The syndrome of acquired glucocorticoid resistance in HIV infection

A Conspectus of Euvolemic Hyponatremia, Its Various Etiologies, and Treatment Modalities: A Comprehensive Review of the Literature

Hyponatremia is the most prevalent electrolyte imbalance encountered among hospitalized patients, athletes, the elderly, patients with chronic ailments, postoperative patients, and a few asymptomatic individuals. Clinical manifestations of hyponatremia can be diverse, with characteristic neurological symptoms. Depending on in-depth medical history, physical examination (including volume status assessment), laboratory investigation, and drug history, patients can be classified broadly as undergoing hypervolemic, euvolemic, or hypovolemic hyponatremia. However, patients with hypervolemic hyponatremia often present with distinctive signs such as edema or ascites, and the clinical presentation of hypovolemic and euvolemic hyponatremia poses significant challenges for clinicians. The convolution in clinical manifestations of patients is due to the varied etiologies of euvolemic hyponatremia, such as syndrome of inappropriate antidiuretic hormone secretion (SIADH), adrenocortical insufficiency, hypothyroidism, psychogenic polydipsia, different classes of drugs (chemotherapeutics, antipsychotics, antidepressants), endurance exercise events, and reset osmostat syndrome (ROS). The management of hyponatremia depends on the rate of hyponatremia onset, duration, severity of symptoms, levels of serum sodium, and underlying comorbidities. Over the last decade, the clinical understanding of hyponatremia has been scattered due to the introduction of innovative laboratory markers and new drugs. This article will be a conspectus of all the recent advancements in the field of diagnosis, investigations, management, and associations of hyponatremia, along with traditional clinical practices. Subsequently, a holistic overview has been laid out for the clinicians to better understand and identify knowledge deficiencies on this topic.

Adrenal insufficiency in HIV/AIDS: a review

INTRODUCTION

Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS).

AREAS COVERED

In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV. It also focuses on the pathophysiology, etiology, diagnosis and management of this endocrinopathy in PLHIV. A literature review was conducted through Medline and Google Scholar search on the subject.

EXPERT OPINION

Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with nonspecific signs and symptoms and may be potentially life threatening if left untreated. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. Overt primary AI also necessitates mineralocorticoid replacement. On the other hand, the management of relative AI remains controversial. In order to reduce the risk of adrenal crisis during periods of stress, the short-term use of glucocorticoids may be necessary in relative AI.

HIV-1 Tat and morphine decrease murine inter-male social interactions and associated oxytocin levels in the prefrontal cortex, amygdala, and hypothalamic paraventricular nucleus

Many persons infected with HIV-1 (PWH) and opioid-dependent individuals experience deficits in sociability that interfere with daily living. Sociability is regulated by the prefrontal cortico-hippocampal-amygdalar circuit. Within this circuit HIV-1 trans-activator of transcription (HIV-1 Tat) and opioids can increase dendritic pathology and alter neuronal firing. Changes in sociability are also associated with dysregulation of hypothalamic neuropeptides such as oxytocin or corticotropin releasing factor (CRF) in the prefrontal cortico-hippocampal-amygdalar circuit. Accordingly, we hypothesized that the interaction of HIV-1 Tat and morphine would impair inter-male social interactions and disrupt oxytocin and CRF within the PFC and associated circuitry. Male mice were exposed to HIV-1 Tat for 8 weeks and administered saline or escalating doses of morphine twice daily (s.c.) during the last 2 weeks of HIV-1 Tat exposure. Tat attenuated aggressive interactions with an unknown intruder, whereas morphine decreased both non-aggressive and aggressive social interactions in the resident-intruder test. However, there was no effect of Tat or morphine on non-reciprocal interactions in the social interaction and novelty tests. Tat, but not morphine, decreased oxytocin levels in the PFC and amygdala, whereas both Tat and morphine decreased the percentage of oxytocin-immunoreactive neurons in the hypothalamic paraventricular nucleus (PVN). In Tat(+) or morphine-exposed mice, regional levels of CRF and oxytocin correlated with alterations in behavior in the social interaction and novelty tests. Overall, decreased expression of oxytocin in the prefrontal cortico-hippocampal-amygdalar circuit is associated with morphine- and HIV-Tat-induced deficits in social behavior.

HIV and the Pituitary Gland: Clinical and Biochemical Presentations

Human immunodeficiency virus (HIV) can have profound impact on the function of the pituitary gland. We have performed an electronic literature search using the following database: PubMed, Medline, Scopus, and Google Scholar. These databases were searched using the keywords HIV, pituitary glands, cancer, pituitary apoplexy, and infertility. HIV can cause hypopituitarism and also can lead to diabetes insipidus. The impact can be slow and insidious, and diagnosis depends on high index of clinical suspicion. The effect on anterior pituitary gland can be associated with growth hormone deficiency, hypothyroidism, adrenal insufficiency, premature menopause, erectile dysfunction, and infertility. HIV can cause pituitary apoplexy, and this should be treated as an endocrine emergency. Importantly, HIV can be associated with pituitary lymphoma and pituitary cancer. Therefore, joined management between HIV physicians, clinical biochemists and endocrinologists may help in establishing pituitary dysfunction.

HIV and symptoms of depression are independently associated with impaired glucocorticoid signaling

Chronic inflammation caused by HIV infection may lead to deficient glucocorticoid (GC) signaling predisposing people living with HIV to depression and other psychiatric disorders linked to GC resistance. We hypothesized that comorbid HIV and depressive symptoms in women would synergistically associate with deficits in GC signaling. This cross-sectional study used samples obtained from the Women's Interagency HIV Study (WIHS). The Centers for Epidemiological Studies (CES-D) was used to define depression in four groups of women from the Women's Interagency HIV Study (WIHS): 1) HIV-negative, non-depressed (n = 37); 2) HIV-negative, depressed (n = 34); 3) HIV-positive, non-depressed (n = 38); and 4) HIV-positive, depressed (n = 38). To assess changes in GC signaling from peripheral blood mononuclear cells (PBMCs), we examined baseline and dexamethasone (Dex)-stimulated changes in the expression of the GC receptor (GR, gene: Nr3c1) and its negative regulator Fkbp5 via quantitative RT-PCR. GR sensitivity was evaluated in vitro by assessing the Dex inhibition of lipopolysaccharide (LPS)-stimulated IL-6 and TNF-α levels. Depressive symptoms and HIV serostatus were independently associated with elevated baseline expression of Fkbp5 and Nr3c1. Depressive symptoms, but not HIV status, was independently associated with reduced LPS-induced release of IL-6. Counter to predictions, there was no interactive association of depressive symptoms and HIV on any outcome. Comorbid depressive symptoms with HIV infection were associated with a gene expression and cytokine profile similar to that of healthy control women, a finding that may indicate further disruptions in disease adaptation.

The Syndrome of Inappropriate Secretion of Anti-Diuretic Hormone (SIADH) and Brucellosis

BACKGROUND Our study aimed to demonstrate the frequency of the syndrome of inappropriate ADH secretion (SIADH) and associated factors during the course of brucellosis in children and adolescents. MATERIAL AND METHODS The study included children and adolescents aged 0-18 years old diagnosed with brucellosis between 2012 and 2014. The data were collected from patient charts. The diagnosis of brucellosis was made based on titrations >1:160 in standard Wright tube agglutination tests and/or positive culture tests. SIADH diagnosis was made based on the following criteria: euvolemic hyponatremia, serum Na+ <135 mmol/L, presence of serum hypoosmolarity (serum osmolarity <275 mOsm/L), increased urinary sodium (>25 mmol/L with normal dietary salt intake), low uric acid (<2 mg/dL), absence of kidney, thyroid or adrenal disease, and any anti-diuretic use. RESULTS The study included 160 children and adolescents with mean age of 9.58±3.95 years (range: 2-18 years) including 70 girls (43.8%) and 90 boys (56.2%). When the patients were stratified based on SIADH, it was found that SIADH was present in 35 patients (21.9%). SIADH was associated with elevated glucose (p<0.001), ALT (p<0.05), AST (p<0.05), LDH (p<0.001), CRP (p<0.001), and MPV (p<0.001); and decreased potassium (p<0.05), chloride (p<0.001), albumin (p<0.001), total protein (p<0.05), and hemoglobin (p<0.05) levels. CONCLUSIONS Our study reports on the frequency, clinical characteristics, predisposing factors, and management of SIADH that can develop in children and adolescents diagnosed with brucellosis.

A Rare Mechanism of Hyponatremia in HIV Disease

Patient: Male, 25

Final Diagnosis: Corticosteroid reistance

Symptoms: Weakness

Medication: —

Clinical Procedure: Diagnosis

Specialty: Nephrology

The effects of HIV-1 infection on endocrine organs

Early in the HIV epidemic, multiple endocrine and metabolic abnormalities were observed in HIV-infected patients. These abnormalities were either related glandular infection or infiltration with opportunistic diseases or the effects of systemic inflammation and severe illness on hormonal function and metabolic homeostasis. This review describes the epidemiology and pathogenesis of dyslipidemia, disorders of bone homeostasis, and dysfunction of the adrenal, gonadal, and thyroid axes in the untreated HIV-infected patient. While this review is most applicable to the HIV epidemic in the developing world where effective antiretroviral therapy is not available, understanding the effect of systemic inflammation on endocrine and metabolic function in the untreated HIV-infected person has valuable lessons for the pathogenesis of endocrine disease in HIV-infected patients receiving antiretroviral treatment.

Assessment of the hypothalamic-pituitary-adrenal axis in critical illness

Cortisol is the main corticosteroid secreted from the human adrenal cortex, and it has a crucial role for survival in stressful conditions. An adequate increase in levels of cortisol helps patients to cope with the severity of the disease in the acute phase of critical illness. Either higher or lower than expected cortisol levels were found to be related to increased mortality. Prolonged activation of the hypothalamic-pituitary-adrenal (HPA) axis can result in hypercortisolemia or hypocortisolemia; both can be detrimental to recovery from critical illness. Primary and secondary adrenal insufficiency, relative adrenal insufficiency, tissue resistance to glucocorticoids, adrenocorticotrophic hormone deficiency and immune-mediated inhibition of the HPA axis can be the cause of the impairment of the secretion or action of cortisol in critically ill patients. Recently, some authors offered the term 'critical illness-related corticosteroid insufficiency' to better point out the relative adrenal insufficiency that is seen during critical illness. Patients with critical illness-related corticosteroid insufficiency not only have insufficient circulating cortisol but also have impaired cellular utilization of cortisol. In this article, how adrenal dysfunction presents in critical illness and how appropriate diagnosis and management can be achieved in the critical care setting will be discussed.

Adrenal insufficiency in critical illness

One of the more controversial areas in critical care in recent decades relates to the issue of adrenal insufficiency and its treatment in critically ill patients. There is no consensus on which patients to test for adrenal insufficiency, which tests to use and how to interpret them, whether to use corticosteroids, and, if so, who to treat and with what dose. This review illustrates the complexity and diversity of pathophysiological changes in glucocorticoid secretion, metabolism, and action and how these are affected by various types of illness. It will review adrenal function testing and give guidance on corticosteroid replacement regimens based on current published literature. There remain inherent difficulties in interpreting the effects of glucocorticoid replacement during critical illness because of the diversity of effects of glucocorticoids on various tissues. Investigation and treatment will depend on whether the likely cause of corticosteroid insufficiency is adrenal or central in origin.

Immune modulation of the hypothalamic-pituitary-adrenal (HPA) axis during viral infection

Compelling data has been amassed indicating that soluble factors, or cytokines, emanating from the immune system can have profound effects on the neuroendocrine system, in particular the hypothalamic- pituitary-adrenal (HPA) axis. HPA activation by cytokines (via the release of glucocorticoids), in turn, has been found to play a critical role in restraining and shaping immune responses. Thus, cytokine-HPA interactions represent a fundamental consideration regarding the maintenance of homeostasis and the development of disease during viral infection. Although reviews exist that focus on the bi-directional communication between the immune system and the HPA axis during viral infection (188,235), others have focused on the immunomodulatory effects of glucocorticoids during viral infection (14,225). This review, however, concentrates on the other side of the bi-directional loop of neuroendocrine-immune interactions, namely, the characterization of HPA axis activity during viral infection and the mechanisms employed by cytokines to stimulate glucocorticoid release.

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.

The effects of steroid hormones in HIV-related neurotoxicity: a mini review

This review examines the interaction of steroid hormones, glucocorticoids and estrogen, and gp120, a possible causal agent of acquired immune deficiency syndrome-related dementia complex. The first part of the review examines the data and mechanisms by which gp120 may cause neurotoxicity and by which these steroid hormones effect cell death in general. The second part of the review summarizes recent experiments that show how these steroid hormones can modulate the toxic effects of gp120 and glucocorticoids exacerbating toxicity, and estrogen decreasing it. We then examine the limited in vivo and clinical data relating acquired immune deficiency syndrome-related dementia complex and steroid hormones and speculate on the possible clinical significance of these findings with respect to acquired immune deficiency syndrome-related dementia complex.

It is hazardous to treat HIV patients with interferon-alpha

Interferon-alpha is shown to play a key role in the progressing immunodysfunction that characterizes HIV infection. In particular, interferon-alpha is responsible for the development of an autoimmune state that is prone to serious complications. Therefore, treatment of HIV patients with IFN-alpha is hazardous. There are results suggesting that anti-interferon-alpha immunization might be a method for prophylaxis and treatment of the autoimmune state in HIV patients. This treatment may prevent complications of HIV infection and the transition to AIDS.

A review of fatigue in people with HIV infection

Fatigue is often cited by clinicians as a debilitating symptom suffered by the many who are infected with HIV. This article provides a review of HIV-related fatigue, including research on possible physiological causes such as anemia, CD4 count, impaired liver function, impaired thyroid function, and cortisol abnormalities. Psychological causes of fatigue, particularly depression, are reviewed as well. Measurement issues, such as the use of inappropriate tools, the problem of measuring the presence or absence of fatigue, and the use of tools developed for other groups of patients, are reviewed. The need for a comprehensive fatigue tool that is appropriate for people with HIV is discussed. Current treatment research, including thyroid replacement, hyperbaric oxygen, and dextroamphetamine, is presented. Finally, the implications for further research, including the need for qualitative studies to learn more about the phenomenon, develop an instrument to measure fatigue, and examine variables together to get a complete picture of this complex concept, are reviewed.

Acquired immune deficiency syndrome: the glucocorticoid solution

Documented evidence supports the "cortisol connection' theory of acquired immune deficiency syndrome, linking glucocorticoid metabolism with immune function, and human immunodeficiency virus with them both. The peptide T subregion of gp 120 of human immunodeficiency virus apparently utilizes cellular melanocyte stimulating hormone receptors to competitively inhibit the blocking of interleukin-1 by melanocyte-stimulating hormone. Interleukin-1 stimulates CD8+ T-lymphocyte proliferation, as well as causing the release of corticotropin-releasing hormone, thereby stimulating the release of adrenocorticotrophic hormone and cortisol. Gp 120 also induces upregulation of adrenocorticotrophic hormone-related messenger ribonucleic acid. This apparently separate glucocorticoid metabolic route utilized by human immunodeficiency virus is the basis of the cortisol excess seen in human immunodeficiency virus infection. In vitro glucocorticoid-resistant lymphoid cells are resistant to human immunodeficiency virus infection as well. Viral resistance is also observed in patients who demonstrate glucocorticoid resistance. Glucocorticoid-responsive elements are contained in the human immunodeficiency virus (proviral and viral) genome that appear to regulate human immunodeficiency virus replication. Similarly, lymphoid-cell development and regulation depend on glucocorticoids. One may take advantage of this view of human immunodeficiency virus pathogenesis to create new methods of treatment.

Pathogenesis of oral Kaposi's Sarcoma in HIV-infection: relevance of endogenous glucocorticoid excess in blood and saliva

Endogenous glucocorticoid excess with concomitant hypercortisolaemia and increased saliva levels of the free active hormone, is a common feature of HIV-infected/AIDS patients. Exposure of the oral tissues to virtually uninterrupted high burden of glucocorticoids through saliva may contribute to the high frequency of oral Kaposi's sarcoma (KS) in these patients. AIDS-KS cells contain unusually high levels of glucocorticoid receptor protein and recent studies indicate that growth of these cells in culture is significantly stimulated by glucocorticoids, particularly in the presence of growth factors, such as oncostatin-M. The suggestion that glucocorticoid excess may be important in the pathogenesis of KS in AIDS is not in conflict with the suspected aetiological role of newly reported KS-associated herpesviruses (KSHV), since steroid hormones may upregulate the expression of the viral gene. The latter is consistent with the observation that infection by specific oncogenic viruses does not necessarily result in cancers in the human, and does require the presence of other cellular factors or events.

Elevated cortisol levels in whole saliva in HIV infected individuals

Free cortisol concentrations in unstimulated whole saliva samples, collected at 10.00 to 11.00 h, from 23 unmedicated HIV-positive patients and 14 control subjects were measured by radioimmunoassay. Mean cortisol level (nmol/l +/- SD) was significantly higher in the HIV patients than in control subjects (27.4 +/0 9.3 vs. 10.1 +/- 3.5). Two HIV patients with pseudomembranous candidiasis had the highest saliva cortisol concentrations (mean of 48.5 nmol/l). Two other HIV patients (one with Kaposi's sarcoma and the other with periodontitis) had a mean cortisol value of 29.9 nmol/l. The possibility of plasma contamination of whole saliva in the HIV patients with inflammatory oral mucosal lesions notwithstanding, our findings suggest an increased oral burden of cortisol in both the asymptomatic and symptomatic HIV-infected individuals. Glucocorticoids caused immunosuppression, provide selective growth advantage to various microorganisms including the fungi, and enhance replication or reactivation of latent viruses (e.g. EBV, CMV, Kaposi's sarcoma-associated herpes viruses). Our findings suggest a need to evaluate the relevance of endogenous glucocorticoid excess in blood and saliva to the causation of some major AIDS-associated oral lesions such as candidiasis, Kaposi's sarcoma, oral hairy leukoplakia and necrotizing gingivitis.