Aashi
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A 52-year-old man presents to the primary care clinic with thinning of his face and wasting of his arms and legs. The patient has a past medical history of HIV infection. He is on gemfibrozil, ritonavir, lamivudine, and stavudine. He has been compliant with his medications and does not take over-the-counter medications. He is afebrile and in no acute distress. There has been a 6-lb weight loss since the last visit six months ago. There is a soft, nontender, fatty mass noted in the dorsocervical region. The neck is supple and nontender. There is truncal obesity and thinning of the face, arms, and legs. His glucose level is 184 mg/dL, his cholesterol is 260 mg/dL, triglycerides are 340 mg/dL, and his CD4 count is 398/μL with an undetectable viral load. What is the next best step in diagnosing this patient's clinical findings?
(A) 24-hour urinary cortisol level
(B) Dexamethasone suppression test
(C) Excisional biopsy
(D) No further work-up is needed
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| drashishmahajan
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B
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| drashishmahajan
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i chked frm the harrison it says tht ritonavir can cause the redistribution of the fat .... ao this is drug induced.... option 4
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| Aashi
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U killed the whole suspense of solving the q dr ashish u cant carry ur harrisons to the examination hall,so try to solve the q without opening any books..we can have open book discussion,once everyone, whoever is interested attempts the q...Just an opinion ..thatz all
GL
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| robin082006
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Why not A?
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| Aashi
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Answer:
(D) No further work-up is needed
Explanation:
This patient presents with a buffalo hump on his upper back and hypertrophy of the cervicodorsal pad. This is a manifestation of fat redistribution from the cheeks, temples, and extremities to the neck, abdomen, and breasts. This fat redistribution syndrome is caused by protease inhibitors and is associated with insulin resistance and thus the elevated serum glucose. Ritonavir and all protease inhibitors can increase the serum level of statins, resulting in severe myalgias and rhabdomyolysis. This is why the patient is on gemfibrozil to control his lipid abnormalities. Gemfibrozil does not interact with protease inhibitors. High cholesterol and triglyceride levels are common side effects in patients on protease-inhibitor therapy. Although the cause of the metabolic abnormalities and the relation to HIV therapies is not known, this patient requires no further evaluation. The mechanism of protease-inhibitor lipodystrophy is not known. The usual tests for Cushing's syndrome, such as the 24-hour cortisol level and the dexamethasone suppression test, will be normal.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| drashishmahajan
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asshi i was bit curious to know the side effects of ritonavir other thn wht given in kaplan .... thts why i 1st attemptd the q ... thni chked in the harrison
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