Assessment of Adrenal Dysfunction in Patients with HIV Infections

Siva Prakash, S (2006) Assessment of Adrenal Dysfunction in Patients with HIV Infections. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: The adrenal gland is frequently involved in patients infected with human immunodeficiency virus (HIV). Although clinical manifestations of adrenal dysfunction are uncommon in patients infected with HIV, subclinical functional abnormalities of the hypothalamic - pituitary - adrenal axis are frequent1. Patients with acquired immunodeficiency syndrome are found to have increased basal cortisol and reduced stimulated cortisol release. This imbalance may be related to progression of the infection by inducing a shift from T(H)1 to T(H)2 immunologic responses. Also adrenal reserve may be marginal in HIV - infected patients. Clinically evident adrenal insufficiency is uncommon and, whenpresent, it is observed in advanced stages of the infection. Patients with AIDs are also at risk of acquiring opportunistic infections like tuberculosis, cytomegalovirus infections etc, which may involve adrenal gland and result in adrenal hypofunction. Cortisol levels are also subject to variations in HIV infected patients who are on antibiotics such as ketoconazole, rifampicin, etc. Taking into consideration the various factors which alter the HPA axis and plasma cortisol levels, the study was conducted to assess the adequacy of function of the HPA axis by estimation of basal cortisol level, since a basal cortisol value >15 μg / dl invariably indicates an intact HPA axis2. Adrenal dysfunction also could contribute to morbidity and mortality in HIV infected patients. AIM OF THE STUDY: Assessment of adrenal dysfunction in patients with HIV infections. MATERIALS AND METHODS: Study design: Prospective, cross - sectional study. Subjects: Patients admitted in medical wards of Government General Hospital, Chennai, who were detected to have HIV infection (HIV-1 and HIV-2) by ELISA were enrolled in the study. The study group consisted of 61 patients (45 males, 16 females). The control group was formed by age and sex matched 20 normal individuals. Informed consent was obtained from patients and controls. All patients tested positive for HIV infection by ELISA over 12 years of age were included in the study. Exclusion Criteria: 1. Patients who were concurrently taking any of the following drugs: Phenytoin, Rifampicin, Ketoconazole, Corticosteroids, Oral contraceptive pills. 2. Pregnancy, 3. Liver disease. METHODOLOGY: Detailed history, symptoms and signs of adrenal hypofunction were noted3. All patients were completely examined and routine urine and blood investigations were taken. Clinical evaluation of adrenal insufficiency included the following symptoms. * Fatigue and postural dizziness * Gastrointestinal symptoms: nausea, vomiting, diarrhoea, abdominal pain, constipation. Measurement of blood pressure to detect postural hypotension (defined as a postural decrease from the supine to standing position of atleast 20 mmHg of systolic pressure or 10 mmHg of diastolic pressure, within 3 minutes of standing up). Estimation of serum sodium, serum potassium, blood glucose and eosinophil count was done in all patients as part of evaluation of adrenal insufficiency. The patients were staged in accordance to WHO guidelines and the nature of concurrent diseases or infections were noted. CONCLUSIONS: 61 patients and 20 controls were studied for clinical and biochemical evidence of adrenal dysfunction in HIV infections. • The patients whom we evaluated in the medical wards comprised predominantly of males (74%). • 84% of the patients admitted during the study period were in stage - IV disease (WHO clinical stage). • Basal cortisol levels were significantly elevated in patients with HIV infections compared to controls. Patients who had concurrent tuberculosis had significantly higher basal cortisol levels than those with HIV infection alone. • Symptoms and signs of adrenal hypofunction had significant association with hypocortisolemia. • Hyponatraemia had statistically significant correlation with low cortisol levels. • Low CD4 cell count had significant correlation with hypocortisolemia and therefore may predict adrenal insufficiency. SUMMARY: The adrenal gland is frequently involved in patients with HIV infections. Structural and functional alterations of the adrenal glands, and involvement of the HPA axis can occur. Our study on patients infected with HIV has shown that adrenal dysfunction is common resulting in higher basal serum cortisol level. There is a significant association of clinical features of adrenal insufficiency, CD4 cell count with hypocortisolaenia. Adrenal insufficiency is observed in advanced stages of the infection. Hence hypocortisolemia should be treated regardless of the existence of associated symptoms, whereas hypercortisolemia in the absence of features of Cushings syndrome is common and should not promote treatment nor specific studies.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Adrenal Dysfunction ; Patients ; HIV Infections ; Assessment.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 25 Mar 2018 04:30
Last Modified: 25 Mar 2018 04:30

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