C h a p t e r 1 6
Disorders of the Immune Response
369
Pulmonary KS usually is a late development of the
disease and causes dyspnea, cough, and hemoptysis
(coughing up blood).
68
With prolonged survival, the number of persons
with AIDS who develop
non-Hodgkin lymphoma
has
increased steadily.
2
The clinical features are nonspecific
and include fever, night sweats, and weight loss (see
Chapter 11). Because the manifestations of non-Hodgkin
lymphoma are similar to those of other opportunistic
infections, diagnosis often is difficult. Diagnosis can be
made by biopsy of the affected tissue.
The high prevalence of human papillomavirus
(HPV) infection in persons with AIDS has been linked
to the development of
cervical carcinoma
and anal
carcinoma in both HIV-positive men and women.
2
Gynecologic examination with cervical cytologic
analysis for HPV should be part of the routine eval-
uation of HIV-infected women. Since HPV can also
cause anal dysplasia, a precursor of anal carcinoma,
cytologic evaluations of the anal canal are also rec-
ommended for both HIV-infected men and women.
A quadrivalent vaccine to prevent HPV infection became
available in 2007. The safety and immunogenicity of
this vaccine among HIV-infected men and women are
being studied.
69
Wasting Syndrome and Metabolic
Disorders
Wasting Syndrome.
The wasting syndrome, which
is an AIDS-defining illness, is characterized by invol-
untary weight loss of at least 10% of baseline body
weight in the presence of diarrhea, more than two
stools per day, or chronic weakness and a fever.
70
This diagnosis is made when no other opportunistic
infections or neoplasms can be identified as causing
these symptoms. Factors that contribute to wasting
are anorexia, metabolic abnormalities, endocrine dys-
function, malabsorption, and cytokine dysregulation.
Treatment for wasting includes nutritional interven-
tions such as oral supplements or enteral or parenteral
nutrition, as well as pharmacologic agents, includ-
ing appetite stimulants, cannabinoids, and megestrol
acetate.
Metabolic Disorders.
A wide range of metabolic and
morphologic disorders are associated with HIV infec-
tion, including insulin resistance and diabetes, lipodys-
trophy, hyperlipidemia, and mitochondrial disorders.
71
It is not known why insulin resistance appears to be
increased in people with HIV infection; however, most
experts believe it is secondary to dysregulation of meta-
bolic pathways or to indirect effects through mitochon-
drial toxicity linked to adipocyte toxicity.
72
Moreover,
metabolic complications among people with HIV infec-
tion have been increasing since the introduction of
potent HAART.
The term
lipodystrophy
is frequently used to describe
the body composition changes with or without the
other metabolic derangements. Lipodystrophy related
to HIV infection includes symptoms that fall into two
categories: changes in body composition and metabolic
changes.
73
The alterations in body appearance are an
increase in abdominal girth, buffalo hump develop-
ment (abnormal distribution of fat in the dorsoclavical
area), wasting of fat from the face and extremities, and
breast enlargement in men and women. Most individu-
als experience either lipohypertrophy or lipoatrophy.
Mixed patterns of fat changes are less common.
74
The
metabolic changes include elevated serum cholesterol,
low HDL cholesterol, elevated triglyceride levels, and
insulin resistance. Originally attributed solely to the
use of protease inhibitors, the pathogenesis of these
metabolic derangements is complex and there may be
multiple confounding factors.
75
FIGURE 16-11.
Kaposi sarcoma.
(A)
Intraoral Kaposi sarcoma
of the hard palate secondary to HIV infection.
(B)
Cutaneous
brown Kaposi sarcoma lesions located over the medial left
ankle and foot. (From the Centers for Disease Control and
Prevention Public Health Image Library. Nos. 6070, 5515. A
courtesy of Sol Silverman, Jr; B courtesy of Steve Kraus.)
A
B
