testosterone supplementation in the setting of hypogonadism may also improve lean body mass, mental status, and anemia. We review the epidemiology, diagnosis, pathogenesis, and treatment options of both hypogonadism and ED among HIV-infected men.

MRI in the differential diagnosis of a sellar mass

Whilst pituitary adenomas are the commonest cause of a sellar mass, there are a number of other neoplastic, infectious, inflammatory, developmental and vascular aetiologies that should be considered by the radiologist. We discuss and illustrate these lesions and indicate the various magnetic resonance imaging features that are helpful in formulating an appropriate differential diagnosis.

Two case reports of pituitary adenoma associated with Toxoplasma gondii infection

The involvement of the pituitary in cases of toxoplasmosis has been described in the literature only rarely. This is the first report to describe pituitary adenoma in association with Toxoplasma gondii infection. The two patients were 43 and 19 year old women. Radiological examination revealed tumours in the sellar region. Microscopically, the tumours consisted of small homogeneous polygonal or round cells. Toxoplasma cysts were found among the tumour cells, a finding confirmed by Toxoplasma gondii specific antibody immunohistochemistry. The association between pituitary adenoma and toxoplasma raises the possibility that T gondii might be involved in the development of certain cases of pituitary adenoma.

Human immunodeficiency virus infection and the thyroid

Abnormalities of thyroid function are associated with a number of systemic conditions, including patients infected with human immunodeficiency virus (HIV). Most patients with early HIV infection and a stable body weight have normal thyroid function. Subtle abnormalities of a number of thyroid function tests have been reported during the early asymptomatic phase of HIV disease. These include an inappropriately normal triiodothyronine (T(3)) and reduced reverse triiodothyronine (rT(3)), and increased thyroxine-binding globulin (TBG) levels. Opportunistic infections involving the thyroid gland, neoplasms such as lymphoma and Kaposi's sarcoma, and medications can alter the thyroid function in individuals with more advanced HIV infection. If thyroid dysfunction is diagnosed in an HIV-infected patient, it should be treated in the usual manner. However, high index of suspicion and caution in the interpretation of thyroid function tests in patients with HIV disease are needed for optimal diagnosis and treatment.

Neuroendocrine abnormalities associated with HIV infection

Functional derangement of every endocrine organ system has been reported in association with HIV infection. The changes in endocrine function may be related to the viral infection of the gland, to systemic effects of HIV or an opportunistic infection, to infiltration by a neoplasm such as Kaposi's sarcoma, to a complication of treatment, or generation of cytokines. A wide spectrum of endocrine abnormalities is observed in HIV-infected patients. Some of these abnormalities are similar to those seen in other systemic illness, whereas others are unique to HIV infection. The clinical significance of many of these endocrine abnormalities is not well understood.

Endocrine and Metabolic Manifestations of HIV Infection and AIDS

Since the first descriptions of acquired immune deficiency syndrome (AIDS) and human immunodeficiency virus (HIV), a great deal of knowledge has been accumulated on how these entities interact with the endocrine system. Recently new information has been received on autoimmune dysregulation causing thyroid abnormalities after highly active antiretroviral therapy (HAART), as well as metabolic dysregulation occurring in the setting of protease inhibitors. We review the pathophysiologic abnormalities of the endocrine systems due to HIV infection as well as the endocrine effects of drugs commonly used in HIV management. The spectrum of endocrine dysfunction associated with HIV is growing and the intensive care physician must be aware of these potentially reversible abnormalities.

Hyperinsulinemic hypoglycemia associated with possible hypopituitarism in a patient with acquired immunodeficiency syndrome

OBJECTIVE

To describe endocrine dysfunctions associated with human immunodeficiency virus (HIV) infection.

METHODS

We present a case report, discuss the laboratory findings, and suggest potential contributing factors in this complex milieu.

RESULTS

A 44-year-old man infected with HIV was admitted with loss of consciousness after a grand mal seizure and was found to have a prolonged course of hypoglycemia in conjunction with increased serum levels of insulin and C peptide. Iatrogenic hypoglycemia was excluded by laboratory evaluations. Hypothalamic-pituitary dysfunction was suspected because the serum growth hormone and cortisol concentrations during hypoglycemia were low. Radiologic evaluation of the brain revealed no structural abnormalities involving the hypothalamic-pituitary area. A normal cortisol response to adrenocorticotropic hormone stimulation (cosyntropin, 250 mg) was documented on two occasions. The cause of the severe hypoglycemic episode and the possible hypothalamic-pituitary-adrenal axis dysfunction in this patient is unknown.

CONCLUSION

Despite the complexity of endocrine disorders in HIV-infected patients, the course of the disease in this patient underscores the possibility that some of the endocrinologic changes may be reversible.

Post-traumatic selective hypogonadotropic hypogonadism

A very small proportion of hypopituitarism is due to head trauma, which may have occurred from days to years earlier. In the literature we found only three cases (two males, one female) of post-traumatic hypopituitarism in whom the hormone deficiency was claimed to be restricted to the gonadotrophs and considered to be permanent after a period of follow-up ranging from less than one year to four years. Here we describe a 26 yr-old male patient who, eight years after a motorcycle accident, was evaluated for hypogonadism and followed-up for three years. Serum testosterone, basal and GnRH-stimulated FSH and LH remained undetectable over the first 22 months of follow-up. Then, basal and GnRH-stimulated gonadotropins moved progressively into the normal range. Basal and dynamic evaluation of the other anterior pituitary hormones was persistently normal. At the 15th month of follow-up there was a change in the pituitary CT scan, presumably due to pituitary revascularization. Therefore, our patient disproves that post-traumatic isolated gonadotropin deficiency is irreversible.

Growth hormone secretion in HIV-positive versus HIV-negative hemophilic males with abnormal growth and pubertal development. The Hemophilia Growth and Development Study

Growth and pubertal development in hemophilic males, age 6-19 years at baseline, were evaluated over a 3.5-year period in 207 HIV-positive and 126 HIV-negative subjects as part of the Hemophilia Growth and Development Study.

METHODS

Thyroid function, insulin-like growth factor I (IGF-1) levels, bone age, cranial magnetic resonance image normality, CD4+ counts, and serum testosterone levels of study participants were measured at baseline. An extensive endocrine evaluation was performed in subjects who demonstrated declines in height for age (measurement <5th percentile with two pervious heights >10th percentile), who had not achieved Tanner stage 4 level of pubertal development by age 15 years or who had abnormal growth velocity, which included assessment of peak stimulated growth hormone response after clonidine stimulation, 12-hour growth hormone profiles, and serum beta carotene levels (triggered protocol).

RESULTS

For almost the entire group (-99%), thyroid function tests were normal for age. IGF-1 levels were normal for 93% of the cohort. A total of 120 subjects, 89 HIV-positive and 31 HIV-negative, had an abnormality of growth, pubertal development, or both; 34 (11.1%) HIV-positive and 4 (3.6%) HIV-negative subjects had declines in height (p = .001), 20 (23.3%) HIV-positive and 5 (15.8%) HIV-negative subjects had not achieved Tanner stage 4 by 15 years of age (p = .372) and 59 (43.4%) HIV-positive and 23 (25.6) HIV-negative subjects had abnormal growth velocity (p < 0.001). Among subjects with abnormal height or growth velocity, the HIV-positive group had significantly lower mean age-adjusted testosterone levels than did the HIV-negative group (p = .030). Within the HIV-positive group, older subjects with abnormal height or growth velocity had significantly lower mean bone age than subjects of similar age without growth abnormalities (p = .0092). Extensive testing was done in 39 patients (32 HIV-positive, 7 HIV-negative). Half of the HIV-positive subjects had mean 12-hour growth hormone levels <3 ng/ml, 47% had peak stimulated levels <10 ng/ml, 28% had peak spontaneous values <10 ng/ml, and 38% had low levels of IGF-1. In the HIV-positive cohort, there was no difference in the rate of abnormalities of growth hormone secretion between those with CD4+ counts > or = or <200 cells/mm3 and between those subjects that met the 1987 Centers for Disease Control (CDC) surveillance definition of AIDS. In the subset of HIV-positive patients with abnormal peak growth hormone levels after clonidine stimulation, growth hormone response correlated positively with CD4+ count (r = .657, p = .0056) and beta carotene concentration (R = .596, p = .0192).

CONCLUSIONS

The results of this longitudinal study suggest that abnormalities of growth and pubertal development, particularly an abnormal growth velocity, are common in HIV-infected hemophilic boys and adolescents. These abnormalities might serve as indicators of the presence of HIV infection in this at-risk population. Since thyroid function tests and IGF-1 levels were normal, the etiology of growth impairment in HIV infection does not appear to be secondary to inadequate caloric intake or acquisition, or severe illness such as that caused by recurrent or persistent infection. Rather, HIV infection appears to lead to diminished growth hormone production or release and decreased androgen secretion, even before the development of AIDS and immunocompromise. These results provide a rationale for trials of treatment with growth hormone or androgens in patients with abnormalities of endocrine function.

Endocrinologic complications of HIV infection

A variety of endocrine disorders occur in HIV-infected patients. The abnormalities may be a consequence of HIV infection, or may result from opportunistic infections, associated malignancies, illness-associated cytokine production, or use of therapeutic agents. Observations and controversies concerning adrenal, gonadal, thyroidal, and metabolic abnormalities are discussed. Heightened awareness of problems that might otherwise be overlooked will permit timely diagnosis and treatment of identified problems, which will enhance and potentially prolong the lives of people infected with HIV.

Endocrine implications of human immunodeficiency virus infection

Endocrine abnormalities occur frequently in HIV-infected patients. Although the majority of endocrine disorders reflect chronic infection, stress, and malnutrition, some disorders are characteristic of HIV infection or AIDS and deserve particular clinical attention. Identification of HIV patients at risk of frank endocrine disorders, rapid and correct diagnosis, and appropriate management are essential steps to minimize morbidity and mortality. Finally, increasing evidence from in vitro studies suggests that various hormones may influence HIV replication as well as the course of HIV disease and associated disorders. Future studies on the molecular mechanisms of hormones on HIV action and clinical studies on the effects of hormones as adjunctives to established forms of therapy may stimulate development of novel therapeutic strategies that will benefit HIV-infected patients.

Clinical features of adrenal insufficiency in patients with acquired immunodeficiency syndrome

OBJECTIVE

Adrenal insufficiency (AI) is a well known complication of AIDS. However, the clinical and biochemical features of AI in HIV infected patients have not been extensively studied.

DESIGN

A retrospective clinical study.

PATIENTS

We reviewed clinical records of 74 AIDS patients with clinical and/or biochemical indications of AI who underwent Synacthen testing in order to determine adrenocortical function during a 5-year period.

MEASUREMENTS

AI was diagnosed when cortisol levels failed to rise above 496 nmol/l at any time during the test. Cortisol was measured by RIA.

RESULTS

Sixteen patients (22%) were diagnosed with AI. Most were young males and all of them had a known risk factor, principally i.v. drug users. The main complaint was fatigue. Hyponatraemia or hyperkalaemia were uncommon. All of them were severely immunosuppressed, with AIDS-defining conditions from at least 6 months before the diagnosis of AI, and had been diagnosed with at least one disease that has been reported to produce AI in AIDS patients. Survival was poor. Thirteen of these patients (81%) died within 6 months. Basal cortisol levels were lower than 275 nmol/l in 75% of patients with AI but in only 2% of the group of 58 patients who had normal adrenal responses to Synacthen.

CONCLUSIONS

Adrenal insufficiency features in AIDS patients with advanced disease, without specific findings and with a history of previous opportunistic diseases. Basal cortisol values at 0830 h lower than 275 nmol/l are highly suggestive of adrenal insufficiency in patients with AIDS.

A unique thyroid hormone response element in the human immunodeficiency virus type 1 long terminal repeat that overlaps the Sp1 binding sites

Long terminal repeat (LTR) of human immunodeficiency virus (HIV) type 1 is activated by thyroid hormone (T3) receptor alpha (T3R alpha) in the absence of ligand. Addition of T3 reverses this effect. This activity is mediated by a high affinity T3 response element (T3RE) within the HIV-1 LTR, termed the HIV-T3RE (bases -74 to -50), which coincides with the Sp1 element as demonstrated by mobility shift, DNaseI footprinting, and methylation interference analyses. HIV-T3RE mediates ligand-independent activation of transcription by T3R alpha when linked to a heterologous promoter. In addition, the viral transactivator Tat synergizes with T3R alpha to activate the HIV-1 LTR in the absence of T3, which is relieved in its presence. These findings have implications for the possible control of HIV-1 LTR activity by T3.

Testicular dysfunction in human immunodeficiency virus-infected men

This review pertains to gonadal function in men with human immunodeficiency virus (HIV) infection, who often exhibit clinical and biochemical evidence of hypogonadism. Hypogonadotropic hypogonadism appears to be the most commonly encountered abnormality, although complete anterior pituitary insufficiency and primary gonadal failure have been reported. Levels of sex hormone-binding globulin (SHBG) are either unchanged or increased. Plasma levels of estrogens, progesterone, androstenedione, dehydroepiandrosterone sulfate (DHEA-S), and prolactin vary. Pathologically, except for involvement by opportunistic infections, no significant abnormality in the hypothalamic-pituitary area has been described, but evidence of orchitis is commonly present. The cause(s) of these abnormalities remains unclear. The possible factors leading to hypogonadism in HIV-infected men include HIV infection itself, opportunistic infections, chronic debilitating illness, and effects of cytokines on the hypothalamic-pituitary-gonadal axis. Further studies are needed to clarify the cause(s) of testicular dysfunction in HIV-infected men and its clinical significance, treatment, relevance to the progression of HIV infection, and influence on the immune system.

Aetiology and pathogenesis of hormonal and metabolic disorders in HIV infection

Many hormonal and metabolic disturbances are documented in HIV infection, the most important of which is the wasting syndrome associated with progressive HIV infection. We are only now beginning to understand the pathogenesis of these disturbances. In rare cases, infiltration of endocrine tissue by secondary infectious or malignant processes is the underlying cause of hormonal insufficiency. In most instances, however, hypofunction is secondary to the well-known effects of severe illness. Similarly, hyperfunction of the adrenal axis along with many of the derangements in substrate metabolism are also likely to be secondary to severe illness, perhaps through activation of cytokines and other molecules. Specific disturbances in asymptomatic patients are more difficult to document and may represent unique and as yet unexplained manifestations of HIV disease. Hypermetabolism and depletion of lean body mass are most profound in the acutely ill patient with active secondary infection. At this stage, the HIV-infected patient is in a catabolic state and adaptive mechanisms which normally decrease energy expenditure and preserve lean body mass are either overridden or not operative. Strategies to reverse the catabolic state and diminish wasting are only now being developed.

Thyroid dysfunction in HIV infection

During infection with HIV, overt clinical or biochemical thyroid dysfunctions are rare. When present, thyroid failure generally results from the destruction of the thyroid gland by opportunistic infections such as Pneumocystis carinii, or tumoural processes such as KS. Less frequently, hypothalamic-pituitary failure due to central nervous system infections is involved. Some cases of thyroiditis with thyrotoxicosis or hypothyroidism due to Pneumocystis carinii have also been reported. Subtle alterations of thyroid function tests are more common in HIV infection and are sometimes already detectable in the early phase of the disease. Contrary to what is observed in severe non-thyroidal illnesses, the low T3 syndrome and the sick euthyroid syndrome are less marked; these changes are mainly present in the final stage of the disease, when anorexia and weight loss occur, and indicate a poor outcome. Unique abnormalities of thyroid function indices have also been recently documented. A progressive elevation in serum TBG--but not in other binding proteins such as CBG and SHBG--accompanying the decline of the CD4 lymphocyte count, and associated with a concomitant increase in the serum T4 value, has been reported. An unusual prolonged maintenance of normal T3 levels with a paradoxical decrease in serum rT3 values has also been recognized. Finally, a hypothyroid-like regulation of the pituitary-thyroid axis, possibly directed to limit hypermetabolism in HIV infection, has been observed. The recognition of these particular thyroid profiles is of clinical importance as serum TBG appears to be a specific marker of the progression of HIV infection and serum T3 a reliable prognostic indicator for AIDS.

Hypothalamic and pituitary function in AIDS

Clinically relevant HP dysfunction occurs infrequently in the course of HIV infection and AIDS, and is usually due to destruction or infiltration of the region by opportunistic infections. However, more subtle defects occur with much greater frequency. Since these impairments, especially in the gonadotrophic and corticotrophic axes, are observed in HIV patients before the development of ARC or AIDS, direct involvement of the hypothalamus or pituitary by the neurotropic HIV virus or by other HIV-mediated factors is possible. Further investigation of hypothalamic and pituitary hormones by provocative means, in addition to assessment of the pulsatile secretion of these hormones, at all stages of HIV infection will be needed to clarify the role of the virus in these individuals.

Impaired parathyroid hormone release in human immunodeficiency virus infection

Patients with human immunodeficiency virus type 1 (HIV-1) seropositivity exhibited significantly lower intact serum parathyroid hormone (PTH) values (mean, 13.6 ng/liter; n = 44) than healthy controls (mean, 38.1 ng/liter; p < 0.001; n = 50). The reduction was greater among patients with no or mild immunodeficiency (> 400 x 10(6) CD4+ lymphocytes/ml blood; n = 22) than in those with severe immunodeficiency (< 200 x 10(6) CD4+ lymphocytes/ml blood; n 22; p = 0.03), although total serum calcium was normal in all groups. Patients with severe immunodeficiency demonstrated an inverse correlation between total serum calcium and serum PTH (r2 = 0.367; p < 0.01), which was also present in healthy controls (r2 = 0.482; p < 0.001), but not among the seropositive patients with no or mild immunodeficiency (r2 = 0.017; p = 0.58). Parathyroid cells express a protein recognized by antibodies directed against CD4, the HIV-1 receptor. This implies that these cells may be directly infected with HIV-1 and also interact with circulating autoantibodies against CD4, thus resulting in impaired PTH release.

Thyroid hypofunction related with the progression of human immunodeficiency virus infection

Thyroid function was evaluated in 119 human immunodeficiency virus (HIV) infected patients at different stages of infection, compared with euthyroid normal subjects and hepatitis C virus infected blood donors as control groups. The low T3 state, well documented in severe nonthyroidal illnesses, was not found in these HIV infected patients. They showed lower FT4 levels and higher TSH and TBG values than euthyroid normal controls. These findings suggested a thyroid hypofunction becoming more evident with the progression of the infection as also supported by the presence of antithyroid autoantibodies mainly found in the symptomatic stages of the infection.

Acral hyperpigmented macules and longitudinal melanonychia in AIDS patients

Two patients with AIDS are described who developed acral hyperpigmented macules of the fingers, palms and soles, buccal mucosa and genitalia, associated with longitudinal melanonychia. These pigmentary changes seemed to be independent of zidovudine and were associated in one with diffuse melanoderma and elevated levels of alpha-MSH. Histological and ultrastructural studies showed an increase of the dendrites and pigmentation of the melanocytes and few melanosomes in the keratinocytes.

Endocrine manifestations of human immunodeficiency virus (HIV) infection

Endocrine manifestations of HIV infection include both pathological changes and disturbances in function. Mechanisms include direct infection of glands by HIV or opportunistic organisms, infiltration by neoplasms, side effects of drugs, and production of humoral factors that may alter metabolism. The adrenal gland is most often affected, but virtually every endocrine system may be involved. Dysfunction is often subtle, with symptoms overlapping those of the HIV infection itself. Endocrine manifestations may be found at any time in the course of the disease, from the asymptomatic HIV-positive stage through full-blown AIDS. Optimal management of these patients may include a careful search for, and appropriate treatment of, associated endocrine abnormalities.

Biochemical thyroid profile in patients infected with the human immunodeficiency virus

Over a 2-year period, thyroid function was studied in 102 patients infected with the human immunodeficiency virus (HIV) and in 102 age- and sex-matched controls with various infectious diseases. Biochemical abnormalities were observed in 1-20% of the patients, depending on thyroid indices, but thyroid disease (hypothyroidism) was diagnosed in only 1. Compared to controls, patients, especially those with the acquired immunodeficiency syndrome (AIDS), had a significant increase in serum thyroxine-binding globulin, a lower T3 and free thyroxine index, and a higher frequency of thyroglobulin antibodies.

Pathology of the pituitary gland in patients with the acquired immune deficiency syndrome (AIDS)

The pituitary gland was examined at autopsy in 88 patients who died with acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC). Pathologic findings included focal to widespread necrosis and/or fibrosis of the anterior pituitary gland in 10 cases, evidence of cytomegalovirus infection without an apparent inflammatory component in the anterior pituitary in 3 cases, and microglial nodules in the pars nervosa in 5 cases. In one instance, a multinucleated giant cell identical to those associated with direct human immunodeficiency virus infection of brain was identified in the pars nervosa. One patient showed focal anterior pituitary infection by Cryptococcus neoformans in the context of widespread and severe cryptococcosis. These findings are discussed in relation to the possible clinical manifestations and the neuropathologic and systemic pathologic findings in AIDS patients.

Toxoplasmosis and the acquired immune deficiency syndrome

The literature on toxoplasmosis in the acquired immune deficiency syndrome is reviewed with reference to more than 140 cases from various centres. The incidence, pathogenesis, clinical features, diagnosis, treatment and prognosis are considered.

Endocrine disorders in men infected with human immunodeficiency virus

Gonadal, adrenal, and thyroid functions were evaluated in 70 men seropositive for human immunodeficiency virus (HIV) infection, clinically categorized as asymptomatic (n = 19), AIDS-related complex (ARC) (n = 9), or acquired immunodeficiency syndrome (AIDS) (n = 42). Twenty of 40 men (50 percent) with AIDS were hypogonadal. Mean serum testosterone concentrations in both ARC (292 +/- 70 ng/dl) and AIDS (401 +/- 30 ng/dl) men were significantly less than in asymptomatic (567 +/- 49 ng/dl) or normal men (608 +/- 121 ng/dl). Of these hypogonadal men, 18 of 24 (75 percent) had hypogonadotropic hypogonadism. Seven of eight hypogonadal men (88 percent) had a normal gonadotropin response to gonadotropin-releasing hormone administration. Hypogonadism correlated with lymphocyte depletion and weight loss. Adrenal cortisol reserve, evaluated by adrenocorticotropin stimulation, was normal in 36 of 39 patients (92 percent) with AIDS. Indices of thyroid function were normal with the exception of one ARC man with a low free thyroxine index. In conclusion, hypogonadism is common in men with HIV infection and may be the first or most sensitive endocrine abnormality.

Clindamycin in a murine model of toxoplasmic encephalitis

We investigated the efficacy of clindamycin in a murine model of toxoplasmic encephalitis using direct intracerebral inoculation. Clindamycin reduced mortality from 40% in normal mice and 100% in cortisone-treated mice to 0% in both groups. Although we were unable to document appreciable levels of clindamycin in the brains of infected mice, the histological features of cerebral infection were markedly altered. The formation of large numbers of cysts and the intense inflammatory response seen in the brains of normal mice and the unchecked infection and tissue necrosis in the brains of cortisone-treated mice were absent in the brains of clindamycin-treated mice. Enumeration of cysts in the brains of mice 10 weeks after infection revealed a significantly lower number in the clindamycin-treated mice. Spread of infection to other organs was also decreased during clindamycin administration. These observations suggest that clindamycin may have a role in the therapy of toxoplasmic encephalitis.

Management of infectious complications in acquired immunodeficiency syndrome

Infectious complications are the most common cause of death in patients with acquired immunodeficiency syndrome (AIDS). Opportunistic infections associated with defects in both T and B lymphocyte function have been observed. Invasive infections, including those secondary to procedures both in and out of the hospital, must also be considered. Reliance on serologic antibody tests is ill-advised since antibody response is often not effective. Since simultaneous infections frequently develop in patients with AIDS, attempts to identify pathogens by culture and histopathology should be aggressive and thorough. With rapid diagnosis and therapy, many of the infections will respond. Prolonged treatment is indicated as recrudescence is common.