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Lipoatrophy Is the Predominant Presentation of HIV-Associated Lipodystrophy in Southern India

Article in Clinical Infectious Diseases · July 2004

DOI: 10.1086/392516 · Source: PubMed

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6 authors, including: Some of the authors of this publication are also working on these related projects: Punto Seguro: Conditional Economic Incentives to Reduce HIV/STI Risks among Male Sex Workers in Mexico City View project Gradients in Depressive Symptoms by Socioeconomic Position Among Men Who Have Sex With Men in the EXPLORE Study View project Sreekanth K Chaguturu Massachusetts General Hospital

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N Kumarasamy Voluntary Health Services Multi-Specialty Hospital and Research Institute

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Suniti Solomon YR Gaitonde Centre for AIDS Research and Education

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Kenneth Mayer Beth Israel Deaconess Medical Center

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1646 • CID 2004:38 (1 June) • CORRESPONDENCE

Table 1. Clinical characteristics of 8 south Indian patients who de- veloped lipoatrophy while receiving antiretroviral therapy (ART).

Patient group, variable Mean no.

• f months

Patients receiving ART (n p 8) Time receiving ART 46 Time to morphologic change while receiving ART 21 Patients receiving HAART (n p 5a) Time receiving HAART 24 Time to morphologic change while receiving HAART 20 Patients receiving 2-drug therapy (n p 4) Time receiving 2-drug therapy 44 Time to morphologic change while receiving 2-drug therapy 22

a One patient received both dual nucleoside therapy and HAART

.

septic arthritis in patients with hepatic cir- rhosis, especially in those with pneumo- coccal primary peritonitis.

• J. Mun

˜oz, R. Paredes, I. Diaz, I. Basabe,

• V. Pomar, M. Blazquez, J. M. Guardiola,
• M. Gurguı

´, and P. Domingo Infectious diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain References

• 1. Ross JJ, Saltzman CL, Carling P, et al. Pneu-

mococcal septic arthritis: review of 190 cases. Clin Infect Dis 2003;36:319–27.

• 2. Capdevila O, Pallares R, Grau I, et al. Pneu-

mococcal peritonitis in adult patients: report

• f 64 cases with special reference to emergence
• f antibiotic resistance. Arch Intern Med

2001;161:1742–8.

• 3. Dugi DD, Musher DM, Clarridge JE, et al.

Intraabdominal infection due to Streptococcus

• pneumoniae. Medicine 2001;80:236–44.
• 4. Marin E, Navas C, Martin-Vivaldi J, et al. Sep-

tic arthritis due to Streptococcus bovis in a pa- tient with cirrhosis of enolic etiology. Rev Esp Enferm Dig 2003;95:506–8.

• 5. Malnick SD, Attali M, Israeli E, et al. Spon-

taneous bacterial artrhitis in a cirrhotic pa-

• tient. J Clin Gastroenterol 1998;27:364–6.
• 6. Rosas J, Casellas JA, Carnicer F, Batlle E. Septic

arthritis caused by Streptococcus agalactiae in a patient with liver cirrhosis [in Spanish].Med Clin (Barc) 1991;97:755.

• 7. Colebunders R, Cytryn E, Thys JP. Group B

streptoccocus arthritis. Clin Rheumatol 1983;2:427–9.

• 8. Pearson RD, Spiva D, Gluckman J. Cirrhosis
• f liver with septic arthritis due to Escherichia

coli: unusual locus minoris resistenciae for bacteremic cirrhosis. N Y State J Med 1978; 78:1762–3.

• 9. Schlaeffer F, Riesenberg K, Mikolich D,Sikuler

E, Niv Y. Serious bacterial infections after en- doscopic procedures. Arch Intern Med 1996; 156:572–4.

• 10. Mang G, Walter E, Bertschinger P, et al. Bac-

terial infections following sclerosing therapy for esophaeal varices [in German]. Schweiz Med Wochenschr 1993;123:1796–801.

Reprints or correspondence: Dr. Jose Mun ˜oz, Infectious Dis- eases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Av. Sant Antoni Maria Claret, 167, 08025 Barcelona, Spain (meth_2@hotmail.com). Clinical Infectious Diseases 2004;38:1645–6 2004 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2004/3811-0030$15.00

Lipoatrophy Is the Predominant Presentation

• f HIV-Associated

Lipodystrophy in Southern India Sir—Because of the declining costs of an- tiretroviral drugs and the production of drugs by generic manufacturers, tertiary care centers in resource-limited areas are now able to provide antiretroviral therapy to HIV-seropositive patients [1]. However, despite the unprecedented benefits of HAART, there appear to be metabolic and morphologic complications associated with therapy. These long-term adverse ef- fects have been described primarily in the Western world, where use of antiretroviral therapy is more widespread. At YRG CARE, a nonprofit organiza- tion and tertiary referral care center in southern India that provides medical and psychosocial care for nearly 4000 people living with HIV infection, all patients re- ceiving antiretroviral therapy (ART) have had anthropometric measurements taken at each clinic visit, starting in January

• 2002. Among 286 patients receiving ART,

we have identified 8 patients who devel-

• ped lipoatrophy (6 with buccal atrophy

and 5 with limb fat atrophy) while re- ceiving ART (table 1). Weight and height measurements were

• btained with a standardized scale. Body

mass index was calculated as weight in kilograms divided by the square of height in centimeters. Anthropometric measure- ments were obtained in triplicate by 1 trained observer, and the data presented is the mean of the 3 measurements. Bio- electric impedance analysis was performed with the Quantum II analyzer (RJL Sys- tems) while the patient was recumbent. Body composition was calculated with Body Composition Analysis software, ver- sion 1.2 (Cyprus). CD4 lymphocyte counts were performed by flow cytometry (Becton Dickinson). Five of the patients were male. The av- erage age of the 8 patients was 41 years, whereas the mean age of patients seen at this clinic is 32 years. The 8 patients re- ceived antiretroviral therapy for anaverage

• f 46 months. The mean increase in CD4

cell counts for this cohort was 268 cells/ mL in 4 months, whereas the mean in- crease for all patients receiving antiretro- viral therapy at this clinic ( ) is 159 n p 286 cells/mL in 4 months. The 8 patients had a median difference of 6 kg/m2 (range, 2.9 kg/m2–14.2 kg/m2) between their highest and lowest BMI values. Every patient sub- jectively noticed atrophy. Five patients complained of loss of limb fat, 4 noted changes in their thighs, and 2 noted changes in their arms. Their self-assess- ments were confirmed by observations made by a primary care provider, who noted buccal atrophy in 6 and limb fat atrophy in 5. Four patients developed morphologic changes while receiving 2-drug therapy,

CORRESPONDENCE • CID 2004:38 (1 June) • 1647

Table 2. Antiretroviral drugs received by 8 south Indian patients who developed lipoatrophy while re- ceiving antiretroviral therapy.

Drug

• No. of patients

receiving drug Mean no.

• f months patients

received drug Azidothymidine 6 12 Lamivudine 8 17 Stavudine 8 19 Didanosine 4 22 Efavirenz 1 23 Nevirapine 3 15 Nelfinavir 3 10 Indinavir 1 14

and the other 4 developed morphologic changes while receiving HAART. The av- erage time to morphologic change was 20 months (22 months for those receiving dual nucleoside therapy and 19 months for those receiving HAART). All of the patients in this report received stavudine for an average of 19 months (table 2). As the number of patients receiving an- tiretroviral therapy increases in the devel-

• ping world, and patients survive longer

with HIV infection, prospective studiesin- vestigating metabolic and morphologic changes are needed to better understand regional differences in the risk factors for and presentation

• f

HIV-associated lipodystrophy.

Suneeta Saghayam,1 Sreekanth K. Chaguturu,2

• N. Kumarasamy,1 Suniti Solomon,1

Kenneth H. Mayer,2 and Christine Wanke3

1YRG Centre for AIDS Research and Education,

Chennai, India; 2Miriam Hospital, Brown Medical School, Providence, Rhode Island, and 3Tufts University School of Medicine, Boston, Massachusetts References

• 1. Kumarasamy N, Solomon S, Peters E, et al.

Antiretroviral drugs in the treatment of people living with human immunodefi- ciency virus: experience in a South Indian tertiary referral centre. J Assoc Physicians India 2000; 48:390–3.

Reprints or correspondence: Dr. N. Kumarasamy, YRG Centre for AIDS Research and Education, VHS-YRG CARE Medical Center, M. G. R. Film City Rd., Tharamani, Chennai 600113, India (kumarasamy@yrgcare.org). Clinical Infectious Diseases 2004;38:1646–7 2004 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2004/3811-0031$15.00

Efficacy of Albendazole Ointment on Cutaneous Larva Migrans in 2 Y

• ung

Children Sir—Cutaneous larva migrans, caused by subcutaneous migration of animal hook- worm larvae, is now easy to treat orally with ivermectin or albendazole [1]. How- ever, both of these drugs are contraindi- cated in young children, and topical treat- ments must thus be considered. Freezing the leading edge of the cutaneous trail should be avoided, because it is both in- effective and painful. Topical application

• f 10%–15% thiabendazole solution or
• intment to the affected area is effective,

but thiabendazole is no longer marketed by the manufacturer. This prompted us to test a 10% albendazole ointment in 2 chil- dren who presented with cutaneous larva migrans. Patient 1 was 2-year-old boy weighing 11 kg who was seen at Hopital Pitie-Sal- pe ˆtrie `re (Paris, France) in May 2003. He had traveled with his parents to Senegal from 1 to 7 March 2003. He reported a mobile pruritic skin lesion on the left but- tock that had been present since 28 April

• 2003. A physical examination on 3 May

2003 revealed a serpiginous erythematous cutaneous track ∼10 cm long on the left

• buttock. We treated the patient with a 10%

albendazole ointment, prepared by crush- ing three 400-mg tablets of albendazole in 12 g of petroleum jelly and applied thrice daily for 10 days. The cutaneous lesion disappeared within a week after treatment was initiated, and no relapses occurred during 16 months of follow-up. Patient 2 was a 2-year-old girl weighing 10 kg who first presented in September

• 2003. She had traveled with her parents

to the Dominican Republic from 10 to 31 August 2003. She first reported a mobile pruritic skin lesion on the left foot on 10

• September. A physical examination on 13

September revealed a serpiginous ery- thematous cutaneous track ∼5 cm long on the left foot. She received the same course

• f treatment as patient 1, and the lesion

disappeared within a week after treatment was received. Three months later, patient 2 presented with a 3-cm serpiginous er- ythematous lesion on the right shoulder. She received the same topical treatment as before, and the lesion disappeared within a week after treatment was received. No further relapses occurred during 2 months

• f follow-up.

These findings suggest that topical ap- plication of 10% albendazole ointment 3 times per day for 10 days is a safe and effective treatment for cutaneous larva

• migrans. Although patient 2 subsequently

developed a second episode of cutaneous larva migrans, this occurred in a different area of her body and therefore cannot be attributed to failure of the initial treat-

• ment. In addition, the same treatment was

as effective in the second episode as it had been in the first, and no further episodes have occurred. These findings suggest that 10% alben- dazole ointment is an effective treatment for cutaneous larva migrans. This topical treatment is particularly suited tochildren, for whom available oral treatments are contraindicated.

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