Chapter 59: HIV Lipodystrophy/Facial Lipoatrophy

INTRODUCTION

HIV lipodystrophy describes a constellation of changes in subcutaneous and visceral fat distribution in patients on antiretroviral therapy. In distinction to “lipoatrophy” (which describes local fat loss), lipodystrophy refers to both the accumulation of fat as well as the loss of fat in other areas. In HIV lipostrophy, the findings include subcutaneous fat loss in the malar and buccal fat pads, ie, facial lipoatrophy, as well as on the extremities. It also features fat accumulation on the dorsocervical fat pad, (Fig 59.1) ie, buffalo hump, breasts, and intra-abdominal cavity. Its characteristic appearance is significant, in that it reduces patient compliance with antiretroviral therapy and deprives patients of HIV status privacy, particularly in communities where HIV rates are high. This disorder is also associated with a host of metabolic disorders with long-term impact on health including hyperglycemia, hyperlipidemia, and hypertriglyceridemia. Treatments vary according to the clinical findings.

EPIDEMIOLOGY

Incidence: 25% to 83% of patients treated with antiretrovirals depending on criteria used

Age: All ages, but older age is predictive of severity

Race: None

Sex: Equal, severe findings more frequent in females

PRECIPITATING FACTORS

Antiretroviral therapies are the precipitating factor. It also presents infrequently in HIV patients naïve to HIV therapy. Typically, patients are on combination therapies.

PATHOGENESIS

Pathogenesis remains unknown. It is a multifactorial disorder that varies according to the medications taken.

DERMATOPATHOLOGY

Complete or near complete loss of fat. Juxtaposition of the dermis and fascia may be seen. Adipocytes are markedly reduced in number and size.

PHYSICAL LESIONS

Fat accumulation and fat loss are displayed.

• Fat accumulation

  • – Dorsocervical fat pad, ie, buffalo hump

  • – Breasts

  • – Intra-abdominal cavity, ie, Crix belly

• Fat loss

  • – Malar and buccal fat pads

  • – Extremities and buttocks

DIFFERENTIAL DIAGNOSIS

Other lipodystrophies facial lipoatrophy from aging, HIV wasting syndrome, Cushing’s disease, malnutrition states, anorexia nervosa, metabolic X syndrome, cachexia secondary to cancer, malabsorption syndromes, thyrotoxicosis, and multiple symmetric lipomatosis.

LABORATORY EXAMINATION

Biopsy is not useful. The clinical findings are sufficient to make a diagnosis. Laboratory workup should include assessment of blood glucose, lipids, and triglycerides. If Cushing’s is clinically suspected, laboratory examination should be performed.

COURSE

HIV lipodystrophy does not spontaneously regress in the absence of treatment or medication change.

KEY CONSULTATIVE QUESTIONS

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