The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

Chapter 5.26 picas Constitutional SymptomsRocío Hurtado, MD and Eric L Krakauer, MD, PhDINTRODUCTIONV■ Constitutional symptoms, reported by more than 50% of people with advanced HIV disease,often significantly compromise both physical functioning and quality of life. 1-3 The most commonconstitutional symptoms include weight loss, fatigue, fever and sweats. These symptomscan be related to myriad potential etiologies including opportunistic infections, malignancy,metabolic dysregulation, medication-related toxicities and advanced AIDS itself.Attempts should be made to determine and, when possible, treat the underlying causes of constitutionalsymptoms. Yet some underlying causes are refractory to treatment, and in many settingsthe necessary resources remain unavailable. Even where highly active antiretroviral therapy(HAART) is available and the chronic phase of HIV disease is prolonged for many patients,constitutional symptoms may arise from or be exacerbated by cumulative co-existing morbiditiesor by toxicities of the antiretroviral medications themselves.Nevertheless, particularly in the late stages of HIV disease, aggressive symptom managementoften can improve a patient’s quality of life regardless of the effects of more disease-specifictherapies. Thus, it is important that clinicians in all settings be skillful both in controlling uncomfortableconstitutional symptoms and in combining HIV-specific and palliative interventionsfor optimal patient care. The following sections and Table 5-1 address the management ofHIV wasting, fatigue, fever and sweats.HIV WASTING■ HIV wasting syndrome is a common AIDS-defining diagnosis in the United States, with anestimated lifetime frequency of 70% to 90% among AIDS patients who receive no antiretroviraltherapy. 4 It is defined by the Centers for Disease Control and Prevention as an involuntary loss ofmore than 10% of baseline body weight in conjunction with fever, weakness or diarrhea for morethan 30 days. However, less stringent definitions, such as loss of 5% to 10% of ideal body weight,are widely employed in clinical practice. 5Mechanisms of HIV wasting are complex and include the following:• Diminished or inadequate nutrient intake• Excessive nutrient loss• Metabolic dysregulation 6, 7Causes of inadequate nutritional intake often include one or more of the following: dysphagia orodynophagia due to candidiasis, cytomegalovirus, herpes simplex virus, or aphthous ulceration;anorexia, nausea, or vomiting due to infection, malignancy, medication side effects, or othersymptoms such as pain; and psychological factors such as depression, anxiety, grief and loneliness.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 123