Endocrine Abstracts

GD following ART occurs rarely, in 3% of HIV-infected women¹. It is suggested that CD4 cells increase in a biphasic pattern following ART initiation, with the expansion of naïve CD4 cells following months after the initial redistribution of memory CD4 cells from lymphoid tissue². A 40-year-old Brazilian lady was diagnosed with HIV in late 2016 following admission with cryptococcal meningitis and salmonellosis, requiring treatment with anti-fungal agents and high dose steroids. Initial CD4 count was 17 cells/µl (540–1660), CD4% 4% (32–60) and HIV viral load was 1804502 copies/ml. Primary adrenal insufficiency was confirmed and treated following presentation with persistent hypotension and fatigue (peak Cortisol post Synacthen of 407 nmol/l, ACTH 111 ng/l (7–63), adrenal and TPO antibodies negative, CT adrenal showed no infiltrative process). ART (emtricitabine/tenofovir, alafenadmide and darunavir/ritonavir) was deferred until five weeks post admission. She developed fevers, vomiting and headaches five days after the initiation of ART, which was attributed to IRIS. 19 months post original diagnosis, she presented with cervical lymphadenopathy (CD4 count 585 cells/µl, undetectable HIV viral load). Following extensive work up, including biopsy, a late IRIS to cryptococcus was diagnosed. High dose steroids resulted in complete resolution of lymphadenopathy. 45 months after ART initiation, she developed symptomatic Graves’ hyperthyroidism with weight loss, tremor and hair thinning. Free T4 (FT4) was 28.9 pmol/l (9–20), thyroid stimulating hormone (TSH) <0.01 mIU/l (0.35–4.94) and TSH receptor antibody 3.7 IU/l (< 1.8)). Prior TFTs and thyroid imaging were normal. Family history was negative for thyroid and autoimmune disease. FT4 reduced to 12 pmol/l on carbimazole 10 mg daily. The onset of GD post ART in this case is outside of the reported 12–36 months heretofore documented². We cannot be definitive if the GD was of new onset independent of HIV status or if it occurred as part of an IRIS. However, the diagnosis of documented late IRIS to cryptococcus may suggest that the GD is a consequence of ART immune reconstitution. This case highlights the importance of remaining vigilant for potential endocrine effects that can occur during clinical follow-up in patients following ART initiation.

References

1. Chen F, Day SL, Metcalfe RA, Sethi G, Kapembwa MS, Brook MG, et al. Characteristics of autoimmune thyroid disease occurring as a late complication of immun reconstitution in patients with advanced human immunodeficiency virus (HIV) disease. Medicine. 2005;84(2):98–106.

2. Hoffmann CJ, Brown TT. Thyroid function abnormalities in HIV-infected patients. Clin Infect Dis. 2007;45(4):488–94.