Liposuction for protease-inhibitorassociated lipodystrophy

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 categories6 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 d i s t ri bution 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.

Liposuction for protease-inhibitorassociated lipodystrophy Samuel Ponce-de-Leon, Mar tin Iglesias, Joel Ceballos, Luis Ostrosk y -Z eic hner

Peripheral lipodystrophy, hyperlipidaemia, and insulin resistance has been reported as a side-effect of proteaseinhibitor treatment for HIV-1 infection.1–3 We report a man who developed lipodystrophy when treated with saquinavir and nelfinavir who had liposuction. A 46-year-old man was diagnosed as having HIV-1 infection by a positive ELISA test in 1989. Treatment was started with zidovudine in 1990. In 1991 zalcitabine was added, and in 1994 saquinavir was started as a third drug. In December, 1995, he noticed a progressive increase in the thickness of his neck. Treatment was modified to nevirapine, nelfinavir, and didanosine. In January, 1997, he complained of a buffalo hump. A magnetic resonance imaging scan showed an abnormal accumulation of fat tissue in the area. He had liposuction without complications and with an acceptable aesthetic result (figure). Although peripheral lipodystrophy is a marker of a systemic metabolic defect, it may contribute to non-compliance with anti-retroviral therapy. Liposuction may be a suitable treatment until better strategies are developed. 1 2

3

Viraben R, Aquilina C. Indinavir-associated lipodystrophy. AIDS 1998; 12: 37–39. Carr A, Samaras K, Burton S, et al. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors. AIDS 1998; 12: 51–58. Walli R, Herfort O, Michl GM, et al. Treatment with protease inhibitors associated with peripheral insulin resistance and impaired oral glucose tolerance in HIV-1-infected patients. AIDS 1998; 12: 167–73.

Division of Hospital Epidemiology ( S Ponce-de-Leon e-mail: sponc e@quet zal.innsz.mx ); Plastic Surgery Service; and Imaging Department, Instituto Nacional de la Nutrición Salvador Zubirán, 14000 México City, México

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. 1

Carr 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: F51–58. 2 Lo JC, Mulligan K, Tai VW, Algren H, Schambelan M. “Buffalo hump” in men with HIV-1 infection. Lancet 1998; 351: 867–70. 3 Gervasoni 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. 4 Carr A, Samaras K, Chrisholm DJ, Cooper DA. Pathogenesis of HIV-1-protease inhibitor associated peripheral lipodystrophy hyperlipidemia and insulin resistance. Lancet 1998; 352: 1881–83. 5 Hirsch 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: 73–75. 6 Centers for Disease Control and Prevention. 1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR Morb Mortal Wkly Rep 1994; 43: 1–10. Division of Pediatric Infectious Diseases, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA (F E Babl e-mail: [email protected])

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Appearance before (A) and after (B) liposuction The patient gave permission for publication of these photographs.

THELANCET • Vol 353 • April 10,1999