1/8. Minimizing HIV/AIDS malnutrition. HIV/AIDS malnutrition influences immune function, disease progression, and quality of life. Changes in dietary intake, altered metabolism, and malabsorption are among the mechanisms that contribute to the nutritional alterations seen in HIV/AIDS. Medical-surgical nurses can help their patients minimize HIV/AIDS malnutrition through early and ongoing assessment, which guides nutritional and pharmacologic interventions. ( info) |
2/8. Resolution of HIV-associated nephrotic syndrome with highly active antiretroviral therapy delivered by gastrostomy tube. There is no consensus regarding the specific management of HIV-associated nephrotic syndrome. We report a child whose first manifestation of human immunodeficiency virus type 1 (hiv-1) infection was nephropathy and wasting syndrome associated with profound immunodeficiency. The patient had a dramatic clinical and immunologic response to triple antiretroviral therapy delivered through a gastrostomy tube, with complete resolution of nephrotic syndrome. A 51/2-year-old African-American girl presented with a 2-week history of cough, chest pain, vomiting, loose stools, abdominal distention, anorexia, and fever. In addition, she had recurrent oral thrush. Her weight and height were below the 5th percentile. She was chronically ill, appearing with oropharyngeal thrush and pitting edema in lower extremities. She had scattered rhonchi and decreased breath sounds on both lung bases. Her abdomen was distended and diffusely tender. A chest radiograph showed consolidation of the right upper and left lower lobes with bilateral pleural effusion. Admission laboratories were consistent with nephrotic syndrome. streptococcus pneumoniae grew from the blood culture and the child responded well to treatment with intravenous ceftriaxone. She was found to be HIV-infected, her CD4( ) cell count was 3 cells/mcL and her plasma hiv-1 rna was >750 000 copies/mL. A percutaneous gastrostomy tube was placed for supplemental nutrition. She was treated with stavudine, lamivudine, and nelfinavir via gastrostomy tube with good clinical response. Twenty-one months after instituting antiretroviral therapy, her weight and height had increased to the 50th and 10th percentile respectively, and she had complete resolution of her nephrotic syndrome. Her CD4( ) cell count increased to 1116 cells/mcL and her viral load has remained undetectable. hiv-1 associated nephrotic syndrome has been described in children with profound immunodeficiency. The course of untreated HIV-associated nephrotic syndrome is rapid progression to renal failure in up to 40% of the children. Regardless of the presence of renal insufficiency, if untreated, it is uniformly fatal. A modest improvement of hiv-1 associated nephrotic syndrome has been observed in patients treated with zidovudine. Steroid and cyclosporine treatment have resulted in improved renal function but long-term use of immunosuppressive therapy has raised concerns about safety. We have described, to our knowledge, the first child with HIV-associated nephrotic syndrome who had a remarkable clinical, immunologic, and virologic response to triple-drug combination therapy given by gastrostomy tube, with complete resolution of proteinuria and normalization of the serum albumin. She also had a striking improvement in weight, height, and quality-of-life. Whether the presence of a gastrostomy tube contributed to the excellent response because of improved compliance is unknown, but warrants systematic evaluation. ( info) |
3/8. A team approach to the treatment of AIDS wasting. Despite the aggressive use of antiretroviral agents, AIDS wasting (AW) affects many persons infected with HIV. AW is characterized by a disproportionate loss of metabolically active tissue, specifically body cell mass--tissue involved with glucose oxidation, protein synthesis, and immune system function. AW correlates with poor quality of life and clinical outcomes. This condition requires a multidisciplinary team approach for effective management. Optimal maintenance of lean body mass and reversal of AW involves a combination of appropriate antiretroviral use, opportunistic infection prophylaxis, optimal nutrition, exercise, body composition monitoring, anabolic agents including growth hormone (rhGH[m]) and testosterone supplementation, mental health support, economic aid, and legal assistance. The team approach to treatment of AW requires the coordinated activity of nurses, dietitians, physicians, pharmacists, social workers, case managers, reimbursement personnel, caregiver(s), physical therapists, and the patient. This article, based on clinical experience treating AW, explains how the condition is managed using a multidisciplinary team approach. ( info) |
| The association between pharmacologic doses of corticosteroids and the development of aseptic bone necrosis has been well documented. Recent reports have described the corticosteroid activity of megestrol acetate. A retrospective review of adverse events reported to the U.S. food and Drug Administration identified three human immunodeficiency virus (HIV) seropositive patients who developed avascular necrosis of the femoral head during treatment with megestrol acetate. All were males, ages 34, 36, and 55 years, and were on therapy for 6, 1.5, and 18 months, respectively, when symptoms of aseptic necrosis occurred in the absence of antecedent trauma. megestrol acetate doses were 640, 320, and 600-1200 mg/d, respectively. Two patients had no history of corticosteroid use whereas the third had taken an undisclosed dose and duration of corticosteroids concurrent with pentamidine administration. Notably, despite the predominant use of megestrol in women for hormone sensitive malignancies, none of the reports of aseptic necrosis occurred in this population. megestrol acetate may be associated with the development of avascular necrosis via its glucocorticoid-like effects. Cachectic acquired immunodeficiency syndrome (AIDS) patients may have additional risk factors that predispose them to aseptic necrosis when receiving megestrol acetate. ( info) |
| Recombinant human growth hormone (rhGH) is an important treatment option for patients with human immunodeficiency virus (HIV) wasting syndrome. Side effects of rhGH are minimal when administered at physiologic and moderately high dosages, as seen in growth hormone deficiency and Turner's syndrome, respectively. The dosage of rhGH is significantly higher to treat wasting syndrome and still is being studied to determine its long-term efficacy and safety. Individuals with HIV infection are at increased risk for adverse effects due to polypharmacy, immune system alterations, and treatment with newer agents that lack long-term safety data. In addition, rhGH's potential for side effects becomes greater when given at high dosages for wasting syndrome. Clinically significant hyperglycemia developed in an HIV-positive man who started rhGH for wasting syndrome 38 days before the diagnosis of diabetes mellitus. ( info) |
6/8. weight gain, improvement in metabolic profile, and CD4 count with insulin administration in an AIDS patient. malnutrition with muscle wasting, weight loss, and decreased immunogenicity is a hallmark of Acquired Immune Deficiency Syndrome (AIDS). Several anabolic agents have been utilized for retarding or preventing progressive wasting with limited success. However, insulin, with its most effective anabolic properties, has not been tried in an attempt to prevent or reverse cachexia in AIDS or any other wasting disorders. We report here the effect of using subcutaneous (s.c.) daily administration of insulin 0.3 U/kg (BW) for 6 months in a subject with AIDS. We noted a marked weight gain, improvement in metabolic profiles, that is, lowering of triglyceride, liver enzymes, glycohemoglobin concentrations, as well as 24-hour urinary excretion of urea nitrogen, protein, and creatinine suggestive of positive energy balance. Simultaneously, a marked rise in CD4 counts and an improvement in the thyroid hormone profile were also noted. A deterioration in these parameters occurred during the period of insulin withdrawal following completion of the study protocol. Resumption of insulin administration, on patient's request, once again resulted in the marked improvement similar to that noted during the study period. No adverse effects, including hypoglycemic episodes, were noted during either phase of insulin administration. The possibility that insulin administration may improve the wasting associated with AIDS may warrant further evaluation. ( info) |
7/8. Eyelid retraction and incomplete eyelid closure secondary to human immunodeficiency virus-associated muscle wasting. Human immunodeficiency virus (HIV)-associated weight loss remains a significant problem, even in the era of highly active antiretroviral therapy. This interventional case report describes eyelid retraction and poor eyelid closure caused by orbicularis atrophy in the setting of HIV-associated muscle wasting. A 65-year-old HIV-infected man sought treatment for chronic ocular irritation. On examination, he was thin with marked temporal wasting. Corneal epithelial defects were present bilaterally. There was 2 mm of superior scleral show in the right eye and trace inferior scleral show bilaterally. With attempted closure, lagophthalmos approached 1 cm in the right eye and was 3 mm in the left eye. The remainder of the examination was unremarkable. gold weight placement achieved symptomatic improvement with adequate eyelid closure. biopsy demonstrated fibrous tissue with an absence of identifiable muscle fibers. In the setting of HIV-associated muscle wasting, orbicularis oculi muscle atrophy may result in eyelid retraction, lagophthalmos, and ocular surface disease. ( info) |
8/8. 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. ( info) |