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Information you requested to fully answer Q on insulin resistance and biopsy results
Feb 1, 2004

Dear Dr. Henry, Many thanks for your response to my Q whether my PCP was right when he said that, if glucose levels were within normal, there was no need to do an insulin resistance test. I asked if you agreed and you asked for more details on my HIV status and regimen.

Basically, I am treatment naive, CD4 count was 980 most recently, with a CD4 percent of 46. VL is often undetectable, occasionally blipping into the 750-1,500 range. The truncal obesity and much larger waist came on after HIV infection.

Since I asked the original Q, I went ahead with an insulin resistance test through another doctor. He said the results showed very high insulin and C Peptide levels and reactive hypoglycosemia (or would it be hyper glycosemia?). Can you please advise what the significance of this is? There is no family history of Diabetes or insulin problems, so this would seem to be a result of disease - the doctor said just to not eat bread and let's wait and see in a couple of months! Is this wise? What are the risks and symptoms of very high insulin and C Peptides and would you place me on medication now if I were your patient? The PCP who said I didn't need an insulin resistance test because normal glucose levels precluded the need is now a bit negative that I had the test done anyway and I think a bit embarrassed that the test showed very high insulin levels. The doctor who did the test at my request is not being proactive on this...just a wait and see approach, so I feel quite concerned and frustrated and really need your advice on the significance of this, the risks and other tests and treatment that may be prudent.

I also have another Q to which I would much appreciate your advice: a skin biopsy on a red circular lesion on my forearmis, according to the Lab, suggestive of cutaneous Lupus erythematosis (there is also mention of "perivascular and perifollicular dermatitis with interface changes". A biopsy of other types of bumps diagnoses "Grover's Disease with " a perivascular mixed cell infiltrate with Eosinophils". Can you please explain what these mean and whether they are associated with HIV infection? What tests would you do to determine different systemic causes of these skin lesions? (I understand that the cutaneous lupus ones can be due to HIV, autoimmune diseases or cancers...is this correct?)

I would appreciate any guidance you can provide on the insulin issue (further tests to establish cause) and on the skin problems (further tests to establish systemic causes - the dermatologist just wants to treat the skin lesions and Grover's bumps). I also recently developed angular chelitis!

Also, do any of these problems indicate problems with my immune system? Is my immune system in worse shape than my normal CD4 numbers and low viral load would suggest?

Many thanks for all your advice and help.

Response from Dr. Henry

For skin biopsy issue (possible lupus) I would try to see a rheumatologist for his/her opinion. For the elevated insulin level that indicates a pre-diabetic state (? part of the metabolic syndrome linked with increase truncal obesity and elevated lipids as well). That could indicate some increased tendency to have those problems aggravated if and when certain HIV meds are started. Your immune system is in good spot from the CD4 count perspective by the angular cheilitis may indicate a qualitative problem (can be caused by HIV). Presently the approach to metabolic syndrome (pre-diabetes) is aggressive exercise and diet intervention. I would go see an endocrinologist (diabetic specialist). I for one am still learning about many of these conditions and welcome the help from my colleagues and don't mind if patients come to me with important information they obtained elsewhere= I eat humble pie routinely! KH



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