Abnormal body-fat distribution in HIV-1-infected children on antiretrovirals
Authors: Franz E Babl, Anne Marie Regan, Stephen I Pelton
Journal: The Lancet (1999)

An increasing number of HIV-1-infected children are being given protease inhibitors (PIs). We identified a 9-year-old girl on PI who developed a buffalo hump. Abnormal body fat distribution has been reported in HIV-1-infected adults1Carr A Samaras K Burton S Freund J Chrisholm DJ A syndrome of peripheral lipodystrophy, hyperlipidemia and insulin resistance in patients receiving HIV protease inhibitors.AIDS. 1998; 12: F51-F58Crossref PubMed Scopus (2195) Google Scholar, 2Lo JC Mulligan K Tai VW Algren H Schambelan M "Buffalo hump" in men with HIV-1 infection.Lancet. 1998; 351: 867-870Summary Full Text Full Text PDF PubMed Scopus (515) Google Scholar, 3Gervasoni C, Ridolfo AL, Trifiro G, et al. Redistribution of body fat in HIV infected women undergoing antiretroviral therapy: clinical, immunological, and metabolic analyses. 38th Interscience Conference on Antimicrobial Agents and Chemotherapy 1998: 1–93.Google Scholar and several aetiological hypotheses have been suggested.4Carr A Samaras K Chrisholm DJ Cooper DA Pathogenesis of HIV-1-protease inhibitor associated peripheral lipodystrophy hyperlipidemia and insulin resistance.Lancet. 1998; 352: 1881-1883Summary Full Text Full Text PDF Scopus (984) Google Scholar, 5Hirsch MS Klibanski A Editorial response: what price progress? Pseudo-Cushing's syndrome associated with antiretroviral therapy in patients with human immunodeficiency virus infection.Clin Infect Dis. 1998; 27: 73-75Crossref PubMed Scopus (20) Google Scholar Little is known about the prevalence and risk factors in children. We estimated the prevalence of abnormal body fat distribution in HIV-1-infected children. A questionnaire was sent to all paediatric AIDS Clinical Trial Group and National Institute of Child Health and Human Development sites between March and August, 1998. 55 of 91 (60%) sites responded. We provided an example of abnormal body fat distribution by describing the case we had encountered as well as descriptions from the literature of abnormal body fat distribution in adults. We then requested background data including the number of HIV-1-infected children (<18 years) on antiretrovirals at each site, and descriptive data about patients with abnormal body fat distribution as defined by the responding practitioner. Demographics, abnormal body fat distribution, viral load, CD4-cell count, information about endocrine evaluation, and medications were collated for the patients with abnormal body fat. 16 sites reported at least one patient with abnormal body fat distribution. Of 2713 patients on antiretroviral therapy, 1069 (39·4%) were managed without a PI, 1644 (60·6%) with a PI. 28 patients (1·0%) had abnormal body fat distribution; four of 1069 (0·4%) were not receiving PIs and 24 of 1644 (1·5%) receiving PIs had developed abnormal body fat (p=0·003; Fisher's exact test). 64% of children with abnormal body fat distribution were female, 43% were African-American, 29% white, 21% Hispanic. Mean age was 10·9 years (range 5–17 years). Abnormal fat distribution was noticed in the abdomen in 17 patients, the upper back in 12, the face in ten, the lower back and the neck in four each; thin limbs were identified in two patients and no specific distribution information was reported for two patients. The length of PI treatment before diagnosis ranged from 1 month to 14 months with a gradually increasing prevalence over time with no plateau. The mean viral load in children with abnormal body fat was 98 000 copies ranging from below 500 to 714 000 copies/mL at the time of reporting. The mean CD4-cell count was 367 cells/mL (range 7–1489). By CDC immune categories6Centers for Disease Control and Prevention1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age.MMWR Morb Mortal Wkly Rep. 1994; 43: 1-10Google Scholar four patients were in category one, 11 in two, and 12 in category three. 18 different combinations of single-drug, double-drug, and triple-drug antiretroviral regimens were identified in patients with abnormal body fat. Two were on nucleoside analogue reverse-transcriptaseinhibitor therapy (RTI) alone and two on RTI and nonnucleoside RTI therapy alone. The remaining 24 patients (86%) received at least one PI including ritonavir (18), saquinavir (five), nelfinavir (four), and indinavir (two). Limitations of our study include the retrospective nature and descriptive, rather than comparative, patient data. Lacking an objective definition, abnormal body fat distribution was defined by the participating medical professionals and therefore is likely to represent an individual's interpretation. Few patients had a comprehensive endocrine evaluation. A definition of abnormal body fat distribution beyond a subjective clinical impression will be necessary to detect subtle cases in children. To clarify the aetiology of this phenomenon further study should include a standardised definition, a comparative determination of risk factors, structured evaluations of endocrine abnormalities, and correlations with specific drugs. Presented, in part, at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), American Society of Microbiology, in San Diego, CA, USA, on Sept 25, 1998.