A 54-year-old man comes to the office for a routine follow-up visit. He feels well and has had no ongoing symptoms but has noticed a slow increase in his weight over the past year. He says, "When the nurse weighed me around this time last year I was 74.8 kg (165 lb) and now I am 82.5 kg (182 lb) . I don't know what's causing that; my diet hasn't changed." The patient was diagnosed with HIV a year ago and initiated on antiretroviral therapy, which improved his CD4 count and viral load. He has no other chronic medical problems and has tested negative for hepatitis B and C viruses. His father had coronary artery disease and died of a myocardial infarction at age 55. The patient has a 28-pack-year smoking history and continues to smoke a pack of cigarettes daily. He used intravenous drugs in the past but is currently not using alcohol or illicit drugs. Temperature is 36.5 C (97.7 F) , blood pressure is 112/72 mm Hg, pulse is 76/min, and respirations are 16/min. BMI is 26.9 kg/m². There is adipose tissue deposition on the back of the neck. Abdominal examination reveals increased girth without a substantial increase in subcutaneous fat and palpable hepatomegaly with a soft, nontender liver edge. No striae, bruising, or skin atrophy are present.
Which of the following is most likely to be associated with this patient's condition?

Question

Quizplus · Accepted Answer

Explanation: This patient with HIV was initiated on antiretroviral therapy a year ago and now has findings consistent with HIV-associated lipodystrophy. Patients with HIV-associated lipodystrophy develop alterations in fat deposition with no change in lean tissue mass. Manifestations include one or both of the following: Lipoatrophy - loss of subcutaneous fat from the face, arms, legs, abdomen, and/or buttocks, which can give patients a skeleton-like appearance. Lipoatrophy is particularly associated with nucleoside reverse transcriptase inhibitors (eg, stavudine, zidovudine). Fat accumulation - dorsocervical fat accumulation leads to a "buffalo hump" and visceral abdominal fat accumulation leads to increased abdominal girth (despite minimal subcutaneous abdominal fat). Fat accumulation is not clearly linked with a particular antiretroviral drug and can occur with any regimen. Patients with HIV-associated lipodystrophy have abnormal lipid and glucose metabolism, which often leads to insulin resistance, dyslipidemia, and an increased risk of cardiovascular disease. (Choice A) Adrenal hyperplasia can cause Cushing syndrome, which often manifests with wasting of the extremities and increased central fat. However, most patients also have other symptoms, including proximal muscle weakness, facial plethora, easy bruising, and/or purple abdominal striae. This patient who is on antiretroviral therapy and has a buffalo hump and increased visceral fat is more likely to have HIV-associated lipodystrophy. (Choice C) This patient has negative hepatitis B and C virus testing and no history of alcohol abuse, making hepatic cirrhosis less likely. In addition, cirrhosis is not typically associated with alterations in fat deposition. This patient's liver is likely enlarged due to increased visceral abdominal fat deposition from HIV-associated lipodystrophy. (Choice D) Patients with HIV are more likely to have testosterone deficiency, which can be associated with increased fat accumulation. However, testosterone deficiency usually also causes a reduction in lean muscle mass and sexual drive. (Choice E) Pituitary adenomas can cause alterations in hormone levels or neurologic manifestations (eg, headache) but are not typically associated with dorsocervical and visceral fat accumulation. This patient is much more likely to have HIV-associated lipodystrophy. Educational objective: Patients with HIV on antiretroviral therapy are at risk for HIV-associated lipodystrophy. Manifestations include lipoatrophy (loss of subcutaneous fat from legs, arms, face, and buttocks), fat accumulation (buffalo hump, increased visceral abdominal fat), or both. Patients with HIV-associated lipodystrophy have high rates of insulin resistance and dyslipidemia and are at elevated risk for cardiovascular disease. References: HIV-associated lipodystrophy: a review of underlying mechanisms and therapeutic options. (http://www.ncbi.nlm.nih.gov/pubmed/18565973) Approach to the human immunodeficiency virus-infected patient with lipodystrophy. (http://www.ncbi.nlm.nih.gov/pubmed/18685115)

A 54-Year-Old Man Comes to the Office for a Routine