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 Table of Contents     
CASE REPORT
Year : 2012  |  Volume : 27  |  Issue : 3  |  Page : 183-184  

Hypermetabolic subcutaneous fat in patients on highly active anti-retroviral therapy treatment: Subtle finding with implications


Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai, India

Date of Web Publication31-May-2013

Correspondence Address:
Venkatesh Rangarajan
Department of Nuclear Medicine and Molecular Imaging, Tata Memorial, Hospital, Parel, Mumbai - 400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.112726

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   Abstract 

Lipodystrophy (LD) is a serious complication of highly active anti-retroviral therapy, characterized by peripheral fat wasting, central adiposity and metabolic changes. Since the disfiguration caused by LD is permanent, the focus of management is on early detection to arrest progression. We report a case where ancillary finding of increased fluorine-18 fluoro-2-deoxyglucose (F-18 FDG) uptake in the sub-cutaneous fat helped early detection of LD and led to early intervention to arrest progression. Though F-18 FDG positron emission tomography/computed tomography scan is not recommended to diagnose LD, conscious reporting of this finding when present can greatly influence patient management.

Keywords: Fluoro-2-deoxyglucose uptake in human immunodeficiency virus, highly active anti-retroviral therapy, lipodystrophy


How to cite this article:
Zade A, Rangarajan V, Purandare N, Shah S, Agrawal A, Jha A, Kulkarni M. Hypermetabolic subcutaneous fat in patients on highly active anti-retroviral therapy treatment: Subtle finding with implications. Indian J Nucl Med 2012;27:183-4

How to cite this URL:
Zade A, Rangarajan V, Purandare N, Shah S, Agrawal A, Jha A, Kulkarni M. Hypermetabolic subcutaneous fat in patients on highly active anti-retroviral therapy treatment: Subtle finding with implications. Indian J Nucl Med [serial online] 2012 [cited 2019 Nov 18];27:183-4. Available from: http://www.ijnm.in/text.asp?2012/27/3/183/112726


   Introduction Top


Lipodystrophy (LD) is a serious complication of highly active anti-retroviral therapy (HAART) and is associated with increased fluoro-2-deoxyglucose (FDG) uptake. Conscious reporting of this ancillary finding may help early identification and intervention to arrest the progression of this serious metabolic disorder.


   Case Report Top


A 34-year-old gentleman, on anti-retroviral therapy since 3 years was treated for lymphoblastic lymphoma. He was referred for fluorine-18 FDG positron emission tomography/computed tomography (PET/CT) study for follow-up evaluation. The scan revealed hypermetabolism in the mid thorax corresponding to esophageal candidiasis [Figure 1]. With a history of HAART therapy of 3 years duration, the scintigraphic findings of increased FDG uptake in the subcutaneous adipose tissue was suggestive of LD. He was treated with antifungal medications. To arrest the progression of LD, stavudine was replaced by tenofovir and diet modification was advised.
Figure 1: Maximum intensity projected image (a) revealed increased linear FDG uptake in the mid thorax and diffuse low grade FDG uptake throughout the body. The diffuse low grade FDG uptake on transaxial PET image at infra axillary level (arrows in Figure b) corresponded to the subcutaneous adipose tissue on correlative CT image (arrows in Figure c). The increased focal FDG uptake on the transaxial PET image in the mid thorax at subcarinal level (arrows in Figure d) corresponded to the oesophagus on correlative CT image (arrows in Figure e)

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   Discussion Top


HAART has increased the life expectancy and also improved the quality of life of people suffering from human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. LD is a late but serious complication of HAART caused by mitochondrial damage of adipocytes and characterized by peripheral fat wasting (lipo-atrophy), central adiposity (lipo-hypertrophy), and metabolic changes, such as hyperlipidemia, hyperglycemia, and insulin resistance. Its incidence is related to the dosage and duration of exposure to anti-retrovirals. [1],[2],[3] Its' prevalence in developing countries, which continue to use older, less expensive antiretroviral drugs, may be as high as 47% after 2 years of therapy. [4] Diagnosis based on anthropometric and biochemical measurements can be made only in the late stages of disease when the disfigurement is largely permanent. Replacement of the offending drug by a less LD-inducing drug in the early stages of disease may arrest its progression. [5],[6] Hence, early detection to arrest progression is of paramount importance. [1] FDG PET/CT study has evolved not only as a tool to improve our understanding of the pathogenesis of HIV-1 infection, but also in diagnosis, staging, restaging, and monitoring therapeutic response in the opportunistic infections and malignancies. [2],[7],[8],[9],[10],[11],[12] Furthermore, increased FDG uptake in subcutaneous adipose tissue has been demonstrated in diagnosed cases of LD. [2],[13] The awareness of this uptake pattern is important when evaluating FDG PET in patients undergoing HAART.

 
   References Top

1.Innes S, Levin L, Cotton M. Lipodystrophy syndrome in HIV-infected children on HAART. South Afr J HIV Med 2009;10:76-80.  Back to cited text no. 1
    
2.Bleeker-Rovers CP, van der Ven AJ, Zomer B, de Geus-Oei LF, Smits P, Corstens FH, et al. F-18-fluorodeoxyglucose positron emission tomography for visualization of lipodystrophy in HIV-infected patients. AIDS 2004;18:2430-2.  Back to cited text no. 2
    
3.Walker UA, Bickel M, Lütke Volksbeck SI, Ketelsen UP, Schöfer H, Setzer B, et al. Evidence of nucleoside analogue reverse transcriptase inhibitor - Associated genetic and structural defects of mitochondria in adipose tissue of HIV-infected patients. J Acquir Immune Defic Syndr 2002;29:117-21.  Back to cited text no. 3
    
4.Aurpibul L, Puthanakit T, Lee B, Mangklabruks A, Sirisanthana T, Sirisanthana V. Lipodystrophy and metabolic changes in HIV-infected children on non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy. Antivir Ther 2007;12:1247-54.  Back to cited text no. 4
    
5.Carr A, Emery S, Law M, Puls R, Lundgren JD, Powderly WG, et al. An objective case definition of lipodystrophy in HIV-infected adults: A case-control study. Lancet 2003;361:726-35.  Back to cited text no. 5
    
6.Fisher M, Moyle GJ, Shahmanesh M, Orkin C, Kingston M, Wilkins E, et al. A randomized comparative trial of continued zidovudine/lamivudine or replacement with tenofovir disoproxil fumarate/emtricitabine in efavirenz-treated HIV-1-infected individuals. J Acquir Immune Defic Syndr 2009;51:562-8.  Back to cited text no. 6
    
7.Sathekge M, Goethals I, Maes A, van de Wiele C. Positron emission tomography in patients suffering from HIV-1 infection. Eur J Nucl Med Mol Imaging 2009;36:1176-84.  Back to cited text no. 7
    
8.Lucignani G, Orunesu E, Cesari M, Marzo K, Pacei M, Bechi G, et al. FDG-PET imaging in HIV-infected subjects: Relation with therapy and immunovirological variables. Eur J Nucl Med Mol Imaging 2009;36:640-7.  Back to cited text no. 8
    
9.Castaigne C, Tondeur M, de Wit S, Hildebrand M, Clumeck N, Dusart M. Clinical value of FDG-PET/CT for the diagnosis of human immunodeficiency virus-associated fever of unknown origin: A retrospective study. Nucl Med Commun 2009;30:41-7.  Back to cited text no. 9
    
10.Liu Y. Demonstrations of AIDS-associated malignancies and infections at FDG PET-CT. Ann Nucl Med 2011;25:536-46.  Back to cited text no. 10
    
11.Mariano-Goulart D, Ilonca D, Bourdon A. Diagnosis of silent myocardial ischemia during the staging of HIV-associated lymphoma with FDG PET/CT. Clin Nucl Med 2009;34:731-3.  Back to cited text no. 11
    
12.Pruzzo R, Redondo F, Amaral H, Glasinovic E, Caviedes I, Glasinovic JC. Anal and rectal syphilis on F-18 FDG PET/CT. Clin Nucl Med 2008;33:809-10.  Back to cited text no. 12
    
13.Sathekge M, Maes A, Kgomo M, Stolz A, Ankrah A, Van de Wiele C. Evaluation of glucose uptake by skeletal muscle tissue and subcutaneous fat in HIV-infected patients with and without lipodystrophy using FDG-PET. Nucl Med Commun 2010;31:311-4.  Back to cited text no. 13
    


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