HIV wasting syndrome (HIV WS) is characterized by a minimum of 10 percent weight loss which is accompanied by severe diarrhea, chronic weakness and fever lasting for more than three to four weeks and which can only be accounted for by the human immunodeficiency virus (HIV) infection [1]. The weight loss in HIV patients can be acute due to infections or can be gradual due to malabsorption. In HIV WS, the loss of weight is due to a decrease in fat as well as lean body mass irrespective of whether the patient is on treatment with anti-retroviral medications, viral loads, and T-cell counts [2].

Initially, the patient's weight loss is not noticed as wasting although the patient's body composition has begun to change with the patient manifesting clinical features of malnutrition e.g. increase in the extracellular mass to body composition monitoring (BCM) ratio [3]. Failure to exercise may lead to loss of muscle mass in the early stages of HIV infection but its cause in the penultimate stages is still unknown. In HIV patients with diabetes, the protein and muscle mass loss may be even more severe.

Clinically, HIV WS manifests differently amongst men compared to women infected with HIV. In men with HIV WS, there is asthenia with a gradually progressive loss of weight, diminished metabolism and fat sparing versus an excessive decrease in lean body mass (LBM). On the other hand, women have an excessive decrease in body fat compared to LBM and lose more muscle mass in the late stages of the disease [4].

Patients with HIV WS may have concomitant myopathies such as polymyositis or polyarteritis nodosa (PAN) which can confuse the clinical picture. In addition, antiretroviral treatment with zidovudine can also cause myopathy which does not improve even after cessation of the medication [5].

• Hemophilia A

  Patients with wasting syndrome as the only AIDS diagnosis were more likely to be female, to be black or Hispanic, and to have a mode of HIV exposure reported as injecting drug use, heterosexual contact, or transfusion/hemophilia. [ncbi.nlm.nih.gov]

  Congenital absence of Factor VIII results in hemophilia A. Fungus: A general term used to denote a class of microbes including mushrooms, yeasts, and molds. [web.worldbank.org]

  Males were also more likely to acquire HIV infection through contaminated blood products for treatment of hemophilia before universal testing of the blood supply was instituted. [emedicine.medscape.com]

• Weight Loss

  The decrease in fat and lean body mass are responsible for the weight loss. [symptoma.com]

  Selection of the appropriate agent(s) depends on the underlying cause for weight loss, adverse effects, and cost of therapy. [ncbi.nlm.nih.gov]

  Weight loss remains an independent risk factor for mortality, even in the HAART era, and every patient should be weighed regularly. [hivbook.com]

• Prostitute

  He once revealed that he had spent more than 50,000 as a client of “Hollywood Madam” Heidi Fleiss’ prostitution ring. [fellowshipoftheminds.com]

  HIV-1-specific mucosal CD8 lymphocyte responses in the cervix of HIV-1-resistant prostitutes in Nairobi. J Immunol. 2000 Feb 1. 164(3):1602-11. [Medline]. Alimonti JB, Kimani J, Matu L, et al. [emedicine.medscape.com]

• Male Hypogonadism

  TESTOSTERONE REPLACEMENT THERAPY Accrual of lean body mass in hypogonadal HIV-infected patients receiving long-term testosterone replacement therapy is well documented. 74 A diagnosis of male hypogonadism is based on free testosterone level (bioactive [nursingcenter.com]

• Chronic Diarrhea

  Involuntary weight loss of greater than 10 percent associated with intermittent or constant fever and chronic diarrhea or fatigue for more than 30 days in the absence of a defined cause other than HIV infection. [expertscape.com]

  AIDS wasting syndrome: The involuntary weight loss of 10% of baseline body weight plus either chronic diarrhea (two loose stools per day for more than 30 days) or chronic weakness and documented fever (for 30 days or more, intermittent or constant) in [medicinenet.com]

  Defined as profound involuntary weight loss of greater than 10% of baseline body weight, plus either chronic diarrhea (at least two loose stools per day for more than 30 days) or chronic weakness and documented fever (for more than 30 days, intermittent [medical-dictionary.thefreedictionary.com]

• Failure to Thrive

  […] to thrive Slim disease B22.7 HIV disease resulting in multiple diseases classified elsewhere Note: For use of this category, reference should be made to the morbidity or mortality coding rules and guidelines in Volume 2. [apps.who.int]

  Preliminary information indicates that lean body mass is lost in preference to fat mass in HIV-infected children, supporting the theory that failure to thrive in HIV infection is often cytokine mediated. [clinicaltrials.gov]

  It is also detected in children with a “failure to thrive” syndrome, meaning that their current rate of weight gain is lower than in most children of the same age. The weight loss in any case is not intentional. [citiva.com]

  : No change 2019 (effective 10/1/2018) : No change Cachexia R64 cancerous R64 due to malnutrition R64 malignant R64 Disease, diseased - see also Syndrome wasting NEC R64 Inanition R64 Wasting disease R64 ICD-10-CM Codes Adjacent To R64 R62.7 Adult failure [icd10data.com]

• Increased Muscle Mass

  To do this, you can add to your meals: peanut butter legumes (dried beans and peas) cheeses eggs instant breakfast drinks milkshakes sauces You can also maintain or increase muscle mass through exercise, especially with progressive strength-building exercises [hiv.va.gov]

• Muscular Atrophy

  It is a type of chronic muscular atrophy and in CKD, it is associated with PEW, limiting the independence of the patient and their quality of life. It compromises vital organs, with respiratory, musculoskeletal and heart muscle deterioration 18. [revistanefrologia.com]

• Uremia

  HIV wasting syndrome AIDS A clinical complex linked to HIV infection and characterized by marked weight loss, renal failure, and caused by poor nutrition and anorexia, endocrine dysfunction, and catabolic stress–eg, infection, uremia, dialysis; HWS is [medical-dictionary.thefreedictionary.com]

  Vitamin B6 deficiency in uremia and its implications for the depression of immune responses. Kidney Int 1974;5:233-9. [Pubmed] [77] Vanholder R, Van Loo A, Dhondt AM, De Smet R, Ringoir S. [revistanefrologia.com]

• Perseveration

  This could result from persistent or intermittent symptoms, such as depression, severe fatigue, or pain, resulting in a limitation of your ability to do a task, to concentrate, to persevere at a task, or to perform the task at an acceptable rate of speed [ssa.gov]

The workup of HIV WS should be able to identify the condition and exclude other causes of weight loss such as malnutrition, malabsorption, and infections in patients with HIV. It is also important to differentiate it from HIV-lipodystrophy, and hyperlactatemia which can occur with nucleoside analog reverse transcriptase inhibitor (NRTI) therapy [6]. Besides history and physical examination, the workup should include nutritional assessment, serial measurements of weight in standardized conditions [7] to detect and monitor wasting; body mass index (BMI) measurement, weight trends to monitor the patient's nutritional status, bioimpedance analysis over a period of time to evaluate LBM, total body water and fat using regression analysis [8] and sequential anthropometry (mid arm circumference, triceps skinfold thickness) to predict prognosis [9].

An endocrine evaluation to exclude hypogonadism as the cause of wasting and gastrointestinal referral to look for malabsorption are also a vital part of the workup.

Dual-energy X-ray absorptiometry (DEXA), magnetic resonance imaging (MRI), and computed tomography (CT) can provide more accurate information about body composition but are expensive tests and therefore are only being used currently for research purposes.

1. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. Council of State and Territorial Epidemiologists; AIDS Program, Center for Infectious Diseases. MMWR Morb Mortal Wkly Rep. 1987 Aug 14;36 Suppl 1:1S-15S.
2. Mulligan K, Schambelan M. HIV-associated wasting. 2003 Nov. http://hivinsite.ucsf.edu/InSite?page=kb-04-01-08#S1X Accessed 3/3/2017
3. Bell SJ, Bistrian BR, Connolly CA, et al. Body composition changes in patients with human immunodeficiency virus infection. Nutrition. 1997;13:629-632
4. Grinspoon S, Corcoran C, Miller K, et al. Body composition and endocrine function in women with acquired immunodeficiency syndrome wasting. J Clin Endocrinol Metab. 1997;82:1332-1337.
5. Miro O, Pedrol E, Cebrian M, et al. Skeletal muscle studies in patients with HIV-related wasting syndrome. J Neurol Sci. 1997;150:153-159.
6. Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia and liver dysfunction associated with HIV nucleoside analogue therapy: contribution to protease inhibitor-related lipodystrophy syndrome. AIDS. 2000 Feb 18;14(3):F25-32.
7. Grunfeld C, Feingold KR. Body weight as essential data in the management of patients with human immunodeficiency virus infection and the acquired immunodeficiency syndrome. Am J Clin Nutr. 1993 Sep;58(3):317-8.
8. Kotler DP, Burastero S, Wang J, Pierson RN Jr. Prediction of body cell mass, fat-free mass, and total body water with bioelectrical impedance analysis: effects of race, sex, and disease. Am J Clin Nutr. 1996 Sep;64(3 Suppl):489S-497S.
9. Heymsfield SB, McManus C, Smith J, Stevens V, Nixon DW. Anthropometric measurement of muscle mass: revised equations for calculating bone-free arm muscle area. Am J Clin Nutr. 1982 Oct;36(4):680-90.