Pituitary and adrenal gland dysfunction in HIV-infected patients
- Melissa Weinberg, MD
Melissa Weinberg, MD
- Assistant Clinical Professor of Medicine
- University of California, San Francisco
- Morris Schambelan, MD
Morris Schambelan, MD
- Professor Emeritus of Medicine
- University of California San Francisco
In the early AIDS epidemic, the diverse endocrine manifestations of HIV infection were more often a consequence of opportunistic infections (OIs), neoplasms, or concomitant systemic illness. The widespread use of potent antiretroviral therapy (ART) has led to a decline in the incidence of glandular infiltration by OIs and neoplasms and has generated increased attention toward the metabolic complications of HIV therapy, including insulin resistance, dyslipidemia, and alterations in body fat distribution.
This topic review will address the assessment and management of pituitary and adrenal disorders in patients with HIV/AIDS. Issues related to insulin resistance, bone and calcium disorders, and thyroid dysfunction are discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of HIV-associated lipodystrophy" and "Treatment of HIV-associated lipodystrophy" and "Bone and calcium disorders in HIV-infected patients" and "Thyroid gland dysfunction in HIV-infected patients".)
In general, the diagnosis and treatment of a specific endocrinopathy in a patient with HIV infection does not differ from that in an immunocompetent individual. There are, however, some special considerations. HIV infection may cause changes in pituitary and adrenal function that are adaptive and do not require treatment. Furthermore, many of the signs and symptoms of pituitary and adrenal dysfunction are nonspecific and can overlap with other non-endocrine disorders that are common in HIV-infected patients. Finally, many medications that are used to treat HIV infection and its complications can induce endocrine dysfunction (table 1), including affecting pituitary and adrenal hormones.
GLANDULAR INFECTION AND INFILTRATION
Infection by a diverse array of organisms, as well as HIV-associated malignancies (ie, Kaposi's sarcoma and lymphoma), have been detected in the pituitary and adrenal glands (table 2). Such occurrences were far more common prior to the widespread introduction of potent ART, although they may still be observed in patients not receiving ART or who have antiretroviral drug resistant infection.
Tissue is generally required for a definitive diagnosis. When technically feasible, fine needle aspiration (FNA) biopsy of the adrenal gland provides a less invasive alternative to open biopsy. Pheochromocytoma must always be excluded before FNA biopsy of the adrenal gland is performed. Standard functional testing should also be performed since clinically significant endocrine dysfunction may accompany glandular infection or infiltration of the pituitary or adrenal glands.
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- GENERAL PRINCIPLES
- GLANDULAR INFECTION AND INFILTRATION
- PITUITARY GLAND
- Alterations in pituitary function
- The somatotropic axis
- Effects of antiretroviral therapy on pituitary gland function
- Clinical manifestations
- Assessment and treatment of pituitary gland dysfunction
- ADRENAL GLAND
- Alterations in adrenal function
- Dehydroepiandrosterone replacement therapy
- Effects of medications on adrenal function
- - Antiretroviral agents
- - Protease inhibitors with inhaled or injected corticosteroids
- - Other medications frequently used among HIV-infected patients
- Assessment and treatment of adrenal dysfunction
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS
- Pituitary gland
- Adrenal gland