Endocrine implications of human immunodeficiency virus infection

Low prevalence of symptomatic thyroid diseases and thyroid cancers in HIV-infected patients

Thyroid diseases (TDs) have been widely associated with HIV infection. However, data about TDs prevalence and distribution are controversial, and few published studies are available. The aim of our study was to assess prevalence and risk factors of symptomatic thyroid disturbances, including thyroid cancers, in a large cohort of HIV-infected patients. A retrospective cohort study was performed at the Department of Infectious and Tropical Diseases of the University of Brescia, Italy, in the period 2005–2017. We identified all HIV-positive patients with a diagnosis of symptomatic TD in the electronic database of our Department (HIVeDB); we also operated a record-linkage between our data and the Health Protection Agency database (HPADB) of Brescia Province. Multivariate logistic regression analysis was used to determine risk factors associated with TDs onset; an incidence rate analysis was also performed. During the study period, 6343 HIV-infected patients have been followed at our Department; 123 received a diagnosis of symptomatic TD (1.94% of the entire cohort). In the TDs group, almost half of patients were females (n = 59, 48%), mean age was 47.15 years (SD: 11.56). At TD diagnosis, mean T CD4+ cell count was 491 cell/uL and most patients showed undetectable HIV-RNA (n = 117, 95.12%). Among them, 81 patients were found to have hypothyroidism (63 with Hashimoto’s thyroiditis), 21 hyperthyroidism (17 suffered from Graves’ disease), while 11 subjects were diagnosed with a primitive thyroid cancer. Papillary thyroid cancer was the most frequent histotype (n = 7, 63.63%), followed by medullary (n = 2, 18.18%) and follicular thyroid cancer (n = 1, 9.1%). Male gender was a protective factor for TDs development, especially for hypothyroidism (p < 0.001); age emerged as a variable associated with both hypothyroidism (p = 0.03) and thyroid cancer (p = 0.03), while CD4+ cell nadir <200 cell/mm³ was associated with symptomatic hyperthyroidism (p = 0.005). To conclude, symptomatic thyroid dysfunctions rate in well-treated HIV-infected patients is low. Age and gender are crucial elements in the onset of thyroid abnormalities, together with T CD4+ cell nadir. Interestingly, medullary thyroid cancer seems to be much more frequent in HIV-infected patients compared to the general population.

[Adrenalitis]

Inflammation of the adrenal glands is caused by autoimmunopathies or infections and can induce adrenal insufficiency. Autoimmune lymphocytic adrenalitis is often combined with other autoimmune diseases and the most frequent cause of Addison's disease; however, it only becomes clinically apparent when more than 90 % of the adrenal cortex has been destroyed. Histological features are characterized by lymphoplasmacytic inflammation leading to an increased destruction of adrenocortical tissue but less severe courses can also occur. The second most frequent form of adrenalitis is adrenal tuberculosis, showing typical granulomatous findings that are nearly always caused by spreading from a tuberculous pulmonary focus. Other bacterial as well as viral infections, such as Epstein-Barr virus (EBV), cytomegalovirus (CMV) and others, generally affect the adrenal glands only in patients with immunodeficiency disorders. In these infections, the adrenal cortex and medulla are frequently involved to roughly the same extent. Although surgical specimens from inflammatory adrenal lesions are extremely rare, the various forms of adrenalitis play an important role in the post-mortem examination of the adrenal glands for clarification of unclear causes of death (e.g. death during an Addisonian crisis).

Prevalence and Influencing Factors of Thyroid Dysfunction in HIV-Infected Patients

Thyroid dysfunction is more common in human immunodeficiency virus (HIV) patients. But the effects of highly active antiretroviral therapy (HAART) and hepatitis B/C virus (HBV/HCV) coinfection on thyroid function is unclear. We retrospectively reviewed the data of 178 HIV patients and determined the prevalence of thyroid dysfunction and the relationship between thyroid hormone levels, CD4 cell count, HIV-1 duration, HAART duration/regimens, and HBV/HCV coinfection. Of the 178 patients, 59 (33.1%) had thyroid dysfunction, mostly hypothyroidism. Thyroid dysfunction was significantly more frequent in the HAART group (41/104, 39.4%) than in the HAART-naïve group (18/74, 24.3%; P < 0.05). The mean CD4 cell count was significantly lower in patients with hypothyroidism (372 ± 331/μL) than in the other patients (P < 0.05). The FT4 level was significantly lower in the HAART group than in the HAART-naïve group (1.09 ± 0.23 versus 1.20 ± 0.29 pg/mL, P < 0.05). FT3/FT4 levels were negatively related to HIV duration and FT3 levels were positively related to CD4 cell (P < 0.05). HBV patients had lower FT3 levels, while HCV patients had higher FT3 and FT4 levels (P < 0.05). Thyroid dysfunction is more common in HIV patients on HAART, mainly manifested as hypothyroidism. FT3/FT4 levels are correlated with HIV progression. HBV/HCV coinfection increases the probability of thyroid dysfunction.

Prevalence and Predictors of Erectile Dysfunctions among Men on Antiretroviral Therapy in South-western Nigeria

Background:

Erectile dysfunctions (EDs) are common presentations among men on anti-retroviral therapy, many of who had a course to discontinue anti-retroviral drugs or search for alternative treatments.

Aim:

This study assessed the prevalence and predictors of ED among men on anti-retro viral therapies (ART) in a Nigerian population.

Subjects and Methods:

It was a descriptive cross-sectional survey among 234 HIV-positive men on anti-retroviral therapy selected using stratified sampling method after excluding for co-morbidities. Research instrument was semi-structured interviewer administered questionnaire, and data were analyzed using the SPSS software version 17.0 (Chicago IL, USA), while binary logistic regression and Chi-square test were used to demonstrate association between selected categorical variable.

Results:

Mean age of respondents was 37.1 (1.6) years, 85.6% have not missed their medications, self-reported adherence was reported as good among 213 [(90.8%) 213/234], though calculated adherence was 90% among as many as 201 [(85.6%) 201/234]. Pattern of EDs revealed weak erection among 42 [(37.8%) 42/111], 15 [(13.5%) 15/111] said they could no longer achieve erection, 33 [(29.7%) 33/111] said they could not maintain erections, while 27 [(24.3%) 27/111] presented with loss of libido. Delayed and premature ejaculations were reported among 24 [(21.6%) 24/111] and 8 [(7.2%) 8/111] respectively. About 14% (33/234) of respondents said that anti-retroviral drugs could have caused their ED while 78% (183/234) said it should not. A statistically significant association exists between having weak erections and age above 65 years and calculated the adherence <95%, while none exists between having weak erections and missing pills.

Conclusion:

Anti-retroviral drugs are common causes of EDs. Concerns of clients should always be addressed most especially issues that may compromise adherence.

Thyroid dysfunction in human immunodeficiency virus-infected children and its correlation with CD4(+) T lymphocyte count

CONTEXT

Thyroid dysfunction has been reported in human immunodeficiency virus (HIV)-infected individuals including children. Some studies have reported that thyroid dysfunction may be a marker of severity or progression of HIV.

AIMS

The aim was to study thyroid function in HIV-infected children with and without highly active anti-retroviral therapy (HAART).

SETTINGS AND DESIGN

Cross-sectional study carried out at a teaching hospital with Anti-Retroviral Therapy Centre (Centre of Excellence) of National AIDS Control Organization.

SUBJECTS AND METHODS

Thyroid stimulating hormone (TSH), total thyroxine (T4), and total tri-iodothyronine (T3) were analyzed in 60 pediatric HIV cases: 30 on HAART and 30 HAART naive. Correlation of T3, T4, and TSH with CD4 count was assessed.

STATISTICAL ANALYSIS USED

Data reported as mean ± standard deviation and as the number of cases and percentages. Comparison between groups was done by independent sample t-test and χ(2)-test. Spearman's correlation coefficient is used to assess the association between thyroid dysfunction and CD4 count.

RESULTS

Thyroid function abnormality was seen in five out of 30 patients in both patients on HAART or without HAART therapy. Among patients on HAART, three had hypothyroidism, and two had biochemical feature of sick euthyroid syndrome. Among the HAART naive group, sub-clinical hypothyroisim was seen in four, and one had biochemical feature of sick euthyroid syndrome. None of the patients had clinical features of thyroid dysfunction. There is a highly significant correlation (P = 0.01) between TSH and CD4 count.

CONCLUSIONS

Thyroid dysfunction is quite common among pediatric HIV cases. An inverse correlation is seen between TSH and CD4 count indicating trend for hypothyroidism as HIV disease progress.

Thyroid abnormalities

Thyroid abnormalities and nonthyroidal illness complicate human immunodeficiency virus (HIV) infection. Among the effects that result from HIV and other opportunistic infections, distinctive features of HIV infection include early lowering of reverse tri-iodothyromine (T3) levels, with normal free T3 levels. Later, some patients develop an isolated low free thyroxine level. After highly active antiretroviral therapy, the immune system reconstitutes in a way that leads to dysregulation of the autoimmune response and the appearance of Graves disease in 1% to 2% of patients. Opportunistic thyroid infections with unusual organisms are most commonly asymptomatic, but can lead to acute or subacute thyroiditis.

HIV associated hypocalcaemia among diarrheic patients in northwest Ethiopia: a cross sectional study

BACKGROUND

Hypocalcaemia, defined by serum calcium level less than 8.5 mg/dl, could be caused by human immunodeficiency virus (HIV) and diarrheal diseases. In Ethiopia, while morbidities from diarrheal diseases and HIV are serious health problems, studies assessing the interactions amongst of the three do not exist. Therefore, the present study was undertaken to investigate the level of calcium among diarrheic patients with and without HIV co-infection.

METHODS

Consecutive diarrheic patients attending Gondar University Hospital in Ethiopia were enrolled and screened for HIV, intestinal parasites, Shigella and Salmonella. Concentration of calcium in serum was determined using an inductively coupled plasma mass spectrometer.

RESULTS

A total of 206 diarrheic patients were included in the study (109 = HIV positive, 97 = HIV negative). Intestinal parasites and Shigella species were detected in 32.2% and 8.5% of the patients, respectively. The serum calcium levels in the patients who were found positive for Shigella species or intestinal parasites was not significantly different by the presence or absence of HIV co-infection. HIV infected diarrheic patients had significantly lower mean serum calcium levels (7.82 ± 1.23 mg/dl) than those negative for HIV (8.38 ± 1.97) (P = 0.015). The age groups 25-35 and greater than 45 years showed significantly lower mean serum calcium levels (7.77 ± 1.55 mg/dl) in comparison to the other age groups (7.84 ± 1.41 mg/dl, P = 0.009). On the other hand, females presented with significantly lower mean serum calcium levels (7.79 ± 1.60 mg/dl, P = 0.044) than males (8.26 ± 1.65 mg/dl).

CONCLUSION

There is high prevalence of hypocalcaemia among diarrheic patients in northwest Ethiopia. And HIV stood out to be a major risk factor for development of hypocalcaemia among the diarrheic patients in northwest Ethiopia. Further studies are required to substantiate and characterize the mechanisms and consequences of calcium metabolism disorders among HIV infected individuals in the study area.

Tuberculosis of the adrenal gland: a case report and review of the literature of infections of the adrenal gland

Infections of the adrenal glands remain an important cause of adrenal insufficiency, especially in the developing world. Indeed, when Thomas Addison first described the condition that now bears his name over 150 years ago, the vast majority of cases were attributable to tuberculosis. Here we describe a classic, but relatively uncommon, presentation in the United States of adrenal insufficiency followed by a review of the current literature pertaining to adrenal infections.

Sexual Dysfunctions of HIV-Positive Men: Associated Factors, Pathophysiology Issues, and Clinical Management

Sexual dysfunctions in HIV-positive men are associated with an increase in risky sexual behavior and decreased adherence to antiretroviral drug regimens. Because of these important public health issues, we reviewed the literature on the pathophysiology, associated factors and clinical management of sexual dysfunction in HIV-positive men. The goal was to investigate the current research on these issues. Literature searches were performed in June 2011 on PubMed, Web of Science, and PsycInfo databases with the keywords “AIDS” and “sexual dysfunction” and “HIV” and “sexual dysfunction”, resulting in 54 papers. Several researchers have investigated the factors associated with sexual dysfunction in HIV-positive men. The association between sexual dysfunction and antiretroviral drugs, particularly protease inhibitors, has been reported in many studies. The lack of standardized measures in many studies and the varying study designs are the main reasons that explain the controversial results. Despite some important findings, the pathophysiology of sexual dysfunction in the HAART era still not completely understood. Clinical trials of testosterone replacement therapy have shown the treatment to be beneficial to the improvement of sexual dysfunctions related to hypogonadism. However, there are not enough psychological intervention studies to make conclusions regarding the therapeutic effects of psychotherapy.

Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease

The successful introduction of highly active antiretroviral therapy (HAART), a combination of potent antiretroviral agents, including protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors, has impacted positively on morbidity and mortality among human immunodeficiency virus (HIV)-positive patients. Over time, HAART has been associated with a number of metabolic and anthropometric abnormalities, including dyslipidemia and insulin resistance as well as subcutaneous fat loss and abdominal obesity, potentially contributing to cardiovascular risk. Recent studies have more firmly established that both HIV infection and HAART might increase the risk of clinical cardiovascular events. Furthermore, whereas HIV/HAART is associated with multiple aspects of endocrine dysfunction, there has been less focus on bone disease, although some studies indicate a higher prevalence of osteoporosis among HIV-positive subjects compared to HIV-negative controls. The relationship between bone and fat metabolism under HIV-positive conditions deserves further attention, and available data suggest the possibility of an intriguing connection. In the future, an increasing population of aging HIV-positive patients with a spectrum of antiretroviral therapies and accumulation of endocrine abnormalities and conventional cardiovascular risk factors will present preventive and therapeutic challenges to our health-care system.

HIV-1 clade C infection and progressive disruption in the relationship between cortisol, DHEAS and CD4 cell numbers: a two-year follow-up study

BACKGROUND

It is well established that there is mutual interaction between the neuroendocrines and immune systems and that the disturbance in any one system could affect the function of the other. While there is a large body of evidence suggesting negative impact of human immunodeficiency virus type 1B (HIV-1B) infection on both immune and neuroendocrine systems, the consequence of HIV-1 clade C infection (with structural differences from HIV-1B virus) on these systems is not clearly understood.

METHODS

We carried out a 2-year longitudinal study on plasma profile of adrenocorticosteroids, including cortisol and DHEAS and their relationship with declining CD4+ cell counts in neurologically asymptomatic HIV-C infected individuals (N=84) in order to understand the impact of HIV-1 clade C infection on adrenocortical dysfunction and its relationship with the progressive decline in the cell mediated immunity.

RESULTS

We found that while plasma cortisol levels increased significantly at baseline in HIV-1C infected individuals compared to those in HIV-negative controls (HIV-1C+, 9.83+/-0.39 vs controls, 8.04+/-0.45; p<0.01), there was a significant decrease in DHEAS in HIV-1C+ individuals, compared to that in HIV-negative controls (81.02+/-4.9 vs 185.1+/-12.03, p<0.001), and consequently a significant increase in cortisol:DHEAS ratio in HIV-1 clade C infected persons (0.19+/-0.002 vs control 0.058+/-0.006; p<0.001). Moreover, in HIV-1C infected individuals, there was a strong positive correlation between DHEAS and CD4 cells (r=0.2; p<0.05), and a strong negative correlation between cortisol, as well as cortisol:DHEAS ratio and CD4 cells (r=-0.25; p<0.01; and r=-0.31; p<0.001, respectively).

CONCLUSIONS

These findings suggest the persistent and progressive adrenocortical dysfunction during the asymptomatic phase of HIV infection, and that the evaluation of increase in plasma cortisol, a decrease in DHEAS, and an increase in cortisol:DHEAS ratio may serve as important biomarkers preceding the impending down regulation of CD4 cell counts and progressive decline in the immune system function in HIV-1C infection. Furthermore, these findings may indicate the dysregulation of 3beta-hydroxysteroid dehydrogenase (3beta-HSD) activity, the enzyme involved in the biosynthesis of cortisol and DHEA through the pregnenolone-progesterone pathway, and that it may offer an opportunity for drug discovery targeting re-regulation of 3beta-HSD activity for potential therapeutic application in HIV-1C infection.

Has Prolactin a Role in the Hypogonadal Status of HIV-Infected Patients?

Most cases of hypogonadism in human immunodeficiency virus (HIV) infection are of hypophyseal— hypothalamic origin, and hyperprolactinemia, also commonly observed in HIV-infected patients, may cause hypogonadism. We studied 188 HIV-infected men who had simultaneous determinations of gonadal and hypophyseal hormones, and we found that prolactin levels were independently predictive of hypogonadism in multivariate analysis.

Reabsorção no metabolismo ósseo de pacientes HIV-positivos

INTRODUÇÃO: Pacientes infectados pelo HIV apresentam osteoporose ou osteopenia densitométrica numa taxa de 28 a 50%. O objetivo deste estudo é verificar alterações na taxa de reabsorção/formação destes pacientes. MATERIAL E MÉTODOS: Realizou-se revisão sistemática com metanálise de estudos controlados que avaliaram a associação entre osteopenia e/ou alterações no metabolismo ósseo com a infecção pelo HIV. Todos os estudos que incluíam osteocalcina ou NTX com marcadores respectivos de formação e reabsorção ósseos foram incuidos. Cinco estudos foram classificados como evidência classe III e envolveram 456 indivíduos HIV positivos e 590 controles. O NTX teve aumento significante (p < 0.00014) no grupo HIV-positivo, enquanto osteocalcina não se mostrou alterada. CONCLUSÃO: O presente estudo permite concluir que, durante a infecção pelo HIV, o marcador NTX está significantemente elevado, refletido alta atividade reabsortiva no tecido ósseo. Isto aponta um papel importante na atividade osteoclástica na perda óssea de pacientes HIV-positivos.

[Bone mineral loss in patients with human immunodeficiency virus infection]

Life expectancy and quality of life among patients infected with human immunodeficiency virus (HIV) has dramatically improved with the advent of highly active antiretroviral therapy. Nonetheless, with the transformation of HIV infection into a chronic disease, a series of long-term consequences have been observed, among them osteoporosis. The prevalence of this condition is increasing among individuals with HIV infection. Although an epidemic of fragility fractures has not been described in these patients, an increase in the incidence of such fractures is anticipated as the HIV population ages, and this will undoubtedly have an impact on their quality of life. The numerous factors that favor the development of osteoporosis in these patients are related to the infection, itself, and the treatment received.

Assessment of the factors involving in the development of hypothyroidism in HIV-infected patients: a case-control study

OBJECTIVES

Increased prevalence of thyroid dysfunction has been reported in HIV-infected patients, and recent studies have shown hypothyroidism as the most common thyroid function abnormality in this population, especially after treatment with antiretroviral drugs (HAART). The aim of this study is to assess risk factors of hypothyroidism in HIV-infected patients in Iran.

DESIGN

This case-control study was conducted among 15 hypothyroid (cases) and 70 euthyroid (control group) HIV-infected outpatients. Serum Free T4, Free T3, and TSH levels were measured, and data on age, sex, body mass index, opium addiction or injection of illicit drugs, duration of HIV infection and HAART, disease stage, CD4-cell count, opportunistic infection (OI) or malignancy, HCV co-infection, and drug use were collected.

RESULTS

We found no association between hypothyroidism in HIV-infected patients and any parameters measured, and P value was not significant for receipt of HAART (0.141), CD4-cell count (0.094), duration of HIV infection (0.474), duration of HAART (0.418), HCV co-infection (0.146), OI (0.566), or receipt of rifampin (0.816).

CONCLUSION

In this study, age, sex, HAART, mean CD4- cell count, duration of HIV infection, HCV co-infection, and OI were not significant risk factors of hypothyroidism in HIV-infected patients. The occurrence of hypothyroidism may be related to other factors or HIV infection itself. Therefore, hypothyroidism should be considered in all HIV-infected patients.

Coccidioides immitis fungemia: clinical features and survival in 33 adult patients

Coccidioides immitis is a fungus endemic to the southwestern United States. Susceptible hosts, including blacks, Hispanics, Filipinos, Native Americans, and those with compromised immunity, may develop disseminated disease, including fungemia. We retrospectively reviewed the records of all patients (n = 33) with Coccidioides immitis fungemia (CIF) at a 550-bed public hospital in Phoenix, Arizona, from 1990 to 2002. This is the largest reported series of CIF. The purpose of the study was to review the incidence, signs, symptoms, and outcomes of CIF. Twenty-nine patients had human immunodeficiency virus infection. CIF was associated with sepsis, end-stage alcoholic liver disease, and diabetes in four patients. Survival was poor; 24 of the 33 patients died within 28 days. CIF manifested as a systemic inflammatory response syndrome with progressive cardiorespiratory failure. Despite fluid loading, infusion of vasoactive agents, and mechanical ventilation with positive end-expiratory pressure, patients typically experienced a rapidly progressive course and death. CIF portends an ominous prognosis and typically occurs in the setting of advanced human immunodeficiency virus or medical or surgical crises.

Thyroid function in human immunodeficiency virus patients treated with highly active antiretroviral therapy (HAART): a longitudinal study

OBJECTIVE

Given that few and controversial data have been reported on thyroid function in human immunodeficiency virus (HIV) patients on highly active antiretroviral therapy (HAART), we further investigated whether HAART affects thyroid hormones.

DESIGN AND PATIENTS

Two hundred two consecutive adult HIV patients in stable clinical condition were enrolled, 182 on HAART and 20 naïve; 128 were rechecked during follow-up. Body mass index (BMI), CD4 cell count, HIV RNA, hepatitis C and B virus status and infection duration were determined in all HIV patients and HAART duration in treated patients. In all patients and in 60 controls, the following were measured: FT4 and FT3 by radioimmunoassay; TSH, antithyroid peroxidase (TPO) and antithyroglobulin (TG) antibodies by immunoradiometric assay.

RESULTS

Abnormalities in thyroid function tests were found in 23/182 (12.6%) HAART patients, but not in naïve patients. Most abnormalities were subclinical hypothyroidism, with mean FT4 and TSH levels lower and higher, respectively, in HAART patients compared to naïve patients and controls, FT4 levels being significantly lower than controls. TSH negatively correlated with CD4 count nadir and positively with HAART duration. During follow-up, FT4 and FT3 significantly decreased and TSH increased in patients continuing HAART, whereas CD4 counts were unmodified; subclinical hypothyroid conditions persisted and further cases occurred, whereas the only hypothyroid patient who interrupted HAART shows a normalization of thyroid tests. Patients on stavudine, included in most hypothyroid patient protocols, had significantly lower FT4 levels with prolonged treatment.

CONCLUSIONS

HAART, particularly stavudine, is associated with a high prevalence of subclinical hypothyroidism. Hypotheses are made regarding responsible mechanisms and risk factors. Thyroid function should be tested and sequentially rechecked in HAART patients.

Adrenal infections

Adrenal infections are an important but under-recognized clinical entity. The adrenal gland can be infected by a myriad of pathogens including fungi, viruses, parasites, and bacteria. Infection can directly or indirectly cause tissue damage and alteration in endocrine function. Direct damage occurs via microbial replication and local production of toxic compounds, such as endotoxins. Indirect damage results from alterations in the regulation of a host's immunologic and endocrine mediators in response to damage by a microbe at a distant site. Variations in pathogen tropism, adrenal anatomy, and host immune integrity contribute to the progression of active disease and discernable adrenal dysfunction. Early recognition and intervention in the case of adrenal infection can significantly improve outcome, demonstrating the need for increased clinical suspicion in the appropriate clinical setting.

Adverse effects of antiretroviral therapy: focus on bone density

Osteopenia and osteoporosis are the most important bone disorders affecting patients with HIV infection. The available data indicate that HIV-infected patients have a high prevalence of low bone mineral density. Reduced bone mass and alterations of bone metabolism have been found in HIV-infected children, adolescents and adults. The variety and complexity of changes in bone metabolism in patients with HIV infection and the different possible mechanisms triggering bone mineral loss, as well as the different stages of disease and cumulative exposure to antiretroviral drugs at the time of clinical evaluation, may contribute to the wide range of mineral loss observed and to the uncertainty of the role of specific antiretroviral medications.

An Increased Risk of Osteoporosis during Acquired Immunodeficiency Syndrome

Osteoporosis is characterized by decreased bone mineral density and mechanistic imbalances of bone tissue that may result in reduced skeletal strength and an enhanced susceptibility to fractures. Osteoporosis in its most common form affects the elderly (both sexes) and all racial groups of human beings. Multiple environmental risk factors like acquired immune deficiency syndrome (AIDS) are believed to be one of the causes of osteoporosis. Recently a high incidence of osteoporosis has been observed in human immunodeficiency virus (HIV) infected individuals. The etiology of this occurrence in HIV infections is controversial. This problem seems to be more frequent in patients receiving potent antiretroviral therapy. In AIDS, the main suggested risk factors for the development of osteoporosis are use of protease inhibitors, longer duration of HIV infection, lower body weight before antiretroviral therapy, high viral load. Variations in serum parameters like osteocalcin, c-telopeptide, levels of elements like Calcium, Magnesium, Phosphorus, concentration of vitamin-D metabolites, lactate levels, bicarbonate concentrations, amount of alkaline phosphatase are demonstrated in the course of development of osteoporosis. OPG/RANKL/RANK system is final mediator of bone remodeling. Bone mineral density (BMD) test is of added value to assess the risk of osteoporosis in patients infected with AIDS. The biochemical markers also aid in this assessment. Clinical management mostly follows the lines of treatment of osteoporosis and osteopenia.

HIV infection--a risk factor for osteoporosis

Osteopenia and osteoporosis have recently been described as complications of antiretroviral therapy in HIV-infected patients. The advent of highly active antiretroviral therapy in conjunction with improved standard antiviral and antibiotic regimens has dramatically changed the clinical course of HIV infection, resulting in prolonged survival. The pathogenesis and role of each individual medication are poorly understood. Avascular necrosis has also been described in AIDS patients receiving or not receiving antiretroviral therapy. This article is a clinically focused review of the literature on osteopenia, osteoporosis, and mineral metabolism related to HIV infection. In patients with HIV infection, the risks of osteopenia and osteoporosis are not very clear. The suggested risk factors for the development of osteopenia are use of protease inhibitors, longer duration of HIV infection, high viral load, high lactate levels, low bicarbonate levels, raised alkaline phosphatase level, and lower body weight before antiretroviral therapy. There have also been a few case reports of pathologic fractures in AIDS patients with antiretroviral therapy-induced osteopenia and osteoporosis. The underlying mechanism triggering bone loss in HIV-infected patients is unknown. The proinflammatory cytokines tumor necrosis factor and interleukin-6 have been found to be constitutionally produced in increased amounts in HIV-positive individuals, and they may have a role in osteoclast activation and resorption. Serum markers of bone formation are decreased and resorption is increased in patients with advanced clinical disease. Hypocalcemia, hypercalcemia, and abnormalities of the parathyroid hormone axis have been described in HIV infection. Histomorphometric analyses have shown altered bone remodeling in HIV-infected patients when compared with controls. Patients with known risk factors for osteoporosis-advancing age, low body weight, and prolonged duration of HIV infection-and those receiving protease inhibitor treatment should be considered for dual x-ray absorptiometry imaging. If bone mineral density is osteopenic or osteoporotic, then the patient should also be screened for other known medical causes of osteoporosis and consider treatment with a bisphosphonate or, if hypogonadal, testosterone replacement under close monitoring.

Adrenal insufficiency during septic shock

OBJECTIVE

To determine whether a baseline (random) cortisol concentration <25 microg/dL in patients with septic shock was a better discriminator of adrenal insufficiency than the standard (250 microg) and the low-dose (1 microg) corticotropin stimulation tests as assessed by the hemodynamic response to steroid replacement.

SETTING

Intensive care unit.

PATIENTS

Fifty-nine patients with septic shock. Their mean age was 57 +/- 16.7 yrs; 29 were male.

INTERVENTIONS

A baseline cortisol concentration was obtained. Patients then received an intravenous injection of 1 microg of corticotropin (low-dose test) followed 60 mins later by an injection of 249 microg of corticotropin (high-dose test). Cortisol concentrations were obtained 30 and 60 mins after low- and high-dose corticotropin. All patients were administered hydrocortisone (100 mg every 8 hrs) for the first 24 hrs while awaiting results of cortisol assessment. Patients were considered steroid responsive if the pressor agent could be discontinued within 24 hrs of the first dose of hydrocortisone.

MEASUREMENTS AND MAIN RESULTS

Forty-seven percent of patients died. Twenty-two percent of patients met the diagnostic criteria of adrenal insufficiency by the low-dose test and 8% by the high-dose test. However, 61% of patients met the criteria of adrenal insufficiency when we used a baseline cortisol concentration of <25 microg/dL. Twenty-two patients (37%) were steroid responsive; the baseline serum cortisol was 14.1 +/- 5.2 microg/dL in the steroid-responsive patients compared with 33.3 +/- 18 microg/dL in the steroid-nonresponsive patients (p <.0001). Ninety-five percent of steroid-responsive patients had a baseline cortisol concentration <25 microg/dL. Fifty-four percent of steroid responders had a diagnostic low-dose test and 22% a diagnostic high-dose test. Receiver operating characteristic curve analysis revealed that a stress cortisol concentration of 23.7 microg/dL was the most accurate diagnostic threshold for determination of the hemodynamic response to glucocorticoid therapy.

CONCLUSIONS

Adrenal insufficiency is common in patients with septic shock, the incidence depending largely on the diagnostic test and criteria used to make the diagnosis. There is clearly no absolute serum cortisol concentration that distinguishes an adequate from an insufficient adrenal response. However, we believe that a random cortisol concentration of <25 microg/dL in a highly stressed patient is a useful diagnostic threshold for the diagnosis of adrenal insufficiency.

Adrenal insufficiency in the critically ill: a new look at an old problem

Stress from many sources, including pain, fever, and hypotension, activates the hypothalamic-pituitary-adrenal (HPA) axis with the sustained secretion of corticotropin and cortisol. Increased glucocorticoid action is an essential component of the stress response, and even minor degrees of adrenal insufficiency can be fatal in the stressed host. HPA dysfunction is a common and underdiagnosed disorder in the critically ill. We review the risk factors, pathophysiology, diagnostic approach, and management of HPA dysfunction in the critically ill.

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.

Adrenal insufficiency in critically ill patients with human immunodeficiency virus

OBJECTIVE

The adrenal gland is the endocrine organ most commonly involved in patients infected with human immunodeficiency virus (HIV). It is important to recognize patients with adrenal insufficiency, because this disorder may be fatal if untreated. The incidence of adrenal insufficiency in critically ill HIV-infected patients is unclear, partly because different criteria are used to diagnose adrenal insufficiency. To help clarify the incidence of adrenal insufficiency in HIV-infected critically ill patients, we compared the incidence based on the stress cortisol concentration, low-dose corticotropin stimulation test, and high-dose corticotropin stimulation test.

SETTING

Medical intensive care unit.

PATIENTS

Twenty-eight critically ill patients with HIV, mean age 43 +/- 9 years; 20 were male; 54% died.

INTERVENTIONS

We performed a 1-microg (low-dose adrenocorticotropic hormone; LD-ACTH) and 249 microg (high-dose; HD-ACTH) corticotropin stimulation test in HIV-infected critically ill patients not receiving corticosteroids. According to results of the stress serum cortisol concentration and LD-ACTH and HD-ACTH tests, patients were classified as having adrenal insufficiency or as normal. The results of newly revised diagnostic criteria for adrenal insufficiency (i.e., stress cortisol concentration and cortisol response to LD-ACTH <25 microg/dL) were compared with the traditional criteria (i.e., stress cortisol level and response to HD-ACTH <18 microg/dL). In addition, the associations between adrenal insufficiency and the CD4 count, human cytomegalovirus antigenemia, and other risk factors for adrenal insufficiency were determined.

MEASUREMENTS AND MAIN RESULTS

When we used a stress cortisol concentration <18 microg/dL as the sole diagnostic threshold for diagnosis of adrenal insufficiency, 50% (14 of 28) of patients had adrenal insufficiency. The incidence was 75% (21 of 28) when we used a diagnostic threshold of <25 microg/dL for the stress cortisol concentration. When we used both the stress cortisol concentration and LD-ACTH test with a diagnostic cortisol threshold concentration <18 microg/dL, 21% (six of 28) had adrenal insufficiency. The incidence was 46% (13 of 28) when we used a cortisol diagnostic threshold concentration of <25 microg/dL. When we used both the stress cortisol concentration and the HD-ACTH stimulation test with a diagnostic cortisol threshold of <18 microg/dL, 7% (two of 28) had adrenal insufficiency. The incidence of adrenal insufficiency was 21% (six of 28) with a cortisol diagnostic threshold value of <25 microg/dL. Human cytomegalovirus antigenemia was the only variable assessed that was associated with adrenal insufficiency.

CONCLUSION

There is a high incidence of adrenal insufficiency in critically ill HIV-infected patients that varies with the criteria used to diagnose adrenal insufficiency. The LD-ACTH stimulation test is more sensitive than the high-dose test for diagnosing adrenal insufficiency in this population. Because of the high incidence of inadequate adrenal function, all critically ill HIV-infected patients should undergo an evaluation for adrenal insufficiency with the stress cortisol concentration and LD-ACTH stimulation tests.

Serum prolactin concentrations in patients infected with human immunodeficiency virus

PURPOSE

To analyze the prevalence, effects of HAART, and implications of hyperprolactinemia in HIV-infected patients.

METHOD

192 HIV-infected men in stable clinical condition who underwent 355 measurements of prolactin were prospectively studied. Other clinical, immunologic, virologic, and laboratory parameters were also evaluated at the time of each prolactin measurement.

RESULTS

Hyperprolactinemia was observed in 21.4% of the patients. Hyperprolactinemia was more commonly found in patients receiving opioids than in those who were not (p =.03), but it was not influenced by a past diagnosis of AIDS, presence of metabolic disturbances, gynecomastia, or viral load. Patients noninfected with hepatotropic viruses had slightly higher prolactin levels than those who were infected (p =.049). There were significant differences in the rates of hyperprolactinemia according to different CD4 strata, with higher rates in patients with higher CD4 counts. Similarly, hyperprolactinemic patients had higher CD4 counts than patients with normal prolactin (p =.038). Antiretroviral therapy was not associated with prolactin levels.

CONCLUSION

Hyperprolactinemia is a common finding in HIV infection and is observed in about one fifth of male patients in stable clinical condition. It is not related to antiretroviral therapy, metabolic disturbances, liver disease, or viral load. The implications of its association with CD4 counts are unclear and should be investigated.

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.

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.

[Clinical and laboratory renal alterations in patients with acquired immunodeficiency syndrome in relation to anatomopathological findings]

Clinical as well as renal anatomopathological data of 119 patients with acquired immunodeficiency syndrome from the Hospital of the Faculty of Medicine of Triângulo Mineiro, Uberaba, MG, Brazil, were studied. Mean age was 33 +/- 10.4 years (range 18 to 67 years). White (59%) and male (80%) individuals predominated. Ninety percent of patients came from Uberaba or neighborhood. There were 59 (50%) heterosexual, 25 (21%) homosexual, 17 (14%) bisexual and 18 (15%) unknown. Forty three percent were drug abusers. Fourteen (12.2%) of patients had serum creatinine higher than 3mg/dl, ten days before death, 64% of them showed acute tubular necrosis. Seventy one (61%) patients presented hyponatremia and 8 (7%) had hypernatremia. Hypokalemia was detected in 28 (24%) and hyperkalemia in 8 (7%) patients. Twenty four hours urinary protein was detected in 12 patients, 7 of them presenting more than 1g/24h. Two patients showed segmentar focal glomerulosclerosis, one of them with 24h urinary protein level of 5.5 g and serum creatinine 1.5 mg/dl and no edema. The most (56%) patients had tubulointerstitial nephritis. Clinical, laboratory and types of renal disorders in patients with acquired immunodeficiency syndrome are variable. The glomerular diseases were relatively scarce however, tubulointerstitial lesions are quite frequent, mainly interstitial nephritis and acute tubular necrosis. Not always an anatomoclinical correlation could be observed, because many times the electrolyte disorders were frequently observed only functionally.

Decreased bone formative and enhanced resorptive markers in human immunodeficiency virus infection: indication of normalization of the bone-remodeling process during highly active antiretroviral therapy

As cytokines and 1,25-dihydroxyvitamin D [1,25-(OH)2D] appear to have an important role in bone homeostasis, we examined the possibility that human immunodeficiency virus (HIV)-infected patients, characterized by enhanced levels of proinflammatory cytokines and 1,25-(OH)2D deficiency, have disturbed bone metabolism by analyzing serum markers of bone formation (osteocalcin) and bone resorption (C-telopeptide) in 73 HIV-infected patients. HIV-infected patients with advanced clinical and immunological disease and high viral load were characterized by increased C-telopeptide and particularly by markedly depressed osteocalcin levels. HIV-infected patients had enhanced activation of the TNF system. Serum concentrations of p55 and p75-TNF receptors were negatively correlated with osteocalcin, and p75-TNF receptor was positively correlated with C-telopeptide. HIV-infected patients with advanced disease also had decreased serum concentrations of 1,25-(OH)2D, but this parameter was not correlated with osteocalcin or C-telopeptide. During 24 months with highly active antiretroviral therapy there was a marked rise in serum osteolcalcin levels together with a profound fall in viral load and TNF components and a marked rise in CD4+ T cell counts. Also, there was a shift from no correlation to a significant correlation between osteocalcin and C-telopeptide levels during such therapy. The present study suggests disturbed bone formation and resorption during HIV infection. Our findings indicating synchronization of bone remodeling during highly active antiretroviral therapy may represent a previously unrecognized beneficial effect of such therapy and expand our knowledge of the interactions between cytokines and bone in the bone-remodeling process.

The Thyroid in Acquired Immunodeficiency Syndrome

Forty-seven thyroids obtained at autopsy from patients with acquired immunodeficiency syndrome (AIDS) with no clinical manifestations of thyroid disease were analyzed systematically in order to determine the frequency and the major pathological characteristics of thyroid involvement in these individuals. The glands were obtained from 38 men and 9 women aged (on average) 33.6 yr. The specimens were weighed, measured, and evaluated after fixation in formalin Histological examination was performed on at least 10 macroscopically normal and altered areas. The anatomopathological lesions detected in 29 glands (613%) were chronic nonspecific focal inflammation (482%); mycobacteriosis and colloid goiter (172%); histoplasmosis, cryptococcosis, and lipomatosis (133%), and paracoccidioidomycosis and hyperplastic nodules (3A%). Although thyroid disease had not been clinically diagnosed, thyroid involvement was elevated (613%) and in 14 cases (293%) it was related to the immunodeficiency, with mycobacteria being the most common opportunistic agents. There appears to be no report of the association of lipomatosis with AIDS, although this was a frequent finding in the present study (13 7%), exceeding by far the rates reported in the literature (1-2%). Thus, thyroid lesions are frequent in AIDS patients, occurring in two thirds of the patients studied, especially those with disseminated infection.

[Peripheral adrenal insufficiency in AIDS]

BACKGROUND

Lesions of adrenal glands are common findings at autopsy of patients with acquired immunodeficiency syndrome (AIDS). In contrast the diagnosis of symptomatic adrenal insufficiency is rarely established during the lifetime of these patients.

PATIENTS

We report four new cases and review the literature. All four patients had full blown AIDS with a mean CD4 cell count of 19 mu/L. One or more opportunistic disease was present at the time of diagnostic: cytomegalovirus retinitis in two cases, disseminated Mycobacterium avium infection in two, Kaposi's sarcoma in two and Candida esophagitis in one.

RESULTS

The clinical presentation constantly included fatigue, weight loss, severe orthostatic hypotension and gastrointestinal disturbances. Cutaneous hyperpigmentation was present in three cases. In most cases biological abnormalities were typical, such as hyponatremia, urinary Na/K ratio > or = 1, and hyperkalemia. Serum cortisol levels were within the range of normal in three cases but response to the cosyntropin challenge was typically impaired in all cases. Clinical and biological manifestations returned to normal in 1 to 3 weeks after initiation of therapy with cortisol, associated to fludrocortisone in three cases. However, 13 months after diagnosis, three patients were dead.

CONCLUSION

Usually asymptomatic, diagnostic of symptomatic adrenal insufficiency must be suspected even when clinical presentation is atypical because rapid efficiency of hormonal treatment.

Hypercalcemia in an AIDS patient treated with growth hormone

METHOD

Recombinant human growth hormone (rhGH) is a newly approved treatment for weight loss and wasting in patients with AIDS. We report a male patient with advanced AIDS who developed hypercalcemia 2 weeks after institution of rhGH therapy.

RESULTS

Parathyroid hormone, parathyroid hormone-related peptide and 1,25-dihydroxyvitamin D levels were suppressed, suggesting that hypercalcemia was mediated through alternative mechanisms. The hypercalcemia responded to discontinuation of rhGH and a single dose of intravenous pamidronate disodium and has not recurred in 8 months of follow-up.

CONCLUSION

We believe this to be the first reported case of rhGH-induced hypercalcemia in an HIV-infected patient.