LIPODYSTROPHY
E88.1
DESCRIPTION
Both lipoatrophy and lipohypertrophy can occur as a complication or association of cART. The risk factors include virologic response to therapy and pubertal development during protease inhibitor therapy.
Lipodystrophy contributes to non-adherence to ART as a patient may be embarrassed by his/her physical appearance.
Stavudine, didanosine and zidovudine in decreasing order are the main causes of lipoatrophy.
The relationship between lipohypertrophy, hypercholesterolaemia, hypertriglyceridaemia, insulin resistance with puberty, body habitus and ART (especially protease inhibitors), is less clear but an association has been described.
DIAGNOSTIC CRITERIA
- Lipoatrophy:
- Subcutaneous fat loss (lipoatrophy) of the face, extremities or buttocks.
- Lipohypertrophy:
- Fat accumulation (lipohypertrophy) in the abdomen, or over the dorsocervical spine (buffalo hump) and breast enlargement.
- Excessive breast enlargement during puberty (lipomastia).
- Insulin resistance may be suspected if there is:
- fasting hyperglycaemia,
- frank diabetes or acanthosis nigricans,
- biochemical features include an elevated fasting C-peptide or an abnormal glucose/insulin ratio.
- Abnormal lipid profile: See Chapter: Cardiovascular System, Dyslipidaemia .
- hypercholesterolaemia, i.e. total cholesterol level > 5 mmol/L; and
- hypertriglyceridaemia, i.e. fasting triglyceride level > 1.7 mmol/L with possible consequences of premature atherosclerosis.
GENERAL AND SUPPORTIVE MEASURES
- Dietary modification and exercise for lipohypertrophy, insulin resistance and abnormal lipid profile.
MEDICINE TREATMENT
Modification of ART, e.g. replace stavudine with abacavir or tenofovir, depending on the age of the child/adolescent with lipoatrophy.
Note:
Viral suppression must be present for a single drug substitution. If viral suppression is not present obtain expert advice.
If hyperlipidaemia is confirmed,
- Refer to Chapter: Cardiovascular System, Dyslipidaemia for medicine treatment recommendations.
REFERRAL
- All patients for confirmation of diagnosis and initiation of therapy.
See Chapter: Endocrine System, Obesity .
IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS)
D89.3
DESCRIPTION
Clinical deterioration can occur after starting cART due an improvement in the immune system response to organisms already causing infection, e.g.
- M bovis BCG ,
- C. neoformans ,
- M. tuberculosis (MTB) ,
- Aspergillus,
- M. avium complex ,
- C. albicans ,
- M. leprae ,
- Human Herpes viruses,
- P. jiroveci ,
- Human Papilloma virus,
- CMV,
- Hepatitis B and C viruses (HBV, HCV),
- JC virus.
There are 2 manifestations of IRIS:
- Unmasking occurs when a previously unsuspected condition manifests.
- Paradoxical, i.e. known condition on appropriate treatment becomes worse.
DIAGNOSTIC CRITERIA
- Exclude other active or inadequately treated diseases (including MDR TB).
- Ensure adherence to the prescribed therapy.
- Presentation:
- Usually during the first 6 weeks after starting cART.
- Clinical presentation depends on the causative organism and the organ-system involved, e.g. TB presents with fever, lymphadenopathy, worsening of the original tuberculous lesion, and/or deteriorating chest radiographic manifestations such as miliary pattern or pleural effusion.
MEDICINE TREATMENT
Treat underlying disease aggressively.
Antimicrobial therapy for specific infections.
In severe reactions:
- Prednisone, oral, 1.5 mg/kg daily for 2 weeks followed by 0.75 mg/kg daily for 2 weeks.
Usually cART is continued, and the underlying condition managed.
Local IRIS with M. bovis BCG usually does not require antimicrobial therapy.
WASTING SYNDROME
B22.2
This syndrome appears to be a combination of the direct effects of advanced HIV infection and the occurrence of opportunistic infections.
TREATMENT
Nutritional advice. See Chapter: Alimentary Tract, Malnutrition .
cART may reverse some of the features of HIV wasting syndrome.
Exclude chronic infection, e.g. tuberculosis and M. avium complex , malabsorption and malignancy.