British Journal of Radiology 74 (2001),382-383 © 2001 The British Institute of Radiology
CT appearances of HIV-related lipodystrophy syndrome
L R Gellett, FRCR
1
L Haddon, MRCP
2 and
G F Maskell, FRCR
1
1 Clinical Imaging
2 Genitourinary Medicine, Royal Cornwall Hospital, Truro, Cornwall, UK
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Abstract
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Highly active antiretroviral therapy in HIV-1 infected patients is associated with a lipodystrophy syndrome, characterized by wasting of peripheral fat, central adiposity, hyperlipidaemia and insulin resistance. The CT findings are presented and the differential diagnosis is discussed.
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Case report
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A 27-year-old HIV-positive man, diagnosed in 1995, presented with chronic lower abdominal pain, increasing abdominal distension and weight gain. He had no AIDS-defining illnesses. Highly active antiretroviral therapy (HAART) was started in November 1997 owing to an increasing viral load and a low CD4 count. Treatment consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine 250 mg twice daily and lamivudine 150 mg twice daily) and a protease inhibitor (PI) (indinavir 800 mg three times daily). Triple therapy was stopped after 4 months owing to side effects of nausea, poor appetite and abdominal bloating. It was restarted 1 year later for a falling CD4 count.
In July 2000 he presented with painful abdominal distension. Clinical examination showed marked truncal obesity, thin extremities and striae on his thighs. His body mass index had increased from 19 to 26 since commencing HAART. At this stage he was found to be diabetic. Total cholesterol and HDL cholesterol levels were normal but the triglyceride level wasraised at 3.6 mmol l-1. An early morning plasma cortisol level was normal. CD4 count was154 cells ml-1 and viral load was 1578 copies ml-1.
CT demonstrated abnormal fat proliferation throughout the abdomen in a perivisceral distribution. In comparison, there was little subcutaneous fat. The intraabdominal organs, including the adrenal glands, were normal and there was no ascites (Figure 1
). Chest radiography and abdominal ultrasound were normal.
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Discussion
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The standard treatment for HIV-1 infected patients in western countries since 1996 has included two NRTIs and usually one or more PI or a non-nucleotide reverse transcriptase inhibitor. These regimens are known as highly active antiretroviral therapy (HAART). HAART has resulted in virological, immunological, clinical and survival benefits [1]. However, this therapy is associated with a lipodystrophy syndrome characterized by fat wasting of the limbs, buttocks and face as well as accumulation of fat in the cervicodorsal region, breasts and abdominal cavity. Hyperlipidaemia and insulin resistance are additional features of the syndrome [2].
The pathogenesis of this syndrome is unclear. It has been suggested that the effect may be associated with the use of PIs [2], although it has also been reported in HIV patients naive to PIs [3]. Recommendations for treatment cannot be made until the metabolically mediated mechanisms responsible for the development of this syndrome are understood.
The development of intraabdominal fat deposition in HIV patients on antiretroviral treatment often presents with abdominal cramping and pain. CT in HIV patients with lipodystrophy has shown that the central adiposity is due to perivisceral fat rather than accumulation in the subcutis [4]. The adverse effects are mainly cosmetic. It is not yet known whether vascular complications associated with impaired glucose tolerance and hyperlipidaemia will develop in these patients.
CT in our patient demonstrated marked accumulation of intraabdominal fat, especially in the lower abdomen. Fat deposition was also observed within the wall of the sigmoid colon (Figure 2). This is usually seen in patients with inflammatory bowel disease, but the patient had no clinical evidence or past history of inflammatory bowel disease, although biopsies had not been obtained to exclude subclinical inflammation. There was no ureteric deviation or abnormality of the bladder contour to suggest pelvic lipomatosis. The patient had a normal random morning cortisol level and had not been taking exogenous steroids, making a diagnosis of Cushing's Syndrome unlikely.
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Figure 2. CT showing proliferation of intraabdominal fat, especially around the sigmoid colon and rectum, with fat hypertrophy within the wall of the sigmoid colon (arrow).
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HIV-related lipodystrophy syndrome is an increasingly recognized disorder associated with antiretroviral therapy. The incidence is likely to increase with current treatment regimens and radiologists should be aware of the features of this condition when asked to investigate an HIV-positive patient with abdominal symptoms.
Received for publication October 23, 2000.
Accepted for publication January 24, 2001.
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References
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Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 counts of 200 per cubic millimeter or less. N Engl J Med 1997;337:725–33.[Abstract/Free Full Text]
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Carr A, Samaras K, Burton S, et al. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS 1998;12:F51–8.[Medline]
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Madge S, Kinloch-de-Loes S, Mercey D, et al. Lipodystrophy in patients naive to HIV protease inhibitors. AIDS 1999;13:735–7.[Medline]
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Miller KD, Jones E, Yanovski JA, et al. Visceral abdominal-fat accumulation associated with use of indinavir. Lancet 1998;351:871–5.[Medline]
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