Redistribuição de gordura corporal e alterações no metabolismo de lipídeos e glicose em pessoas vivendo com HIV/AIDS / Body fat redistribution and changes in lipid and glucose metabolism in people living with HIV/AIDS

RESUMO: Introdução: A síndrome da lipodistrofia do HIV é caracterizada por alterações no metabolismo e na composição corporal, que aumentam o risco cardiovascular de pessoas vivendo com HIV/AIDS (PVHA) em uso da terapia antirretroviral de alta potência (TARV). Objetivo: Avaliar a prevalência de lipodistrofia e de alterações do metabolismo de lipídios e glicose em PVHA em uso da TARV. Métodos: Para avaliação antropométrica foram aferidos peso, estatura e circunferência abdominal (CA). Para avaliação da lipodistrofia foi realizado o exame físico (subjetivo) e o exame (objetivo) de absortometria com raios X de dupla energia (DEXA) por meio da razão de massa gorda (RMG). Foram também realizados exames de lipidograma e glicemia de jejum e utilizados os critérios sugeridos pelo The National Cholesterol Education Program III para classificação de alterações metabólicas. Resultados: A amostra final consistiu em 262 pacientes com idade média de 44,3 ± 10,2 anos. A lipodistrofia, de acordo com o exame físico, esteve presente em 47,7% (IC95% 41,7 - 53,8) dos pacientes, enquanto pela RMG (DEXA) sua prevalência foi de 40,8% (IC95% 33,1 - 48,5). A maioria (53,0%; IC95% 47,0 - 59,1) dos pacientes apresentou aumento de adiposidade abdominal segundo a CA. As alterações metabólicas mais presentes foram o HDL reduzido (67,6%; IC95% 61,9 - 73,2) e a hipertrigliceridemia (55,7%; IC95% 49,7 - 61,7). Conclusões: A alta prevalência de lipodistrofia e alterações do metabolismo de lipídios e glicose evidenciam a importância da intervenção precoce nesse grupo de pacientes para prevenir complicações cardiovasculares.

ABSTRACT: Introduction: The HIV lipodystrophy syndrome is characterized by changes in metabolism, and body composition that increase cardiovascular risk of people living with HIV/AIDS (PLWHA) using highly active antiretroviral therapy (HAART). Objective: To assess the prevalence of lipodystrophy and changes in lipid and glucose metabolism in PLWHA in use of HAART. Methods: For the anthropometric evaluation we measured weight, height and abdominal circumference (AC). For the lipodystrophy evaluation we conducted physical examination (subjective) and the (objective) examination of absorptiometry with X-ray dual energy (DEXA) by fat mass ratio (FMR). We also conducted lipid profile tests and fasting glucose and used the criteria suggested by The National Cholesterol Education Program III for metabolic disorders classification. Results: The final sample consisted of 262 patients with a mean age of 44.3 ± 10.2 years. Lipodystrophy, according to the physical examination, was present in 47.7% (95%CI 41.7 - 53.8) of patients, while the prevalence using FMR (DEXA) was 40.8% (95%CI 33.1 - 48.5). Most (53.0%; 95%CI 47.0 - 59.1) of the patients showed increased abdominal adiposity according to AC. The most prevalent metabolic alterations were reduced HDL (67.6%; 95%CI 61.9 - 73.2) and hypertriglyceridemia (55.7%; 95%CI 49.7 - 61.7). Conclusion: The high prevalence of lipodystrophy and changes in lipid and glucose metabolism show the importance of early intervention in this group of patients to prevent cardiovascular complications.

Lipoatrofia semicircular, una visión general a una patología laboral emergente en Chile / Semicircular lipatrophy, an overview of emerging labor pathology in Chile

La Lipoatrofia Semicircular (LS) es una enfermedad idiopática, que se caracteriza por una atrofia reversible y localizada, ya sea total o parcial, del tejido adiposo subcutáneo y que se ubica en zonas de contacto de la piel de las extremidades con el inmobiliario. Se caracteriza por presentarse en brotes endémicos, cuyo único factor en común es el lugar de trabajo. Sus causas son desconocidas, pero en la actualidad se proponen factores asociados como: el contacto de la zona afectada con inmobiliario, presencia de radiación electromagnética, presencia de descargas electroestáticas y humedad ambiental relativa baja. Un modelo actual para explicar la patogenia de esta enfermedad involucra la participación de descargas electrostáticas, que probablemente activarían la liberación de factor de necrosis tumoral a (TNF-a) y desencadenaría la fagocitosis de adipocitos. Actualmente no tiene un tratamiento médico, siendo las medidas preventivas de mitigación de los factores previamente mencionados las que producen una reversión de la lesión. Por otro lado, la presencia de estos brotes generan un gran impacto mediático por lo que también debe ser abordada comunicacionalmente. La presente revisión pretende sintetizar la literatura sobre el tema para exponer el conocimiento actual y lograr una noción de esta nueva enfermedad, tras su primera presentación en brote en nuestro país.

Lipoatrophia semicircularis (LS) (also known as "Semicircular lipoa-trophy") is an idiopathic disease, which is characterized by a reversible and localized atrophy, either total or partial, of subcutaneous adipose tissue and located in areas of skin contact with the real estate tips. It is characterized by appearing in endemic outbreaks whose only common factor is the workplace. Its causes are unknown, but currently associated factors have been proposed, such as: the contact area with the office furniture, the presence of electromagnetic radiation, electrostatic discharge and presence of low relative humidity. A current model to explain the pathogenesis of this disease involves the participation of electrostatic discharges, which probably activate the release of tumor necrosis factor a (TNF-a) and it would trigger phagocytosis of adipocytes. Currently there is no medical treatment, being proactive mitigation measures of the before mentioned factors, those that produce a reversion of the injury. On the other hand, the presence of these buds generates great media impact so it must be also addressed from a communication standpoint. The present review aims to summarize the literature on the subject to present current knowledge and achieve a notion of this new disease, after its first appearance in outbreak in our country.

Una década de terapia anti-retroviral: Perfil de pacientes con 10 años de triterapia de alta efectividad / A decade of antiretroviral therapy: a profile of patients with 10 years of highly effective triple therapy

Introduction: Highly effective antiretroviral triple therapy (TAR3) has led to a significant increase in survival of patients (pts) infected with human immunodeficiency virus. In 1999 it was started in the Chilean public health system, including Arriarán Foundation (FA) access to TAR, reaching full coverage since 2003. By October 31, 2009 124 pts had reached 10 years of uninterrupted TAR3 in FA. Objective: To describe and analyze the profile of pts, their therapeutic regimen (s) and clinical outcomes during 10 years of TAR3. Methods: Retrospective descriptive study. We reviewed the records of pts who had reached 10 years of uninterrupted TAR3 in FA. Demographic data, baseline and virological staging at start of TAR3, comorbidities and complications were recorded. Drug regimens used were analyzed, as well as toxicity, virological and immunological outcomes, frequency and reasons for change in therapy. Complications were classified as opportunistic and not opportunistic during this evolution and the latest known clinical and laboratory data were registered. A database program based on Excel was used. Results: 121/124 pts were available for analysis, 76.8% male, male-female ratio was 3.3:1. Baseline median age: 36 years (20-69); CD4 cells 176/ mm³ (8-1,224) with 65.3% < 200; median viral load (STL): 60,078 copies/ml (1,100- 7,900,000); 36.3% were in clinical AIDS stage. Patients received an average of 3.5 therapies regimens during the decade (range, 1 [14 pts, 11.5%] to 7 [3 pts, 2.4%]), with average duration of 42 months each and a median of 36 months. As initial TAR3 regimen 2 backbone nucleoside analogues (ITRN) was the most frequent, with a protease inhibitor (PI) in 51.2% and non-nucleoside RTIs (NNRTIs) in 38.8%. Adverse reactions were the main reason for change of therapy (24.7%), followed by virological failure (24.2%) and treatment simplification (16.6%). At the latest assessment, all with > 10 years of TAR3 median CD4 was 602 cells/mm³, 11 pts (9%) had CD4 < 200/mm³; 85.2% had undetectable VL (< 80 copies/mL); the remaining 14.8% had a median of 1,800 copies/mL. Only 2 pts (1.7%) were in AIDS clinical stage. Current regimens were 2 NRTI plus 1 NNRTI in 61 pts (50.4%), 2 or more NRTI plus 1 PI in 46 (38%). Seventy two pts (60.3%) had chronic comorbidities at latest follow up. Dyslipidemia, hypertension, diabetes mellitus and renal failure were the most frequent conditions; 17 pts (14%) had clinical lipodystrophy secondary to TAR. Conclusion: Achieving a decade of TAR is already a reality and in the short term will be routine. This is rarely achieved with the initial therapeutic regimen. The major obstacles to prolonged maintenance of a single therapeutic regimen have been adverse effects and virological failure, although current drugs with better efficacy and safety profile may allow longer use for each regimen. Despite the difficulty of treating these pts, they can achieve long-term survival with good virologic control, immune recovery and absence of opportunistic complications associated with HIV infection. Nonetheless, the high frequency of non opportunistic chronic comorbidities and antiretroviral therapy side effects after prolonged or life-long use is becoming a major issue.

La introducción de la triterapia anti-retroviral de alta efectividad (TAR3) ha llevado a un significativo aumento en la sobrevida de los pacientes infectados por virus de inmunodeficiencia humana. En 1999 se inició en el sistema público de salud chileno, incluida la Fundación Arriarán (FA) el acceso progresivo a TAR3, que alcanzó cobertura completa desde 2003. En FA al 31 de octubre de 2009 se compatibilizaban 124 pacientes (pts) que habían alcanzado 10 años de TAR3 ininterrumpida. Objetivo: Describir y analizar el perfil de los pts, sus terapias y la evolución clínica durante el período de 10 años de TAR3. Material y Método: estudio descriptivo y retrospectivo. Se revisaron las fichas de los pts que alcanzaron 10 años de TAR3 en FA. Se registraron datos demográficos, clínicos y clasificación por etapas, co-morbilidades y complicaciones al inicio de tratamiento. Se analizaron los esquemas terapéuticos recibidos, toxicidades y desenlaces virológicos e inmunológicos, así como la frecuencia y razones de cambio de terapias, las complicaciones oportunistas y no oportunistas durante esta evolución y el último estado clínico y de laboratorio conocido. Se empleó una base de datos en base al programa Excel. Resultados: se lograron analizar 121/124 pts, 76,8% hombres, relación hombre:mujer 3,3:1. Mediana basal: edad, 36 años (20-69); recuento de linfocitos CD4 de 176 céls/mm³ (8-1.224), con 65,3% < de 200 céls/mm³; carga viral (CV): 60.078 copias/ml (1.100 -7.900.000); 44/121 (36,3%) en etapa SIDA clínica inicial. Los pacientes recibieron un promedio de 3,5 esquemas de terapias durante el decenio (rango, 1 [14 pts, 11,5 %] a 7 [3 pts, 2,4 %]), con duración promedio de 42 meses en cada uno y una mediana de 36. TAR3 inicial con dos análogos nucleosídicos (ITRN) fue lo más frecuente, con un inhibidor de la proteasa (IP) en 51,2% o con ITR no nucleosídico (ITRnN) en 38,8%. Las reacciones adversas fueron el principal motivo de cambio de esquemas (24,7%), seguido de fracaso virológico (24,2%) y simplificación terapéutica (16,6%). En su última evaluación y con > 10 años de TAR3 la mediana de linfocitos CD4 era de 602 céls/mm³; había 11 pts (9 %) con CD4 < 200/ mm³; 85,2% estaba con CV indetectable (< 80 copias/ mL), 14 (14,8%) con detectabilidad viral, y éstos con una mediana de 1.800 copias/mL. Sólo 2 pts (1,7%) estaban en etapa clínica de SIDA. El esquema de TAR3 actual más frecuente era de dos ITRN más un ITRnN, en 61 pts (50,4%) y luego dos ITRN más un IP en 46 (38%). En 72 pts (60,3%) se pesquisaron co-morbilidades crónicas: dislipidemias, hipertensión arterial, diabetes mellitus y/o insuficiencia renal; 17 pts (14%) presentaban lipodistrofia clínica secundaria a TAR3 Conclusión: Alcanzar una década de TAR3 ya está siendo una realidad y a corto plazo será rutinario. Esto rara vez se logra con la primera terapia, aunque esquemas contemporáneos más efectivos y seguros pueden hacerlo posible a futuro. Los principales obstáculos para lograr mantención prolongada de un solo esquema terapéutico son los efectos adversos y el fracaso virológico. A pesar de las dificultades terapéuticas estos pts pueden alcanzar sobrevida a largo plazo con buen control virológico, recuperación inmune y control de las complicaciones oportunistas asociadas a la infección por VIH. Destaca la alta frecuente de co-morbilidades crónicas no oportunistas y secuelas de la terapia anti-retroviral.

Paniculitis mesentérica asociada con absceso intraabdominal / Mesenteric panniculitis with intraabdominal abcess: report of one case

La paniculitis mesentérica es una enfermedad inflamatoria del tejido adiposo del mesenterio, de presentación infrecuente y que se caracteriza, por el engrasamiento, endurecimiento y nodularidad del mismo. Se pone en consideración un caso clínico en un varón joven, con una forma de presentación poco común que requirió de laparotomía exploradora para realizar el diagnóstico y tratamiento.

We report a 28 years old obese male presenting with abdominal pain of increasing intensity lasting 15 days. In the last days, diarrhea and fever appeared. On abdominal examination a 8 cm painful mass was palpated. An abdominal ultrasound showed an anechoic mass in the epigastrium. An abdominal CAT sean showed an inflammatory mass that involves the small bowel. The patient is subjected to a percutaneous needle aspiration, obtaining 50 mi of a purulent fluid. Due to persistence of fever, the patient was operated finding an inflammation that involved the mesentery and the great omentum and covering abscess. The pathologic study of the surgical piece reported a unspecific nodular mesenteric panniculitis.

Correlation between lumbar lordosis angle and degree of gynoid lipodystrophy (cellulite) in asymptomatic women

INTRODUCTION: Gynoid lipodystrophy (cellulite) has been cited as a common dermatological alteration. It occurs mainly in adult women and tends to gather around the thighs and buttocks. Its presence and severity have been related to many factors, including biotype, age, sex, circulatory changes, and, as some authors have suggested, mechanical alterations such as lumbar hyperlordosis. OBJECTIVE: To correlate the degree of cellulite with the angle of lumbar lordosis in asymptomatic women. METHODS: Fifty volunteers were evaluated by digital photos, palpation, and thermograph. The degree of cellulite was classified on a scale of 1-4. Analyses were performed on the superior, inferior, right and left buttocks (SRB, IRB, SLB, ILB), and the superior right and left thighs (SRT, SLT). The volunteers underwent a lateral-view X-ray, and the angle of lumbar lordosis was measured using Cobb's method (inferior endplate of T12 and the superior endplate of S). The data were statistically analyzed using ANOVA and Spearman's correlation. A significance level of 5 percent was adopted. RESULTS: Volunteers had a mean age of 26.1 ± 4.4 years and a mean body mass index of 20.7 ± 1.9 kg/m². There was no significant difference in lumbar lordosis angle between those with cellulite classes 2 and 3 (p > 0.297). There was also no correlation between lumbar lordosis angle and the degree of cellulite (p > 0.085 and r > 0.246). CONCLUSIONS: The analysis suggests that there is no correlation between the degree of cellulite and the angle of lumbar lordosis as measured using Cobb's method.

[Prevalence of lipodystrophy associated with human recombinant insulin]

Lipodystrophy is potentially a clinical adverse effect, associated with insulin therapy and is believed that usage of human recombinant insulin's is associated with decreasing prevalence of Lipodystrophy. The objective of this study was to determine the prevalence of insulin induced Lipodystrophy, among diabetic out-patients referred to Imam Khomeini Hospital, in Sari during 2007. In this cross sectional descriptive study, 220 diabetic patients referred to the Diabetes Center at Imam Khomeini Hospital, in Sari, who under treatment by insulin at least three months prior to referral was evaluated. First, the demographic and clinical characteristics of the patients were recorded in a questionnaire; then all patients were examined clinically to evaluate lipodystrophy. In all subjects, glycated hemoglobin [HbA1C] was measured to assess the range of blood glucose level control. Recorded data were analyzed by statistical methods, such as descriptive T-test and X[2].Of 220 diabetic patients studied, thirty-five [15.9%] showed clinical evidences of insulin induced Lipodystrophy; 32 out of 35 cases of Lipodystrophic patients [14.5%] had Lipohypertrophy, while 3 cases [1.4%] had Lipoatrophy. The factors included Age, Sex, Education, BMI [Body mass index], type of Diabetes, The duration of insulin consumption and injection site had statistically significant effects on development of insulin induced Lipodystrophy [P<0.05]. The results of this study demonstrated that despite using human recombinant insulin's, the prevalence of insulin induced lipodystrophy, especially Lipohypertrophy, has remained high up to present. Therefore, regular examination of patients for this side effect is necessary, especially in subjects without good control of blood glucose level

Anormalidades metabólicas en pacientes con infección por VIH / Metabolic abnormalities in patients with HIV infection

La terapia antirretroviral altamente activa (TARAA) en pacientes con infección por virus de inmunodeficiencia humana (VIH) disminuyó la morbimortalidad del padecimiento, sin embargo, sus efectos sobre el metabolismo de lipoproteínas, carbohidratos y tejido adiposo son causa frecuente de consulta y en el futuro de morbimortalidad. Nuestro objetivo es describir el estado actual del conocimiento sobre la epidemiología, fisiopatología, diagnóstico y tratamiento de estas complicaciones. Se incluye un análisis crítico de las evidencias existentes. La dislipidemia es multifactorial. Antes del inicio del tratamiento es común encontrar hipertrigliceridemia con concentraciones bajas de colesterol y colesterol HDL. Los medicamentos antirretrovirales, en especial algunos inhibidores de proteasas, tienen efectos adversos sobre el metabolismo de lipoproteínas. A ello se suma la recuperación nutricional y se agrava en presencia de lipodistrofia. El efecto final es hipertrigliceridemia (moderada a severa, en especial con ritonavir) con hipercolesterolemia moderada (< 300 mg/dL). La grasa subcutánea en cara y extremidades inferiores disminuye y se deposita en sitios anormales (cuello, grasa intraabdominal). La evaluación y el tratamiento de estas complicaciones es controversial debido a la falta de evidencias. Las alteraciones metabólicas asociadas a TARAA serán una de las principales causas de morbimortalidad en los próximos años. Por ello, se requieren estudios longitudinales en distintos grupos étnicos que evalúen los determinantes de estas complicaciones y mejores estrategias de prevención y tratamiento. La interacción entre endocrinólogos, infectólogos y otros especialistas será cada vez más frecuente e indispensable en este campo.

Highly active antiretroviral therapy (HAART) decreased the mortality of patients with HIV infection, but its effects on the metabolism of lipoproteins, carbohydrates and adipose tissue are a common cause for seeking treatment. Our purpose is to present the current knowledge available regarding the epidemiology, pathophysiology, diagnosis and treatment of these conditions. A discussion about the limitations of the current evidence is included. HIV-related dyslipidemia is multifactorial. Prior to the treatment, hypertriglyceridemia is found frequently,usually with low cholesterol and HDL cholesterol levels. Antiretroviral agents, especially some protease inhibitors, have adverse effects on plasma lipids. Nutritional recovery and lipodistrophy exacerbate the lipid abnormalities. Hypertriglyceridemia (usually moderate to severe) and moderate hypercholesterolemia (< 300 mg/dL) are the most common end-results. Subcutaneous fat of the face and limbs decreases and it is deposited in the neck and in the abdomen. The diagnosis and treatment of these conditions are controversial due to the lack of appropiate evidence. The metabolic complications of HAART could be a leading cause of mortality in the near future. Thus, longitudinal studies, including subjects from several ethnic groups are needed to identify the main factors involved in the pathophysiology and to assess several therapeutical and preventive strategies. Collaboration between HIV specialists and other health professionals (i.e. endocrinologysts) will be required to accomplish these goals.

Lipodistrofia secundaria al uso de antirretrovirales inhibidores de proteasas / Lipodistrophy secondary to the use of antiretrovirals pretease inhibitors

El uso de inhibidores de proteasas en el tratamiento de la infección por HIV-1, ha revolucionado la sobrevida de éstos enfermos. Pero también se lo ha asociado a diabetes mellitus de nuevo comienzo, hiperlipidemia y lipodistrofia. Presentamos tres pacientes con lipodistrofia secundaria y comentamos la fisiopatogenia y tratamiento

Tratamiento antirretroviral / Antiretroviral therapy

En el presente trabajo se analizan los beneficios y limitaciones de la terapia antirretroviral de alta eficacia (HAART). Los objetivos de esta terapia son reducir la carga viral plasmática lo máximo posible y durante el mayor tiempo posible. Esto implica alcanzar niveles de carga viral no detectables con técnicas ultrasensibles. Se evalúan los resultados obtenidos con los principales esquemas de tratamiento asi como sus indicaciones y efectos adversos.

Lipodistrofia generealizada congênita - relato de um caso / Congenital generalized lipodystrophy - a case report

A lipodistrofia generalizada congênita é doença é doença rara, de etiologia desconhecida, provavelmente hereditária e de caráter autossômico recessivo, com predominância no sexo feminino. Neste trabalho é relatado um caso de lipodistrofia generalizada congênita em um homem de 36 anos de idade, que apresentava clinicamente dispnéia e diabetes mellitus. No estudo radiográfico foram evidenciadas lesões líticas no esqueleto, fibrose intersticial pulmonar e pobreza de gordura abdominal. Serão descritos aos achados radiologógicos e anatomapatológicos, além da revisão da literatura sobre o assunto.

Sindrome de Lipodistrofia Congénita Generalizada / Congenital generalized lipodystrophy syndrome

El actual estudio trata sobre la forma de presentación y evolución de los pacientes con lipodistrofia congénita generalizada o el Síndrome de Seip-Berardinelli. Se caracteriza por la ausencia de tejido graso subcutáneo, cirrosis hepática, desarrollo de diabetes resistente a la insulina, hiperlipemia, y crecimiento corporal rápido con edad ósea avanzada en la infancia, coexistiendo alteraciones cutáneas, desarrollo muscular exagerado y compromiso de otros órganos. Se presentan 3 casos de esta patología diagnosticados entre 9 y 19 meses de edad. Las 3 pacientes presentaban varias características en común: aparentaban una edad mayor a la cronlógica, cara triangular, abundante cabello, lesiones hiperpigmentadas a predominio de pliegues, marcada disminución de tejido celular subcutáneo, prominencia muscular y hepatomegalia. Otros hallazgos clínicos sólo se demostraron en una u otra de las pacientes. La evaluación de laboratorio muestra alteración precoz de lípidos a predominio de triglicéridos, conservando la glicemia y la curva de tolerancia a la glucosa dentro de límites normales. Edad ósea avanzada en 1 de los 3 casos. Analizando los datos de las pacientes y de la literatura respecto a la fisiopatología y posibles efectos beneficiosos de los neurolépticos, se sugiere existencia de alguna anomalía a nivel del hipotálamo y/o hipófisis responsable de la presentacióm del cuadro clínico.

Pseudolordose por lipodistrofia da regiäo glútea / Pseudolardosis due to lipodystrophy of the gluteal region

Foi apresentado um caso inusitado de lipodistrofia localizada na regiäo glútea, que simulava lordose da coluna lombo-sacra. Na consulta à literatura näo foram identificados casos parecidos. Indicada a lipoaspiraçäo através de incisäo na extremidade superior do sulco interglúteo, o procedimento foi de fácil execuçäo e proporcionou resultado francamente positivo