Testicular atrophy in AIDS: a study of 57 autopsy cases

Tale of Viruses in Male Infertility

Male infertility is a condition where the males either become sterile or critically infertile. The World Health Organisation assessed that approximately 9% of the couple have fertility issues where the contribution of the male partner was estimated to be 50%. There are several factors that can amalgamate to give rise to male infertility. Among them are lifestyle factors, genetic factors and as well as several environmental factors. The causes of male infertility may be acquired, congenital or sometimes idiopathic. All these factors adversely affect the spermatogenesis process as well as they impart serious threats to male genital organs thus resulting in infertility. Viruses are submicroscopic pathogenic agents that rely on host for their replication and survival. They enter the host cell, hijack the host cell machinery to aid their own replication and exit the cell for a new round of infection. With the growing abundance of different types of viruses and the havoc they have stirred in the form of pandemics, it is very essential to decipher their route of entry inside the human body and understand their diverse functional roles in order to combat them. In this chapter, we will review how viruses invade the male genital system thus in turn leading to detrimental consequence on male fertility. We will discuss the tropism of various viruses in the male genital organs and explore their sexual transmissibility. This chapter will summarise the functional and mechanistic approaches employed by the viruses in inducing oxidative stress inside spermatozoa thus leading to male infertility. Moreover, we will also highlight the various antiviral therapies that have been studied so far in order to ameliorate viral infection in order to combat the harmful consequences leading to male infertility.

Diabetes as a potential compounding factor in COVID-19-mediated male subfertility

Recent work indicates that male fertility is compromised by SARS-CoV-2 infection. Direct effects derive from the presence of viral entry receptors (ACE2 and/or CD147) on the surface of testicular cells, such as spermatocytes, Sertoli cells, and Leydig cells. Indirect effects on testis and concentrations of male reproductive hormones derive from (1) virus-stimulated inflammation; (2) viral-induced diabetes, and (3) an interaction between diabetes and inflammation that exacerbates the deleterious effect of each perturbation. Reproductive hormones affected include testosterone, luteinizing hormone, and follicle-stimulating hormone. Reduction of male fertility is also observed with other viral infections, but the global pandemic of COVID-19 makes demographic and public health implications of reduced male fertility of major concern, especially if it occurs in the absence of serious symptoms that would otherwise encourage vaccination. Clinical documentation of COVID-19-associated male subfertility is now warranted to obtain quantitative relationships between infection severity and subfertility; mechanistic studies using animal models may reveal ways to mitigate the problem. In the meantime, the possibility of subfertility due to COVID-19 should enter considerations of vaccine hesitancy by reproductive-age males.

Viral Infections and Male Infertility: A Comprehensive Review of the Role of Oxidative Stress

Viral infections have been a part of human existence to date, though viruses have posed a huge threat with various outbreaks lately. These threats are associated with reproductive health challenges, especially male infertility. The prime focus of this review is to highlight the mechanisms associated with viral infection-induced male infertility/subfertility and identify new treatment strategies with the aim to preserve male fertility. The reviewed data showed that viral infections stimulate inflammatory responses, resulting in the release of proinflammatory cytokines, which induces oxidative stress. This oxido-inflammatory cycle could continue in a vicious cycle and threaten male fertility. Existing data from human and experimental studies show that viral infection-induced oxido-inflammatory response results in testicular damage, atrophy of the seminiferous tubules and Sertoli cells, and reduced Leydig cell mass. This is accompanied by reduced circulatory testosterone, impaired spermatogenesis, reduced sperm motility, lipid peroxidation, DNA fragmentation and apoptosis of the sperm cells. Based on the available pieces of evidence, antioxidant therapy, in vivo and in vitro, may be beneficial and protects against the potential risk of male infertility from viral infection. It is, however recommended that more clinical studies be conducted to demonstrate the possible protective roles of antioxidants used as adjuvant therapy in viral infections, and in the in vitro treatment of semen samples for those utilizing semen washing and artificial reproductive techniques.

Glucose Metabolism Disorder Induces Spermatogenic Dysfunction in Northern Pig-Tailed Macaques (Macaca leonina) With Long-Term SIVmac239 Infection

Although spermatogenic dysfunction is widely found in patients with human immunodeficiency virus (HIV), the underlying reasons remain unclear. Thus far, potential hypotheses involving viral reservoirs, testicular inflammation, hormone imbalance, and cachexia show inconsistent correlation with spermatogenic dysfunction. Here, northern pig-tailed macaques (NPMs) exhibited marked spermatogenic dysfunction after long-term infection with simian immunodeficiency virus (SIVmac239), with significant decreases in Johnsen scores, differentiated spermatogonial stem cells, and testicular proliferating cells. The above hypotheses were also evaluated. Results showed no differences between SIV- and SIV+ NPMs, except for an increase in follicle stimulating hormone (FSH) during SIV infection, which had no direct effect on the testes. However, long-term SIVmac239 infection undermined pancreatic islet β cell function, partly represented by significant reductions in cellular counts and autophagy levels. Pancreatic islet β cell dysfunction led to glucose metabolism disorder at the whole-body level, which inhibited lactate production by Sertoli cells in testicular tissue. As lactate is the main energy substrate for developing germ cells, its decrease was strongly correlated with spermatogenic dysfunction. Therefore, glucose metabolism disorder appears to be a primary cause of spermatogenic dysfunction in NPMs with long-term SIVmac239 infection.

COVID-19 Pandemic and Male Fertility: Clinical Manifestations and Pathogenic Mechanisms

The novel coronavirus disease-2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a major public health emergency worldwide with over 118.27-million confirmed COVID-19 cases and 2.62-million deaths recorded, as of March 12, 2021. Although this disease primarily targets lungs, damages in other organs, such as heart, kidney, liver, and testis, may occur. Testis is the cornerstone of male reproduction, while reproductive health is the most valuable resource for continuity of the human race. Given the unique nature of SARS-CoV-2, the mechanisms of its impact on the testes have yet to be fully explored. Notably, coronaviruses have been found to invade target cells through the angiotensin-converting enzyme 2 receptor, which can be found in the respiratory, gastrointestinal, cardiovascular, urinary tract, and reproductive organs, such as testes. Coronavirus studies have suggested that testes might be a potential target for SARS-CoV-2 infection. The first etiopathogenic concept proposed by current hypotheses indicates that the virus can invade testes through the angiotensin-converting enzyme 2 receptor. Next, the activated inflammatory response in the testes, disease-associated fever, and COVID-19 medications might be implicated in testicular alterations. Although evidence regarding the presence of SARS-CoV-2 mRNA in semen remains controversial, this emphasizes the need for researchers to pay closer attention to sexually transmitted diseases and male fertility after recovering from COVID-19. In this review the latest updates regarding COVID-19-associated testicular dysfunction are summarized and possible pathogenic mechanisms are discussed.

Viral infections and implications for male reproductive health

Viral infections have haunted humankind since times immemorial. Overpopulation, globalization, and extensive deforestation have created an ideal environment for a viral spread with unknown and multiple shedding routes. Many viruses can infect the male reproductive tract, with potential adverse consequences to male reproductive health, including infertility and cancer. Moreover, some genital tract viral infections can be sexually transmitted, potentially impacting the resulting offspring's health. We have summarized the evidence concerning the presence and adverse effects of the relevant viruses on the reproductive tract (mumps virus, human immunodeficiency virus, herpes virus, human papillomavirus, hepatitis B and C viruses, Ebola virus, Zika virus, influenza virus, and coronaviruses), their routes of infection, target organs and cells, prevalence and pattern of virus shedding in semen, as well as diagnosis/testing and treatment strategies. The pathophysiological understanding in the male genital tract is essential to assess its clinical impact on male reproductive health and guide future research.

Viral threat to male fertility

The detrimental effects of Zika virus (ZIKV) infection on mouse testicular functions have reminded a viral threat to male fertility. A broad range of virus families has tropism for male reproductive system, particularly the testes. Certain virus types of these viruses, such as mumps virus and human immunodeficiency virus (HIV), may severely damage the testes and consequently lead to male infertility. ZIKV has been recently found to damage testicular functions and lead to male infertility in mice. Many other viruses also have detrimental effects on host reproduction. Public attention has been paid to sexually transmitted viruses, such as HIV and hepatitis B and C viruses in humans and likewise in economically important farm animals. This article provides an overview on main viruses affecting the male reproductive system and their detrimental effects on fertility, and outlines some important issues for future study.

A study on hypogonadism in male HIV patients in northeastern part of India

Context:

After the introduction of highly active antiretroviral therapy (ART), the prevalence of hypogonadism among human immunodeficiency virus (HIV)-infected males is decreasing.

Aims:

The aim of this study was (i) to estimate the prevalence of hypogonadism among HIV-infected males and (ii) to determine the risk factors for hypogonadism.

Settings and Design:

This was a cross-sectional study undertaken at ART center of a medical Institute.

Subjects and Methods:

The study recruited HIV-infected males aged 18–65 years receiving ART. Patients with any debilitating chronic illness, diabetes mellitus, chronic smokers or alcoholic, currently on opioids, or methadone were excluded from the study. Androgen Deficiency in Aging Male (ADAM) questionnaire was used to screen patients for the possible presence of hypogonadism. For those screened positive on ADAM questionnaire underwent biochemical evaluation for serum total testosterone, luteinizing hormone (LH), and CD4 count.

Statistical Analysis Used:

The Chi-square test was used to compare different parameters. Pearson's correlation coefficient was used to assess any relationship between CD4 count, LH, and testosterone. P < 0.05 was considered statistically significant.

Results:

In the study, 426 were initially screened and 120 patients who had probable hypogonadism were further evaluated. The mean age of the patients was 41.61 years. The mean body mass index (BMI) of the patients was 22.47 kg/m². The mean duration of ART was 6.13 years and the mean CD4 count was 442.63 cells/mm³. Hypogonadism was seen in 20 (23.3%) and majority (85.7%) had secondary hypogonadism. There was significant association between hypogonadism and CD4 count, but no association was found with BMI and duration of ART.

Conclusions:

Hypogonadism is seen in 23.3% of HIV-infected males. Majority (85.7%) had secondary hypogonadism. There was significant association of hypogonadism with lower CD4 count.

Role of Viral Infections in Testicular Cancer Etiology: Evidence From a Systematic Review and Meta-Analysis

The most represented histotype of testicular cancer is the testicular germ-cell tumor (TGCT), both seminoma and non-seminoma. The pathogenesis of this cancer is poorly known. A possible causal relationship between viral infections and TGCTs was firstly evoked almost 40 years ago and is still a subject of debate. In the recent past, different authors have argued about a possible role of specific viruses in the development of TGCTs including human papillomavirus (HPV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), Parvovirus B-19, and human immunodeficiency virus (HIV). The aim of this present review was to summarize, for each virus considered, the available evidence on the impact of viral infections on the risk of developing TGCTs. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all observational studies reported in English evaluating the correlations between viral infections (HPV, CMV, EBV, Parvovirus B19, and HIV) and TGCTs. The methodological quality of studies included in the meta-analysis was evaluated using a modified version of the "Newcastle-Ottawa Scale." Meta-analyses were conducted using the "Generic inverse variance" method, where a pooled odds ratio (OR) was determined from the natural logarithm (LN) of the studies' individual OR [LN (OR)] and the 95% CI. A total of 20 studies (on 265,057 patients) were included in the review. Meta-analysis showed an association with TGCTs only for some of the explored viruses. In particular, no association was found for HPV, CMV, and Parvovirus B-19 infection (p = ns). Conversely, EBV and HIV infections were significantly associated with higher risk of developing TGCTs (OR 7.38, 95% CI 1.89-28.75, p = 0.004; OR 1.71, 95% CI 1.51-1.93, p < 0.00001). In conclusion, we found adequate evidence supporting an oncogenic effect of HIV and EBV on the human testis. Conversely, available data on HPV and TGCTs risk are conflicting and further studies are needed to draw firm conclusions. Finally, current evidence does not support an effect of CMV and Parvovirus B-19 on testicular carcinogenesis.

HIV and hypogonadism: a new challenge for young-aged and middle-aged men on effective antiretroviral therapy

Male hypogonadism is poorly defined in people living with HIV. Using a reliable free-testosterone assay, we examined the prevalence and risk factors of male hypogonadism among people living with HIV on effective antiretroviral therapy. Male hypogonadism was found in 12.4% of patients, twice the rate reported in the general population of the same age. Two risk thresholds, namely 5 years of antiretroviral therapy and 19% total body fat, may help to identify patients at risk.

Male fertility and skin diseases

Male fertility can be affected by a variety of organs diseases, including the skin. Several genodermatoses affect the skin and several other organs including the male reproductive system, commonly in the form of cryptorchidism and hypogonadism. The most relevant syndromes are associated with dyschromias, such as deSanctis-Cacchione, poikiloderma congenital, LEOPARD, and H syndrome; others with ichthyosis, such as Rud, and trichothiodystrophy; or a group of unrelated genodermatoses, such as ablepharon macrostomia, Coffin-Siris, Gorlin-Goltz, and Werner. Acquired skin diseases may also affect male fertility usually in the form of orchitis or epididymal obstruction or androgen antagonists. These include infections (leprosy and HIV), autoimmune (erythema nodosum leprosum), granulomatous (sarcoidosis, Langerhans cell histiocytosis), nutritional deficiency (zinc), and malignancy. Several therapeutics of skin diseases are notorious for their effects on male fertility, most notably are the cytotoxic drugs (methotrexate), irradiation, and antiandrogens (spironolactone, finasteride). Although the prevalence of these skin diseases is low, the associated male infertility represents a challenge due to the difficulty of its management. Clinical management of the skin diseases should include consideration of their effects not only on the diseases but also on the male reproductive system.

Endocrine alterations in HIV-infected patients

AIMS AND OBJECTIVES

To study the frequency of thyroid, adrenal and gonadal dysfunction in newly diagnosed HIV-infected patients and to correlate them at different levels of CD4 cell counts.

MATERIALS AND METHODS

Forty-three HIV-positive cases were included in the study group. Cases were divided into three groups on the basis of CD4 cell count. Serum free T3, free T4, TSH, Cortisol, FSH, LH, testosterone and estradiol were estimated by the radioimmunoassay method. Hormone levels between cases were compared and their correlation with CD4 count was analyzed.

RESULTS

Prevalence of gonadal dysfunction (88.3%) was the most common endocrine dysfunction followed by thyroid (60.4%) and adrenal dysfunction (27.9%). Secondary hypogonadism (68.4%) was more common than primary (31.6%). Low T3 syndrome, that is, isolated low free T3, was the most common (25.6%) thyroid dysfunction followed by secondary hypothyroidism (16.2%) and subclinical hypothyroidism (11.6%). Adrenal excess (16.3%) was more common than adrenal insufficiency (11.6%). The difference in hormonal dysfunction between male and female was statistically insignificant (P > 0.05). 27.9% of patients had multiple hormone deficiency. There was negligible or no correlation between CD4 count and serum hormone level.

CONCLUSION

In our study, endocrine dysfunction was quite common among HIV-infected patients but there was no correlation between hormone levels and CD4 count. Endocrine dysfunctions and role of hormone replacement therapy in HIV-infected patient needs to be substantiated by large longitudinal study, so that it will help to reduce morbidity, improve quality of life.

Human immunodeficiency virus/acquired immunodeficiency syndrome and infertility: emerging problems in the era of highly active antiretrovirals

OBJECTIVE

To review the effects of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in terms of its associated comorbid conditions and the side effects of antiretroviral treatment on fertility.

DESIGN

PubMed computer search to identify relevant articles.

SETTING

Research institution.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Biological alterations in reproductive physiology may account for subfertility in patients infected with HIV. Psychosocial factors in patients with HIV infection may affect their reproductive desires and outcomes. Antiretroviral medications may have direct toxicity on gametes and embryos. Available evidence indicates that fertility treatments can be a safe option for couples with HIV-discordant infection status, although the potential risk of viral transmission cannot be completely eliminated.

CONCLUSION(S)

Because their potential reproductive desires are increasingly becoming a concern in the health care of young HIV-infected patients, additional data are needed to address the effect of HIV and its treatments on their fertility and reproductive outcomes.

Urologic aspects of HIV infection

Although lifespan has dramatically improved in the human immunodeficiency virus-positive (HIV+) population, HIV and its treatment continue to be a source of substantial morbidity in many organ systems, including the genitourinary tract. As the number of long-term survivors increases with advances in antiretroviral therapy, age-associated urologic symptoms are also becoming increasingly relevant considerations for people living with HIV. Primary care physicians have a major role to play in maintaining the genitourinary health of their HIV+ patients. This role is of great importance not just for the well-being of the individual patient but for the public health, as the genitourinary tract is a common vector for HIV transmission. In this article the authors review the management of the genitourinary system in patients with HIV infection. Particular consideration is given to urinary tract infections, lower urinary tract symptoms, renal insufficiency, sexual and fertility problems, and cancers of the genitourinary tract. Management algorithms are outlined and indications for referral to a urologist are emphasized.

[Gonadotrophic axis dysfunction in men with HIV-infection/aids]

Gonadotrophic axis dysfunction is commonly observed in HIV-infected patients. The pathogenesis is multifactorial and related to duration of HIV infection, direct cytopathic effects of viruses, use of drugs, opportunistic infections, malignancies, and malnutrition, among other factors. In men, reduced levels of testosterone is associated with loss of muscle mass and strength, decreased bone mineral density, lipodystrophy, depression, asthenia, fatigue and sexual dysfunction. In HIV-infected patients with hypogonadism, numerous studies have shown the beneficial effects of testosterone replacement on the metabolic profile and distribution of body fat, with increased body mass weight, and promote better quality of life, reduce the bone mass loss and the rates of depression. Thus, this review aimed to present a brief update of epidemiologic data, pathophysiology aspects and treatment strategies for the major abnormalities of male gonadotrophic axis associated with HIV infection and its treatment.

HIV-AIDS: urologic considerations

The prevalence of HIV continues to grow in the United States and worldwide. HIV-positive patients experience many genitourinary disease processes. With improvements in HIV therapy, patients have questions and concerns pertaining to their quality of life. This article reviews conditions such as HIV-related urinary tract infections, urolithiasis, voiding dysfunction, fertility, sexual dysfunction, HIV-related nephropathy, malignancies, and occupational exposure and prophylaxis. Knowledge of the various HIV manifestations of genitourinary conditions and their treatment options benefits clinicians and improves patient outcomes.

Risk of Germ Cell Tumors among Men with HIV/Acquired Immunodeficiency Syndrome

Background: Men with HIV/acquired immunodeficiency syndrome (AIDS) are reported to be at increased risk for germ cell tumors (GCT), particularly testicular seminoma. We investigated correlates of this association to improve understanding of GCTs.

Methods: Testicular and extratesticular seminoma and nonseminoma cases were found by linking population-based cancer and HIV/AIDS registry data for 268,950 men who developed AIDS in 1980 to 2003. Standardized incidence ratios (SIR) with 95% confidence intervals (95% CI) were used to compare these cases with the number of cases expected in the demographically matched population.

Results: Overall, seminoma risk (161 cases: SIR, 1.9; 95% CI, 1.6-2.2) was increased significantly with HIV/AIDS, whereas nonseminoma risk was not (56 cases: SIR, 1.3; 95% CI, 0.96-1.7). Extratesticular GCT risk also was increased (11 cases: SIR, 2.1; 95% CI, 1.1-3.7). Seminoma risk was elevated regardless of age, race, or HIV/AIDS transmission group. It was highest for disseminated disease (SIR, 4.7; 95% CI, 2.9-7.2) and within 9 months of AIDS onset (SIR, 7.6; 95% CI, 5.8-9.6), but it was unrelated to CD4 count and duration of HIV/AIDS. The excess risk of seminoma declined in more recent calendar periods, and it was no longer elevated (SIR, 1.4; 95% CI, 0.9-1.9) in the highly active antiretroviral treatment era.

Conclusions: Men with HIV/AIDS had an increased risk of seminoma, but this risk may have attenuated with improving anti-HIV/AIDS treatments. Although detection bias could partly explain the excess of this cancer, various lines of evidence support a causal relationship. Possible mechanisms underlying this association include impaired tumor immunosurveillance or AIDS-related testicular atrophy. (Cancer Epidemiol Biomarkers Prev 2007;16(6):1266–9)

Male hypogonadism in systemic disease

Hypogonadism is often observed in the presence of common acute and chronic illnesses in men. Low testosterone levels in these patients can be associated with loss of lean body mass and bone mass density, decline in mood, loss of energy, and sexual dysfunction. The mechanisms explaining hypogonadism and various systemic diseases are not completely understood, but these conditions are likely caused by a combination of stress, nonspecific weight loss, inflammation, and medication. Testosterone replacement can be considered in this population to improve lean body mass, bone mass density, and quality of life. More information is needed regarding the risk benefits of testosterone treatment on health outcomes in men who have systemic illness.

The urological management of the patient with acquired immunodeficiency syndrome

In people infected with the human immunodeficiency virus (HIV) both the CD4 T-cell count and the viral load are used to monitor disease progression to acquired immunodeficiency syndrome (AIDS). CD4 counts of <500/mm(3) are associated with opportunistic infections and certain malignancies, so-called 'AIDS-defining' conditions. Highly active antiretroviral therapy, using combinations of reverse transcriptase inhibitors and/or protease inhibitors, can improve considerably the prognosis of people who are HIV-positive, but such therapy is not yet widely available in many developing countries. People with AIDS are predisposed to urinary tract infection (UTI) by uncommon bacteria and pathogens, e.g. fungi, parasites and viruses, which may affect any urogenital organ; treatment should be culture-specific and long-term, because there is a tendency to recurrence, infection with multiple organisms and resistant isolates. Voiding dysfunction in patients with AIDS is usually a result of neurological complications caused by opportunistic infections, and has a poor prognosis. Of patients with AIDS, 30-50% develop a cancer, especially Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL). KS may involve any urogenital organ, but is usually part of systemic disease. Small lesions on the external genitalia can be treated with laser, cryotherapy or surgical excision, larger lesions with radiotherapy, and disseminated or visceral KS with multidrug chemotherapy. NHL may involve the kidneys, testes and retroperitoneal lymph nodes, thus obstructing the ureters, which may require ureteric stenting or percutaneous nephrostomy. NHL can be treated with radiotherapy and combination chemotherapy. Urolithiasis in patients with AIDS may be caused by indinavir, a protease inhibitor, but the more common types of stones may also occur. Fluid-electrolyte and acid-base disturbances are common in patients with advanced AIDS, secondary to vomiting, diarrhoea, malnutrition or septicaemia. HIV-associated nephropathy occurs in 10-30% of patients, and often leads to renal failure. Testicular atrophy is common, leading to infertility, erectile dysfunction (ED) and decreased libido. Treatment for ED must include counselling about strategies to reduce the transmission of HIV. The risk of HIV transmission after parenteral exposure to blood from an HIV-positive patient is relatively low (0.2-0.4%); the urologist can reduce the risk of transmission during surgery by adopting certain precautions. After occupational exposure to HIV, chemoprophylaxis with antiretroviral medication can significantly reduce the probability of HIV transmission.

AIDS and the urologist

The management of HIV infection has dramatically altered the natural history of the disease. Prevention of opportunistic infections and the development of HAART regimens altered the manifestations and conditions that urologists are being asked to evaluate and manage in this patient population.

Diagnosis and treatment of androgen deficiency in human immunodeficiency virus-infected men and women

Androgen deficiency is a common endocrine abnormality among men and women with human immunodeficiency virus (HIV) infection. Low testosterone concentrations are associated with lower CD4 cell count, advanced stage of illness, medication use, and weight loss. Signs and symptoms may be nonspecific. The most useful laboratory indicator is the serum bioavailable (free) testosterone concentration. A number of different testosterone preparations for treatment of androgen deficiency in HIV-infected men now exist. Administration of im testosterone significantly increases weight and lean body mass, energy, quality of life, and depression scores in HIV-infected men with low testosterone levels. Newer transdermal and gel preparations provide more-consistent steady-state dosing but are not as well tested, and sufficient testosterone concentrations may not be achieved with their use. Androgen deficiency is also common among HIV-infected women. Preliminary studies suggest that use of physiological testosterone administration, to achieve testosterone levels within the normal range, is of benefit in HIV-infected women, but further studies are necessary to define the therapeutic role of androgen therapy in this population.

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.

Viruses in the mammalian male genital tract and their effects on the reproductive system

This review describes the various viruses identified in the semen and reproductive tracts of mammals (including humans), their distribution in tissues and fluids, their possible cell targets, and the functional consequences of their infectivity on the reproductive and endocrine systems. The consequences of these viral infections on the reproductive tract and semen can be extremely serious in terms of organ integrity, development of pathological and cancerous processes, and transmission of diseases. Furthermore, of essential importance is the fact that viral infection of the testicular cells may result not only in changes in testicular function, a serious risk for the fertility and general health of the individual (such as a fall in testosteronemia leading to cachexia), but also in the possible transmission of virus-induced mutations to subsequent generations. In addition to providing an exhaustive account of the data available in these domains, this review focuses attention on the fact that the interface between endocrinology and virology has so far been poorly explored, particularly when major health, social and economical problems are posed. Our conclusions highlight the research strategies that need to be developed. Progress in all these domains is essential for the development of new treatment strategies to eradicate viruses and to correct the virus-induced dysfunction of the endocrine system.

Insulin-like growth factor-I reverts testicular atrophy in rats with advanced cirrhosis

The pathogenesis of hypogonadism in cirrhosis is not completely understood. The levels of insulin-like growth factor-I (IGF-I), an anabolic factor with trophic actions on testes, are reduced in cirrhosis. This study was undertaken to evaluate whether rats with advanced cirrhosis develop hypogonadism and whether the administration of IGF-I exerts beneficial effects on testicular structure and function. Wistar rats with ascitic cirrhosis induced with CCl(4) were allocated into 2 groups (n = 10, each) to receive recombinant IGF-I (20 microg x kg(-1) x d(-1), subcutaneously) or vehicle for 3 weeks. Healthy rats receiving vehicle were used as the control group (n = 10). At baseline, both cirrhotic groups showed similar deterioration of liver function tests. Compared with controls, nontreated cirrhotic rats showed decreased serum levels of IGF-I (P <.05), reduced testicular size and weight (P <.001), and intense histopathological testicular abnormalities, including reduced tubular diameters (P <.001), loss of the germinal line (P <. 001), and diminutions in cellular proliferation, spermatogenesis (P <.001), and testicular transferrin expression (P <.001). In addition, low serum testosterone (P <.01) and high serum LH (P <.01) were present in untreated cirrhotic animals. Cirrhotic rats that received IGF-I showed full recovery of testicular size and weight and of all histopathological abnormalities (P <.001 to <.01 vs. nontreated cirrhotic rats; P = ns vs. controls). Serum levels of sex hormones tended to normalize. In conclusion, IGF-I deficiency may play a pathogenetic role in hypogonadism of cirrhosis. Low doses of IGF-I for a short period of time revert testicular atrophy and appear to improve hypogonadism in advanced experimental cirrhosis.

Testicular Pathologic Changes and the Pituitary-Testicular Axis During Human Immunodeficiency Virus Infection

OBJECTIVE

To chronicle pituitary-testicular axis dysfunction and its clinicopathologic features in homosexual men.

METHODS

Between 1984 and 1992, 84 homosexual men underwent longitudinal follow-up for 4 years. At entry into the study, 28 were seronegative and 56 were seropositive for human immunodeficiency virus (HIV). Although 40 subjects remained asymptomatic (nonprogressors), 16 had progression to acquired immunodeficiency syndrome (AIDS). Of those 16 patients with progression, 8 had AIDS within 2 years (early progressors) and 8 demonstrated AIDS within 4 years after enrollment (late progressors), and all died. The testes of five patients were examined at autopsy. The control group had similar follow-up. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, and bioavailable testosterone (bio-T) were measured in stored sera collected at 2-year intervals. The last hormonal measurement was between 3 and 24 months before autopsy. Comparison was made between autopsied and nonautopsied patients with AIDS as well as between HIV nonprogressors and control seronegative men. The correlation between pathologic findings and hormonal status was examined by regression analysis.

RESULTS

At baseline, testosterone, bio-T, LH, and FSH were not significantly different among all patients and subjects. During the study period, testosterone, bio-T, and serum gonadotropin levels remained unchanged in the seronegative homosexual men. In nonprogressors, serum FSH and LH concentrations remained unchanged, whereas testosterone and bio-T levels decreased significantly during this 4-year period. After progression to AIDS (in both groups of progressors), the serum FSH and LH levels were higher and the serum testosterone and bio-T were lower in comparison with values in the seronegative men. In late progressors to AIDS, FSH and LH increased, whereas serum testosterone and bio-T decreased significantly from baseline. All five patients with AIDS on whom autopsy was done had boundary wall thickening of the seminiferous tubules and decreased spermatogenesis. No significant differences were found in serum testosterone, bio-T, and LH between those in whom autopsy was or was not done; however, FSH was significantly higher in the autopsied cases. The serum testosterone and bio-T levels were negatively correlated with the interstitial inflammation. A significant correlation was also observed between change of bio-T and weight loss.

CONCLUSION

We conclude that dysfunction of the pituitary-gonadal axis is common in HIV-infected men. All patients in whom autopsy was done because of AIDS-related diseases had been hypogonadal 3 to 24 months before death. Decreased spermatogenesis, subacute interstitial inflammation, or both were seen at autopsy of patients with AIDS. Pathologic damage to the testes during AIDS was associated with decreased testosterone and bio-T as well as increased serum gonadotropin levels. In a substantial proportion of men with progression to AIDS, compensated hypogonadism (normal serum testosterone and increased serum LH levels) preceded the development of low serum testosterone level.

Changing testicular histology in AIDS: its implication for sexual transmission of HIV

OBJECTIVES

The understanding of testicular histology in acquired immunodeficiency syndrome (AIDS) is essential, because the sexual route is one of the main means of transmission of the human immunodeficiency virus, which is localized primarily in the germ cells of the testes. It is important to determine whether any changes have occurred in the testicular histologic patterns in the course of the AIDS epidemic.

METHODS

One hundred forty testicular specimens were available from AIDS autopsies during the AIDS epidemic (1981 to 1998). The epidemic was divided into pre-zidovudine (pre-AZT) therapy (1981 to 1987) and antiviral therapy (1988 to 1998) periods; the latter period was further subdivided on the basis of the particular treatment used. Testicular histology was evaluated and correlated with patient age, CD4 T-cell counts, and pathologic findings in other parts of the body.

RESULTS

Testicular histologic findings were categorized into three groups: hypospermatogenesis (group S), spermatogenic arrest (group A), and Sertoli cell only (group O). The percentage of AIDS patients with group S histologic findings remained constant throughout the study period: 26% in the pre-AZT and 28% in the antiviral therapy periods. However, there was a reversal in the percentages of patients in groups A and O: group A decreased from 48% (pre-AZT) to 28% (antiviral) and group O increased from 26% (pre-AZT) to 44% (antiviral). There was no correlation between testicular histologic results and patient age or CD4 count. Opportunistic infections and testicular neoplasms were also identified.

CONCLUSIONS

This study demonstrates that current therapy and prolongation of survival in AIDS patients are associated with a shift in the histologic findings of testes toward a more pronounced loss of germ cells. However, 28% of patients still show significant spermatogenesis at the time of death from AIDS and this subgroup cannot be identified by age or CD4 T-cell counts. The presence of large numbers of residual germ cells in these patients suggests that they may continue to be infectious throughout their disease course.

Testicular germ cells of HIV-seropositive asymptomatic men are infected by the virus

In situ PCR hybridization studies in the testis of infected asymptomatic subjects detected the presence of HIV-1 proviral DNA in the nuclei of germ cells at all stages of differentiation suggesting that HIV-seropositive men produce infected spermatozoa that are released in the genital tract. In all subjects studied spermatogenesis was normal, the presence of provirus was not associated with germ cell damage and a very mild local immune response was observed. The HIV hybridization pattern observed in germ cells supports the hypothesis of a clonal infection. It is suggested the possibility of a direct infection of the germ cells by cell-free virus and that the testis might represent a site of early viral localization, well tolerated because of the immune privilege of this organ.

HIV in testis: quantitative histology and HIV localization in germ cells

The testes of AIDS patients invariably show decreased spermatogenesis and are atrophic. These testicular changes can be grouped into three categories: (1) spermatogenesis present, but decreased; (2) spermatogenic arrest at primary spermatocyte stage; and (3) Sertoli only (or almost Sertoli only). The purpose of this study is 2-fold: firstly, to quantitate the numbers and types of germ cells in these three groups as compared with normals. In addition the presence of HIV-1 DNA positive germ cells was quantitated by PCR in situ hybridization. HIV-1 was identified in 14 of 15 testes from HIV infected adults, and was present in 25-33% of residual germ cells. There was an average of 18.9 HIV infected germs cells/tubule in the spermatogenesis group, 6.3 HIV infected germs cells in the spermatogenic arrest group, and 0.25 HIV infected germ cells in the almost Sertoli only group. HIV-1 DNA was absent in three of the three preadolescent boys testes (HIV acquired in utero). This study quantitates the degree of germ cell loss in AIDS patients and quantitates the degree of HIV positivity of the residual germ cells, thus shedding more light on the testicular HIV burden, with its possible repercussions for sexual transmission of HIV.

Identification and regulation of testicular interferon-gamma (IFNgamma) receptor subunits: IFNgamma enhances interferon regulatory factor-1 and interleukin-1beta converting enzyme expression

Interferon-gamma (IFNgamma) transmits its signal through a specific cell surface receptor (IFNgammaR), which consists of a primary ligand binding alpha-chain (IFNgammaR alpha) and a signaling beta-chain (IFNgammaR beta). Recent studies identified the cytokines IFNgamma, interleukin-6 (IL-6), IL-1alpha, and tumor necrosis factor-alpha in testicular cells. Therefore, we: 1) examined the expression of IFNgammaR alpha and IFNgammaR beta subunits in freshly isolated and purified rat testicular cells; 2) examined the differential regulation of receptor components by cytokines using primary cultures of Sertoli cells; 3) identified the cell signaling pathway components of testicular IFNgammaR; and 4) characterized the functional role of testicular IFNgamma using primary Sertoli cells. We demonstrated the messenger RNAs for both chains of IFNgammaR in rat testicular cells using Northern hybridization analysis. Western blot analysis and immunocytochemistry showed that both specific IFNgammaR protein subunits were present in cultured primary Leydig and Sertoli cells prepared from the testes of immature rats. The expression of both IFNgammaR component messenger RNAs in cultured Sertoli cells was increased by its specific ligand (IFNgamma), as well as IL-1alpha and tumor necrosis factor-alpha, in both a time- and dose-dependent manner. IFNgamma-activation of the Janus (JAK) tyrosine kinases, JAK1 and JAK2 proteins, indicate that IFNgammaR, expressed in the Sertoli cell, is functional. Moreover, IFNgamma modulates the expression of interferon regulatory factor (IRF)-1 and IL-1beta converting enzyme genes in Sertoli cells. Thus, our data are suggestive of a role(s) for IFN-gamma in the regulation of distinct gene expression and cell-specific sensitivity to apoptosis in the testis.

Presence and cellular distribution of HIV in the testes of seropositive subjects: an evaluation by in situ PCR hybridization

Cellular distribution of HIV-1 proviral DNA has been studied, by in situ PCR hybridization, in the testes of infected men who died at various stages of the disease. In seropositive asymptomatic subjects, HIV-1 proviral DNA was present in the nuclei of germ cells at all stages of their differentiation. The presence of provirus did not induce germ cell damage, was associated with normal spermatogenesis, and was not accompanied by morphologic signs of immune response. The observed HIV hybridization pattern of germ cells suggests clonal infection. Mechanisms responsible for HIV penetration in testicular germ cells remain to be clarified; however, the possibility of a direct infection of the germ cells by cell-free virus is suggested. In the testes of AIDS-deceased men, histologic features of hypoplasia with arrested spermatogenesis were evident, and few infected spermatogonia and spermatocytes were observed. The whole of these data demonstrates that the testis is a site of early viral localization that fails to elicit an immunological response, and that HIV-seropositive men produce infected spermatozoa that are released in the genital tract.

Gynecology and family planning care for the woman infected with HIV

This article reviews the interactions between HIV infection and a variety of gynecologic conditions, including lower genital tract neoplasia, pelvic inflammatory disease, menstrual disorders, sexually transmitted diseases, and vaginitis. Important considerations in choosing a family planning method for women infected with HIV-infected women will respond to standard therapy, but require multiple courses of treatment or use of innovative treatment methods. All HIV-infected women deserve careful evaluation for and treatment of gynecologic diseases.

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.

Protozoan infections in the male genital tract

PURPOSE

We reviewed the literature on protozoan infections in the male genital tract, with special reference to histopathological findings and their repercussions on different andrological functions.

MATERIALS AND METHODS

A literature search of the MEDLINE data base from 1966 to May 1995 was done and related articles were identified. The considered terms were parasitology and the male genital organs. Additional searches on infertility, semen and sexually transmitted diseases were performed.

RESULTS

Protozoan infections of the male genital tract are rare and only a few species of parasites are involved. Trichomonas vaginalis, Trypanosoma species, Leishmania donovani, Entamoeba histolytica, Acanthamoeba species, Toxoplasma gondii and Plasmodium falciparum have been described in the male genital tract as producing testicular damage or secondary hypogonadism via hypothalamic-hypophyseal axis alterations.

CONCLUSIONS

Topics of interest were the role of sexual transmission by some parasites, principally T. vaginalis, relationship with subfertility or infertility in the male subject, clinical significance in differential diagnosis with other inflammatory processes, and for some parasites the relationship with opportunistic behavior and immunodeficiency syndromes, including the acquired immunodeficiency syndrome.

Anterior pitutiary and pitutiary-dependent target organ function in men infected with the human immunodeficiency virus

To evaluate pituitary and pituitary-dependent target organ function in men infected with the human immunodeficiency virus (HIV), 26 ambulatory HIV-positive men (13 with acquired immunodeficiency syndrome [AIDS]) and nine healthy control men were administered rapid sequential injections of thyrotropin (TSH)-releasing hormone (TRH), gonadotropin-releasing hormone (GnRH), ovine corticotropin (ACTH)-releasing hormone (oCRH), and human growth hormone-(GH)-releasing hormone (hGHRH). Blood samples were collected before and for 90 minutes after the injections for immunoassay of pituitary hormones, cortisol, testosterone, and free thyroxine (fT(4)). Data were analyzed for each group of men considering basal, peak, and incremental responses to the releasing hormones, as well as the time course of response of each hormone. Mean basal serum GH concentrations were the same in all groups (control, AIDS, and non-AIDS HIV-positive), but stimulated GH levels were substantially higher at all time points in both groups of HIV-positive subjects. Results for prolactin (PRL) were similar, although stimulated PRL levels were increased significantly only in the AIDS group. The mean basal serum TSH concentration and stimulated TSH levels at 60 and 90 minutes were significantly greater in the AIDS group than in the control group. Basal mean fT(4) concentration in the AIDS group was significantly less than in the control group. Mean basal and stimulated serum (total) testosterone concentrations in all groups were the same. However, basal serum luteinizing hormone (LH) concentrations in both groups of HIV-infected men were significantly greater than in controls; stimulated (peak) LH levels were not different from control levels. Basal and peak stimulated plasma ACTH concentrations were significantly increased in both HIV-infected groups. Basal serum cortisol levels were also greater, on average, in HIV-infected groups, although stimulated (peak) cortisol responses were not different. These results indicate that basal serum concentrations of TSH, LH, ACTH, and cortisol are modestly increased in men with AIDS, and that maximum levels of GH, PRL, TSH, and ACTH stimulated by the releasing hormones are also increased in this group. Measurements obtained in the non-AIDS HIV-infected men showed a pattern generally similar to that obtained in men with AIDS, but less marked. The basis for the increased pituitary activity is unknown; we speculate that it is due to modestly impaired target organ function and to increased hypothalamic stimulation.

Genitourinary manifestations of the acquired immunodeficiency syndrome

As the number of HIV-1 infected individuals and AIDS patients continues to increase, more cases involving the genitourinary tract will be encountered. Often, genitourinary manifestations will be the initial presentation of AIDS. Proper diagnosis will require awareness and a high index of suspicion. In addition to routine cultures, opportunistic infections with unusual organisms will require staining for fungi and acid-fast bacilli. Repeat cultures of blood, urine, seminal fluid, and abscess cavities may be required to establish a diagnosis. Prolonged courses of antibiotic treatment for prophylaxis and for relapses are usually required. Clinical understaging and rapid progression of tumors distinguish HIV-1-associated malignancies involving the genitourinary tract. Treatment for these malignancies will depend on the stage of HIV-1 infection. Any concomitant drug therapy and evidence of malnutrition will be important factors in selecting the proper timing and mode of therapeutic intervention. Although AIDS predominantly affects individuals between 30 and 50 years of age, an increasing percentage of patients over 50 years of age are being diagnosed. Common risk factors for acquisition of HIV include homosexuality or bisexuality and transfusion of blood or blood products. For the urologist, it is important to recognize that older patients more frequently present with AIDS at the time of diagnosis of HIV infection. A more rapid course of deterioration and high mortality is noted in this population. Clearly, protocols including surveillance, dosing regimens, and surgical intervention will need to be established and clarified to treat an anticipated increasing number of affected patients. In addition, it appears that adequate adherence to universal precautions is far from being achieved. Close monitoring and active surveillance of infection control may be needed to improve compliance.

Psychosexual problems in people with HIV infection: controlled study of gay men and men with haemophilia

HIV infection can be associated with major psychological and social disturbance. Psychosexual problems would be expected to arise in the context of the infection, in view of the contribution that sexual behaviour can make to the acquisition and spread of HIV infection. Here the results of a study of the psychosexual consequences of HIV infection in gay men and men with haemophilia are presented, with the inclusion of data from control groups. Sixteen HIV-positive and 23 HIV-negative gay men, and 20 HIV-positive and 24 HIV-negative men with haemophilia with sexual partners were studied. HIV infection was found to be associated with the greater risk of development of sexual dysfunction in seropositives, in particular in relation to ejaculatory difficulties, both delayed ejaculation in the case of gay men and men with haemophilia, and premature ejaculation in the case of men with haemophilia. Possible aetiological mechanisms are considered, including the possibility of organic disease. The findings are of relevance to those involved in the care of people with HIV infection.

The effects of disease progression and zidovudine therapy on semen quality in human immunodeficiency virus type 1 seropositive men

OBJECTIVE

To investigate the effects of disease progression and zidovudine antiretroviral therapy on semen parameters in human immunodeficiency virus type 1 (HIV-1) seropositive men.

DESIGN

Cross-sectional analysis of semen parameters of 166 HIV-1 seropositive men in various stages of disease progression as defined by peripheral CD4+ cell count. Clinical symptoms and zidovudine therapy status were obtained from medical records and clinical interviews.

PATIENTS

Human immunodeficiency virus type 1 seropositive men participating in clinical studies at the Fenway Community Health Center (Boston, MA), the University of San Francisco (San Francisco, CA), and Brown University (Providence, RI).

MAIN OUTCOME MEASURES

Ejaculate volume; sperm concentration, motility, forward progression, morphology, total sperm count; seminal immature germ cell; and white blood cell (WBC) concentrations.

RESULTS

Human immunodeficiency virus type 1 seropositive men that were not on zidovudine therapy and were in early disease stage (> 200 CD4+ cells/mm3) had normal semen parameters as defined by World Health Organization criteria. In contrast untreated men in advanced disease stage (< or = 200 CD4+ cells/mm3) had significant reductions in sperm concentration and total sperm count and an increased percentage of abnormal sperm forms. Men receiving zidovudine antiretroviral therapy, regardless of disease stage, had normal semen parameters similar to those of untreated early disease stage patients. Seminal WBC concentrations were not affected significantly by disease progression but were reduced in patients receiving zidovudine.

CONCLUSION

Most HIV-1-infected men in this study had semen parameters consistent with fertility. Disease progression was associated with reduced semen quality, but this effect appeared to be abrogated by zidovudine therapy. Zidovudine was also associated with a significant reduction of WBC numbers in semen. As seminal WBC are principal HIV-1 host cells in ejaculates of HIV-1-infected men, this effect could explain recent laboratory and epidemiological evidence that zidovudine therapy is associated with a reduced prevalence of HIV-1 in semen and a lower rate of sexual transmission.

Pathological changes in the reproductive tract of male rhesus monkeys associated with age and simian AIDS

The pathological changes associated with ageing and simian immunodeficiency virus (SIV) infection in groups of immature, adult and ageing Rhesus monkeys were studied. Eighty three per cent (5 of 6) of uninfected ageing animals had hyperplasia of the prostate, 33 per cent (2 of 6) had mild prostatitis and in 66 per cent (4 of 6) there were calcified concretions in the seminal vesicles. The testes were normal and showed active spermatogenesis. In the SIV-infected animals, two types of lesion occurred; the most common, in 81 per cent (18 of 22 monkeys), was the presence of focal lymphoid infiltrations in the epididymis, prostate or seminal vesicles. The other was hypospermatogenesis (23 per cent, 4 of 17) with degeneration of seminiferous tubules. Immunocytochemical staining demonstrated that the lymphoid masses contained approximately equal numbers of B and T lymphocytes, but the majority of diffusely scattered cells were T lymphocytes. Staining for SIV antigen identified small numbers of positive lymphocytes and macrophages in all tissues.