Patients infected with the human immunodeficiency virus (HIV) have an increased risk of developing endocrine abnormalities. The endocrine system is a group of organs that secretes hormones into the bloodstream to regulate bodily functions. The endocrine system includes the adrenal glands, hypothalamus, pituitary gland, thyroid, and gonads (ovaries and testes).
HIV patients are most likely to develop endocrine abnormalities in response to medications or as a complication of infections or tumors. Common endocrine abnormalities associated with HIV include Addison's disease (adrenal insufficiency), male hypogonadism, pancreatitis, and pituitary dysfunction.
Many endocrine disorders can be successfully treated. However, prognosis varies depending on the specific disorder.
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Overview: Male HIV patients have an increased risk of developing hypogonadism. Hypogonadism is a condition in which the sex organs, also called gonads, are underactive.
The gonads (testes or ovaries) help the body maintain normal physiological function. They secrete hormones essential for reproductive function, development of secondary sexual characteristics, body composition, and mood.
Primary hypogonadism occurs when the gonads are directly affected. Secondary hypogonadism occurs when other parts of the body, such as the hypothalamus or pituitary gland, are causing the gonads to be underactive.
Hypogonadism is prevalent among men with HIV, according to researchers. In early studies, more than half of all men with AIDS had low testosterone levels. It is estimated that males with advanced HIV disease have a lower prevalence of 25% for hypogonadism than men with less advanced HIV.
Causes: Hypogonadism may develop in males if HIV affects the hypothalamus, pituitary gland, and/or the testes, causing a decrease in testosterone levels.
In rare cases infections (such as toxoplasmosis) or HIV-related cancers (such as lymphoma) have been shown to cause lesions on the pituitary gland and/or hypothalamus. These lesions may prevent the pituitary and hypothalamus from secreting hormones necessary for proper gonadal function.
In addition, certain medications may also cause secondary hypogonadism in HIV-infected males. For instance, a man-made hormone called egestrol acetate (such as Megace®) may cause severe hypogonadism in HIV-infected males.
Malnutrition and/or chronic illness may cause secondary hypogonadism in HIV-infected men.
Symptoms: If the body does not produce enough testosterone during fetal development, the growth of male sex organs may be impaired. Male children born with HIV and hypogonadism may have female genitals, ambiguous genitals that are neither male or female, or underdeveloped male genitals. If hypogonadism occurs during puberty, the male may experience decreased development of muscle mass, impaired growth of body hair, impaired growth of genitals, excessive growth of the arms and legs in proportion to the trunk of the body, development of breast tissue, and lack of deepening of the voice. Hypogonadism during adulthood may cause erectile dysfunction, infertility, decreased body hair growth, increased body fat, decreased testicle size, decreased muscle mass, development of breast tissue, and osteoporosis (hollow, brittle bones).
Diagnosis: Hypogonadism is diagnosed when a patient experiences symptoms that are characteristic of the disorder and has low levels of testosterone in the blood. If tests confirm that the patient has low levels of testosterone, hypogonadism is diagnosed. Additional tests may be performed to determine the underlying cause. If a patient with hypogonadism is receiving hormone therapy, the medication is the suspected cause.
A blood test is performed to measure the levels of testosterone in the blood. This test is typically performed early in the day because testosterone levels are generally highest in the morning. Healthy males typically have 300-1,000 nanograms of testosterone per deciliter of blood.
Treatment: HIV patients typically experience an improvement in symptoms once the underlying cause is treated.
If hormone replacement therapy is the suspected cause of symptoms, a healthcare provider may recommend a different dose or medication.
If HIV is the suspected cause, patients should begin treatment with highly active antiretroviral therapy (HAART). This is a combination of different antiretrovirals that suppresses HIV and boosts the body's immune system.
If an infection is the suspected cause, patients typically receive medications called antimicrobials. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. The specific drug and dose depend on the type and severity of the infection, as well as the patient's overall health.
Only in rare cases do HIV patients require testosterone injections. This is because most HIV patients with hypogonadism do not experience testicular failure. If testosterone therapy is needed, patients typically receive injections with the hormone once every two to three weeks.
Prevention: Since most cases of hypogonadism in HIV patients are caused by infections, patients should receive HAART. This combination therapy suppresses HIV, which subsequently boosts the immune system, making patients less vulnerable to infections.
Overview: Patients infected with the human immunodeficiency virus (HIV) have an increased risk of developing pancreatitis, a severe inflammation of the pancreas. Pancreatitis occurs when the digestive enzymes in the organ become active too soon. Instead of becoming active in the intestines, they become active inside the pancreas, where they can cause organ damage.
The pancreas is located behind the stomach. It produces enzymes that are released into the small intestine to break down protein in food. The pancreas also produces insulin, a hormone that helps regulate the amount of sugar in the blood.
Although HIV patients are more likely to develop pancreatitis than HIV-negative patients, it is still considered a rare condition. For instance, researchers from one study found that less than one percent of 976 HIV patients who were receiving anti-HIV drugs (antiretrovirals) developed the condition.
Causes: HIV patients may develop pancreatitis as a result of heavy alcohol consumption, gallstones that block a tube in the pancreas called the pancreatic duct, infections (such as mycobacterium avium complex), or medications such as pentamidine (Pentam®).
Symptoms: Acute symptoms of pancreatitis appear suddenly and may lasts for several hours or even days. Common symptoms include nausea, rapid pulse, fever, vomiting, and severe abdominal pain and swelling. The abdomen may be tender when touched. Drinking alcohol causes the symptoms to worsen.
If the underlying cause of pancreatitis is not treated, the condition may become chronic (long-term). Common symptoms of chronic pancreatitis include nausea, vomiting, fever, and unintentional weight loss. Chronic pancreatitis may lead to complications, such as temporary diabetes, malnutrition, and severe pain.
Diagnosis: A blood test may be performed to determine whether the digestive enzymes from the pancreas are present in the blood. Patients with pancreatitis will test positive for these enzymes. This is because the enzymes in the pancreas leak outside of the organ and into the bloodstream.
Imaging studies, such as an abdominal X-ray or computerized tomography (CT) scan, may be performed to determine whether the pancreas is larger than normal. Both of these tests, which are performed at the hospital, produce images of the internal organs. Patients with pancreatitis will have an inflamed pancreas.
An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at the hospital to evaluate the damage of the pancreas. During the procedure, a thin, flexible tube with a camera is inserted through the mouth and into the small intestine. The tube then hooks into the bile duct, allowing the healthcare provider to see the pancreas. During the test, a small tissue sample may be removed and analyzed in a laboratory for infections or cancer. Because this procedure may damage the pancreas if not performed by a qualified physician, it is only conducted if all other tests are nondiagnostic. There is also a slight risk of infection.
Treatment: Acute pancreatitis usually improves after about one week of treatment. Most cases of acute pancreatitis require hospitalization for a few days, and patients typically experience a full recovery. However, if the condition is left untreated, scarring may occur in the organ. Once the organ becomes scarred, the condition cannot be reversed and the patient requires long-term treatment to manage the symptoms. Alcohol avoidance and pain medications can effectively relieve symptoms of chronic pancreatitis.
If a medication is suspected to be causing acute pancreatitis, a healthcare provider may recommend an alternative dose or medication.
Oral pain relievers, such as meperidine (Demerol® Hydrochloride), have been used to treat pain caused by pancreatitis. Oral anti-inflammatories, such as naproxen (Naprosyn®, Synflex®), or high doses of aspirin may also help reduce pain.
Antimicrobials are used to treat infections that cause pancreatitis. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections.
If a gallstone is causing acute pancreatitis, a surgical procedure called endoscopic sphincterotomy is usually required. This procedure is used if the gallstone is blocking the biliary ducts. During the procedure, which is performed at a hospital, the patient receives general anesthesia and is asleep during the surgery. Then, a thin flexible tube, called an endoscope, is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder. Once the gallbladder is removed, patients can expect a full recovery. Some patients may experience more frequent bowel movements and/or loser-than-normal stools or diarrhea. In some cases, these symptoms may gradually improve over time. Complications are rare but may include damage to the common bile duct, bleeding, and infection. Non-surgical procedures, such as bile salt tablets or sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
Patients with chronic pancreatitis typically receive enzyme therapy with supplements, such as pancrelipase (Pancrease®, Viokase®). These are man-made versions of the pancreatic enzymes that are leaking out of the organ. These supplements are typically taken before and during meals and snacks.
Because the pancreatic enzymes may damage the cells that produce insulin, insulin injections may be given to patients who are experiencing symptoms of diabetes.
In severe cases, patients may undergo a surgical procedure to destroy the nerves near the pancreas. Once the nerves are dead, they can no longer transmit pain signals to the brain and the patient does not feel pain. Surgery is only performed in patients who have severe pain that cannot be managed with other treatments.
Prevention: Avoid or minimize alcohol consumption because it may lead to pancreatitis. Patients should eat a reduced fat diet. High amounts of fat increase the risk of developing gallstones and gallstones may cause pancreatitis. Patients should receive highly active antiretroviral therapy (HAART) to help prevent infections that may cause pancreatitis. HAART is a combination of anti-HIV drugs (antiretrovirals) that suppresses HIV and boosts the body's immune system. In order to prevent complications of pancreatitis, patients should take medications exactly as prescribed.
Overview: There have been reports of pituitary disorders in HIV/AIDS patients. The pituitary gland is a pea-sized gland located at the base of the brain. This gland secretes various hormones that regulate bodily functions, including growth. A part of the brain, called the hypothalamus, releases hormones that control the function of the pituitary gland.
There have been reports of HIV patients who developed underactive pituitary glands in response to a parasitic infection called toxoplasmosis. This has occurred when the parasite infiltrates the pituitary gland and forms lesions. As a result, the pituitary gland is unable to function properly.
The most common pituitary disorder associated with HIV is hyponatremia. This condition occurs when the patient has low levels of sodium in the blood. The pituitary gland and hypothalamus are involved in sodium regulation. They produce and release antidiuretic hormone (ADH) into the bloodstream. This hormone causes the kidneys to conserve water. Patients develop hyponatremia if too much water is conserved.
According to one study, more than 50% of hospitalized patients with advanced HIV had hyponatremia.
Although hyponatremia is most common among acutely ill, hospitalized HIV patients with opportunistic infections, studies have also found that the incidence among stable HIV outpatients is also high, about 20%.
Causes: Some infections commonly associated with HIV, such as toxoplasmosis, may lead to an underactive pituitary gland. This happens when the infection causes lesions to form on the pituitary gland. Consequently, the gland is unable to secrete enough hormones needed for proper function.
Hyponatremia in HIV patients may be caused by the syndrome of inappropriate antidiuretic hormone secretion (SIADH), according to one study. This syndrome is characterized by excessive levels of antidiuretic hormone (ADH) in the bloodstream. Stress or medications are most likely to cause SIADH. Many HIV patients who developed hyponatremia were taking either opiate or barbiturate medications, which are known to stimulate the production of ADH.
In addition, low levels of blood in the body can also stimulate the pituitary gland to secrete more ADH. One study found that 88% of HIV patients with hyponatremia had decreased levels of blood circulating in the body in response to intravenous saline solution. HIV patients with severe infections often receive intravenous saline at the hospital.
Symptoms: Symptoms of an underactive pituitary gland vary depending on the affected hormones and severity of the deficiency. In general, symptoms may include sensitivity to cold, fatigue, weakness, decreased appetite, weight loss, abdominal pain, low blood pressure, headache, and vision problems.
Symptoms of hyponatremia may include fatigue, disorientation, headache, muscle cramps, and nausea. Extremely low levels of sodium can cause serious effects, including seizures and coma.
Diagnosis: A blood test is performed to diagnose an underactive pituitary gland. A healthcare provider will measure the amount of pituitary hormones present in the blood. Low or nonexistent levels of one or more pituitary hormones indicate an underactive thyroid.
Several blood and urine tests are available to diagnose hyponatremia. A serum sodium blood test may be conducted to determine the amount of sodium in the fluid portion of the blood, called the serum. Healthy patients typically have 135-145 milliequivalents of sodium per liter of blood. Patients with hyponatremia have less than 135 milliequivalents of sodium per liter of blood.
A serum osmolality test measures the amount of chemicals, including sodium, that are dissolved in the serum. Serum osmolality is controlled partly by ADH, also called vasopressin. The normal osmolality of blood is 275-295 milliosmoles per kilogram. Low serum osmolality indicates hyponatremia.
A urine osmolality test measures the amount of chemicals, including sodium, that are dissolved in the urine.
The normal osmolality of urine is 50-1,400 milliosmoles per kilogram. A urine sodium test measures the amount of sodium in urine.
Urine is collected over a 24-hour period and then analyzed in a laboratory. Normal urine sodium values are 15-250 milliequivalents per liter of urine a day.
Treatment: Treatment for an underactive pituitary gland varies depending on the severity of the condition and specific type of hormone deficiency. Some patients may return to normal function once the underlying infection is treated. Some patients may also require treatment with hormone therapy.
Patients who have hyponatremia that is caused by diuretics or an abnormal increase in ADH do not usually require medical treatment. Instead, the patient is encouraged to drink less water each day.
Injecting a solution of 5% sodium chloride into the bloodstream can treat severe hyponatremia.
Prevention: Patients should receive prompt treatment for infections, especially those that may lead to an underactive pituitary gland. Patients receiving either opiate or barbiturate therapy for lung disease should be monitored for hyponatremia