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| Fig. 39.5 Lipodystrophy. Visceral abdominal fat accumulation is seen in this HIV-positive patient who had been taking indinavir for 3 years. |
A syndrome of lipodystrophic changes is temporally associated mainly with use of protease inhibitors, and possibly with nucleoside reverse transcriptase inhibitors. It is characterized by enlargement of the dorsocervical fat pad (“buffalo hump”), breast hypertrophy, visceral abdominal fat accumulation (“crix belly,” “protease paunch”) (Fig. 39-5), peripheral fat wasting with prominence of the superficial veins, and loss of
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| Fig. 39.6 A and B, Enfuvirtide injection site reactions manifesting as erythematous subcutaneous nodules. (Courtesy of the Walter Reed Army Medical Center teaching files.) |
fat in the buccal, temporal, and buttocks areas. Lipodystrophic changes have been associated with hypertriglyceridemia, hypercholesterolemia, hyperglycemia, insulin resistance, and hyperinsulinemia. Evidence of associated Cushing’s syndrome or disease is lacking. Lipodystrophic changes have occasionally been reported in patients not taking protease inhibitors. Histologic findings in patients with lipoatrophy include atrophy of the subcutaneous fat, fat lobules with variably sized and often large adipocytes, prominent capillary vascular proliferation, and focal lymphocytic infiltrate and lipogranuloma formation. The exact mechanism involved in these changes is not clear. In addition, antiretroviral therapy has recently been temporally associated with symptomatic angiolipomatosis. Also, painful periungual inflammation (paronychia) of the fingernails and toenails has been reported with use of indinavir and lamivudine. Cutaneous side effects have been described with enfuvirtide (Fuzeon, T-20) use. This drug is a member of a new class of HAART known as fusion inhibitors and is administered subcutaneously. Reported skin side effects are very common and include erythema, induration, nodules, and cysts at the injection sites (Fig. 39-6A,B).
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