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1/13. bezafibrate-induced improvement in glucose uptake and endothelial function in protease inhibitor-associated insulin resistance.

    protease inhibitors used as therapy for hiv-1 infection have been associated with metabolic side-effects such as peripheral fat wasting, central adiposity, hyperlipidaemia and insulin resistance. This metabolic disorder is known as the lipodystrophy syndrome. This syndrome can be recognized by the early appearance of an increase in serum triglyceride, cholesterol and plasma-free fatty acid levels. Here, we describe an hiv-1 positive patient with the lipodystrophy syndrome in whom a decline in serum triglycerides was seen along with a significant improvement in glucose uptake following treatment with bezafibrate for 3 months. This improvement may be a consequence of the Randle effect, i.e. increased availability of plasma-free fatty acids is negatively correlated to glucose uptake. We also noted a significant improvement in endothelial-dependent flow-mediated dilatation after treatment with bezafibrate. This effect could result from the increased glucose uptake observed and a decrease in insulin resistance secondary to the lowered triglyceride levels by bezafibrate. We conclude that bezafibrate may be of clinical utility in the lipodystrophy syndrome, through its beneficial effects on insulin resistance, glucose uptake and endothelial dysfunction. ( info)

2/13. A case of HIV-associated facial lipoatrophy treated with 1000-cs liquid injectable silicone.

    BACKGROUND: patients infected with the HIV may experience HIV-associated lipodystrophy, a symptom of which is facial lipoatrophy, a dramatic loss of subcutaneous facial tissue. This visible manifestation of HIV infection causes significant psychosocial pain for patients and has been associated with impaired compliance with medical regimens. OBJECTIVE: To improve the appearance of facial lipoatrophy in a safe, long-lasting, expeditious, and relatively economical manner. methods: An HIV-associated lipodystrophy patient with facial lipoatrophy underwent multiple sessions of soft-tissue augmentation therapy with liquid injectable silicone (LIS) using the microdroplet serial puncture technique. RESULTS: Administration of LIS by the microdroplet serial puncture technique produced satisfactory improvement of areas of facial atrophy. The treatment time is limited, the patient discomfort and morbidity are minimal, and results are long lasting. patients report significant satisfaction with treatment. CONCLUSION: LIS administered by the microdroplet serial puncture technique is a safe and effective method for treating HIV-associated facial lipoatrophy and compares favorably with other methods of tissue augmentation. ( info)

3/13. Improvement of fat redistribution, insulin resistance and hepatic fatty infiltration in hiv-associated lipodystrophy syndrome by pioglitazone: a case report.

    hiv-associated lipodystrophy syndrome is a syndrome occurring in HIV-infected patients who were treated with highly-active antiretroviral therapy (HAART), especially regimen containing protease inhibitors. The syndrome consists of fat redistribution, with loss of subcutaneous fat and increase in visceral fat, and metabolic disturbances, including glucose intolerance or overt diabetes and dyslipidemia. No standard treatment has been established for this syndrome. Pioglitazone is an oral antidiabetic agent that acts primarily on adipose tissue to reduce insulin resistance. The authors report a 50-year old HIV-infected woman who developed hiv-associated lipodystrophy syndrome after 3 months of HAART. She had significant weight loss with obvious loss of subcutaneous fat, together with development of hypertension, diabetes and dyslipidemia. After treatment with 30 milligrams of pioglitazone daily, her body weight increased within the first month of treatment. subcutaneous fat loss was restored. Improvement in glycemic and lipid control was also noted. CT scan of the abdomen revealed that fatty infiltration in the liver was markedly decreased. Visceral fat as assessed by CT scan had also decreased. Pioglitazone appeared to have beneficial effects in this patient. ( info)

4/13. Tumor-level serum testosterone associated with human immunodeficiency virus lipodystrophy syndrome.

    BACKGROUND: Human immunodeficiency virus (HIV) lipodystrophy syndrome consists of insulin resistance, hyperlipidemia, increased waist-to-hip ratios, and relative hyperandrogenemia, which resembles polycystic ovary syndrome. CASE: A 30-year-old HIV-positive multipara with lipodystrophy syndrome had an elevated level of serum total testosterone (244 ng/dL) in the tumor range. CONCLUSION: In HIV lipodystrophy syndrome, marked elevations of total serum testosterone in the range reserved for androgen-producing tumors may occur. The elevated testosterone levels are derived from the ovary and are responsive to gonadotropin suppression. ( info)

5/13. Efavirenz-associated gynecomastia: report of five cases and review of the literature.

    The prognosis of HIV infection has improved dramatically since the introduction of highly active antiretroviral therapy (HAART). However, numerous adverse effects and limitations regarding tolerability remain a concern. Lipomastia (pseudogynecomastia), a breast enlargement due to central adiposity, may occur as part of a fat redistribution syndrome which has been associated with HAART regimens and several pathogenic mechanisms have been advocated in its development. Here we report an observational longitudinal study of five patients diagnosed of gynecomastia associated with efavirenz-based HAART regimens. All cases reached successful immunologic and virologic responses to HAART. The delay of appearance of gynecomastia from the beginning of HAART ranged between 4 to 15 months. In all five cases, gynecomastia regressed after efavirenz withdrawal (mean period of 5 months). In summary, we think that HAART induced gynecomastia should be suspected in HIV patients receiving efavirenz-containing regimens. Although pathogenesis is unclear, this study and a review of the English literature implicates two possible mechanisms: (a) immune restoration processes and (b) efavirenz mediated estradiol-like effects. ( info)

6/13. HIV disease and an atherosclerotic ascending aortic aneurysm.

    Cardiovascular dysfunction appears to be an important complication of human immunodeficiency virus (HIV) infection and is being reported with greater frequency. There have been recent reports in the literature of HIV patients who suffer from vascular lesions such as large artery vasculopathy secondary to vasculitis, as well as accelerated atherosclerosis of the coronary arteries. The latter has been linked to patients on protease inhibitors that are used as part of a highly active antiretroviral therapy (HAART) regimen and have also been implicated in a lipodystrophy syndrome. We report a rare case of an HIV-infected patient on HAART who presented with a large ascending aortic aneurysm associated with symptomatic severe aortic regurgitation. A noteworthy finding on pathological analysis of the aorta was an etiology of accelerated atherosclerosis rather than the more expected vasculitis. ( info)

7/13. Diastasis recti abdominis in HIV-infected men with lipodystrophy.

    Diastasis recti abdominis is a condition in which the rectus abdominus muscle separates in the midline at the linea alba producing a ventral herniation. We have observed the occurrence of this condition in HIV-infected men attending an osteopathic clinic. Two such cases are described in detail. An apparent association with hiv-associated lipodystrophy syndrome and implications for management are explored. ( info)

8/13. Use of hyaluronic acid for soft tissue augmentation of HIV-associated facial lipodystrophy.

    BACKGROUND: Lipodystrophy syndrome is a devastating complication of antiretroviral therapy in individuals with human immunodeficiency virus (HIV). The appearance of the associated facial lipoatrophy can be demoralizing and stigmatizing for the affected individuals to a point at which it may compromise their compliance with antiretroviral medication. OBJECTIVE: We describe the use of hyaluronic acid as an intradermal filler for correction of this disfiguring problem. methods: We treated five patients with grade 2 to 3 facial lipoatrophy. Each patient received approximately 5 to 6 cc in total of hyaluronic acid in the malar area via intradermal injection. RESULTS: There were no adverse events. We found that this technique provided a good cosmetic result with high patient satisfaction. At 6-month follow-up, sustained longevity was observed. CONCLUSIONS: We propose the use of hyaluronic acid for HIV-associated facial lipoatrophy as an efficacious and safe, but temporary, option for this problem until a more cost-effective option is available. ( info)

9/13. Epidural spinal lipomatosis with acute onset of paraplegia in an HIV-positive patient treated with corticosteroids and protease inhibitor: case report.

    STUDY DESIGN: Case report. OBJECTIVE: To report a case of HIV-related lipodystrophy with a rapid onset of symptoms from epidural lipomatosis in the wake of protease inhibitor and steroid treatment. SUMMARY OF BACKGROUND DATA: Symptomatic spinal epidural lipomatosis is considered to be a rare condition usually presenting with slowly progressive cord or nerve root compression. Only 2 cases of spinal lipomatosis in HIV-related lipodystrophy have been reported. methods: We describe the case of a 41-year-old male with HIV who received protease inhibitor medication and had neurologic deficits rapidly develop. RESULTS: The patient had complete paraplegia develop within 12 hours from admission following a 1-day history of unsteady gait and a 3-day history of leg numbness. After diagnosis of epidural lipomatosis on magnetic resonance imaging, the patient underwent decompressive thoraco-laminectomy. He recovered well and was able to walk by postoperative day 4. CONCLUSION: It is important to maintain an awareness for the possible association between HIV lipodystrophy and symptomatic epidural lipomatosis. ( info)

10/13. Persistence of lipoatrophy after a four-year long interruption of antiretroviral therapy for HIV1 infection: case report.

    BACKGROUND: HIV-infected patients on long-term highly active antiretroviral therapy often present peculiar patterns of fat redistribution, referred to as lipodystrophy. In spite of recent investigations, it is not known whether and to what extent the main features of lipodystrophy--that is lipoatrophy of peripheral fat at face, limbs and buttocks, as well as fat accumulation at breasts, abdomen and the dorso-cervical region--can be reversible once clinically manifest. CASE PRESENTATION: A 35 year old Caucasian HIV infected female developed severe diffuse lipodystrophy while on highly active antiretroviral therapy. A remarkable increase of breast size, fat accumulation at waist, and a fat pad on her lumbar spine were paralleled by progressive and disfiguring lipoatrophy of face, limbs and buttocks. The patient decided to interrupt her therapy after 20 months, with a stably suppressed viremia and a cd4 lymphocyte count > 500/microL. She could carry on a safe treatment interruption for longer than 4 years. Most sites of fat accumulation switched to nearly normal appearance, whereas lipoatrophy was substantially unchanged at all affected sites. CONCLUSION: our observation provides pictorial evidence that lipoatrophy may not be reversible even under ideal circumstances. Therefore, strategies to prevent lipoatrophy should be considered when defining therapeutic regimens for HIV infected patients, especially those at high risk. ( info)
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