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ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 68
| Issue : 2 | Page : 127-134 |
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| The correlation between anthropometric variables and muscular strength in patients coinfected with leprosy and HIV |
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Diego Vinicius da Costa Novais1, Mariana Garcia Borges do Nascimento1, Geovanna Lemos Lopes1, João Augusto Gomes de Souza Monteiro de Brito2, Thomaz Xavier Carneiro1, Givago Silva Souza1, Marília Brasil Xavier3
1 From the Núcleo de Medicina Tropical, Universidade Federal do Pará (UFPA), Belém, Pará, Brazil
2 Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil
3 From the Núcleo de Medicina Tropical, Universidade Federal do Pará (UFPA); Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil
| Date of Web Publication | 27-Apr-2023 |
Correspondence Address:
Marília Brasil Xavier
Research Laboratory in Tropical Dermatology and Endemic Diseases, Núcleo de Medicina Tropical, Universidade Federal do Pará (UFPA), Belém, Pará, Brazil, Generalíssimo Deodoro Ave, 92, Umarizal, Belém - 66055-240, Pará
Brazil
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_799_22
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 Abstract | | |
Background: Peripheral nerve disease may lead to physical disability because of decreased muscle strength and/or loss of sensitivity in the dermatomes of affected peripheral nerves. Both human immunodeficiency virus (HIV)- and leprosy-affected patients can develop neurological damage; therefore, the coinfection of these diseases presents new challenges to the health care of these patients. Aims and Objective: This study aimed to investigate the motor alterations of patients coinfected with HIV and leprosy and their relationship with clinical and anthropometric characteristics, compared with individuals with isolated diseases. Materials and Methods: In this cross-sectional study, 90 individuals were divided equally into three groups: HIV/acquired immunodeficiency syndrome (AIDS) group, leprosy group and HIV/leprosy group. All individuals underwent an evaluation of muscle strength and upper limb endurance adjusted for the Brazilian standards, a palm print pressure test using a digital dynamometer and anthropometric measurements (weight, height and skin folds). Results: The HIV/leprosy group had the highest mean body mass index, followed by the leprosy group and the HIV/AIDS group. Skinfolds were similar between the groups. Multiple linear regression, adjusted for sex and age, revealed the coinfection of HIV and leprosy as possible contributor to a worse prognosis of muscle function, highlighting the bilateral reduction in the levels of palm print compression strengths compared with isolated diseases (HIV and leprosy). High CD4 count and shorter antiretroviral therapy duration were associated with worse indices of muscle strength, such as gripping and resistance, in coinfected patients. Conclusion: Patients coinfected with HIV and leprosy exhibited greater motor damage than those with isolated diseases. Thus, motor damage may be related to the sum of the neurological manifestations of the two morbidities.
Keywords: Acquired immunodeficiency syndrome, HIV, leprosy
How to cite this article:
da Costa Novais DV, do Nascimento MG, Lopes GL, Monteiro de Brito JG, Carneiro TX, Souza GS, Xavier MB. The correlation between anthropometric variables and muscular strength in patients coinfected with leprosy and HIV. Indian J Dermatol 2023;68:127-34 |
How to cite this URL:
da Costa Novais DV, do Nascimento MG, Lopes GL, Monteiro de Brito JG, Carneiro TX, Souza GS, Xavier MB. The correlation between anthropometric variables and muscular strength in patients coinfected with leprosy and HIV. Indian J Dermatol [serial online] 2023 [cited 2023 Jun 7];68:127-34. Available from: https://www.e-ijd.org/text.asp?2023/68/2/127/375212 |
| Introduction | |  |
Leprosy is a chronic infectious disease that has affected human populations for centuries. Although intense programmes are run to combat leprosy, it remains endemic in many countries. According to the World Health Organization, 214.783 new cases of leprosy were reported in 2016.[1]
In leprosy, nerve damage is the most common cause of physical incapacity and may occur in the entire spectrum of the disease: before diagnosis, during treatment or even after medical discharge, resulting in an acute or chronic phenomenon. This physical impairment may be caused by an inflammatory reaction, resulting in the compression of the afflicted nerve, culminating in neural function alteration.[2],[3],[4],[5] These alterations, especially the loss of sensory and motor functions and neuropathy-induced deformities, are the most frequent and severe consequences of leprosy reactions.[6],[7]
Human immunodeficiency virus (HIV) infection is a chronic disease that has a high prevalence rate in the Brazilian population and can lead to impairment of the peripheral nervous system. Peripheral neuropathies are estimated to occur at a frequency of 30%–50%. Neurological complications can occur at any stage of the infection and may be opportunistic or a consequence of the direct toxic effects of the virus or the used therapy. Moreover, their incidence tends to increase in the more advanced stages because of the prolonged use of antiretroviral drugs.[8],[9],[10],[11],[12],[13],[14],[15]
In addition, people living with HIV, particularly those with acquired immunodeficiency syndrome (AIDS) who are receiving highly active antiretroviral therapy (HAART), are likely to develop lipodystrophy. Lipodystrophy is characterised by atrophy in the face and upper and lower limbs with fat accumulation in the abdomen and breasts.[16]
Both HIV and leprosy can affect peripheral nerves and cause sensory and motor damage and irreversible incapacities with serious damage to the functionality of individuals, in addition to metabolic disorders in HIV infection. Hence, it is relevant to investigate whether the coinfection of these two diseases can intensify and/or accelerate neural and/or metabolic damage. Thus, this study aimed to investigate the motor alterations and their relationship with the clinical and anthropometric parameters in patients coinfected with HIV and leprosy and to compare these characteristics between individuals with isolated diseases and those with coinfection.
| Materials and Methods | | |
This was an analytical cross-sectional study conducted at the dermatology outpatient clinic of the Tropical Medicine Institute of the Federal University of Pará (NMT/UFPA), which has a specialized service for the care of leprosy patients with a team of multidisciplinary professionals, and the Center for Attention to Health in Acquired Infectious Diseases (Casa Dia), which provides outpatient care to people living with HIV/AIDS. Both are located in Belém, Pará, Brazil.
Convenience samples of individuals who received services from June 2017 to September 2017 and met inclusion criteria were included in the study. After the selection, patients were divided into three groups: HIV/AIDS group, leprosy group and HIV/leprosy group.
Inclusion criteria were patients of both sexes and ages between 18 and 80 years, as follows: patients diagnosed with leprosy by an experienced dermatologist, following the Brazilian Ministry of Health guidelines;[17] HIV patients confirmed by positive enzyme-linked immunosorbent assay and Western blot serology, flow cytometry for peripheral blood CD4 counts, including those diagnosed with AIDS (a CD4 T count of 200 cells/mL and/or clinical conditions that define the disease);[18] HIV- and leprosy-coinfected patients. Exclusion criteria were as follows: pregnant women; anabolic steroid or growth hormone users; patients with coinfection other than leprosy; patients with comorbidities such as diabetes, chronic neurological diseases and brain tumours; and patients with a history of motor changes caused by a disease other than leprosy.
Included subjects were submitted to an upper limb strength/resistance of superior members (SRTSM) test performed by the same assessor following the protocol reported by Benedetti et al. (2007).[19] However, the material for the test was changed as reported by Borges et al. (2008),[20] and 2 kg dumbbells were used for women and 4 kg for men. Each patient was asked to perform elbow push-ups for 30 seconds using a chair without arms, while keeping the dominant hand wearing the halter parallel to the ground. After a 1-minute rest interval, they were asked to perform elbow push-ups for 30 seconds. The greatest number of elbow push-ups performed in 30 seconds was recorded.[19],[20]
Grip strength was measured using an e-clear digital dynamometer following the manufacturer's instructions. The grip strength of each limb was measured three times (evaluation time: 5 seconds), with a 90-second interval between each evaluation. The highest value of the three attempts was recorded in kgf.
The anthropometric parameters measured in this study were as follows: (1) height, (2) weight and (3) skin folds (tricipital, oblique and subscapular supra-iliac), measured using compact a clinical adipometer. The index of corporal mass or Quetelet index, developed by Adolphe Quételet, was defined as the body mass divided by the square of the body height and is expressed in units of kg/m2.
Weight and height measurements were performed according to the guidelines for the collection and analysis of anthropometric data in health services, the Technical Standards of the Food and Nutritional Surveillance System.[21] Skin folds were measured following the method recommended by Heyward and Stolarczyk (2000)[22] using the compass. To ensure the reliability of the measurements, the intra-examiner or test–retest reliability strategy was used; that is, the same examiner performed three measurements at different moments.[23]
A database was created in Microsoft Excel® (version 2013) using the obtained data. Statistical analysis was performed using the Statistic Package for Social Sciences (SPSS statistics). Data are presented using the central and percentage trends. The analysis of nominal variables was performed using the Chi-square test or the G-test, as appropriate. Quantitative variables were compared using analysis of variance with Tukey's post hoc test and Student's t-test. The P value of significance was set at 0.05.
| Results | | |
[Table 1] summarises the sociodemographic and clinical characteristics of the patients. The most common clinical form in the leprosy group was borderline (n = 14; 46.7%), and in the HIV/leprosy group, the most common clinical form was tuberculoid (n = 11; 36.7%). | Table 1: Characterisation of the study population according to the groups
Click here to view |
The use of illicit drugs and smoking were not common in the study population. The level of physical activity was similar among the groups, without significant differences. However, the frequency of physical activity was slightly higher in the leprosy (n = 6; 20.0%) and HIV/leprosy (n = 10; 33.3%) groups than in the HIV/AIDS group (n = 7; 23.3%).
Anthropometric analysis [Table 2] revealed that the HIV/leprosy group had the highest average body mass index (BMI; 26.3 ± 2.8), followed by the leprosy (25.4 ± 3.5) and HIV/AIDS (24.1 ± 3.5) groups. The intergroup comparison revealed a significant difference in BMI between the HIV/leprosy and HIV/AIDS groups. Women and physical activity practitioners had lower BMI, but without significant differences. To determine whether the CD4+ level, time to HIV diagnosis and HAART time were potential confounders for BMI, we compared the BMI levels of HIV- and leprosy-coinfected individuals and HIV carriers and found that these parameters did not influence the association; the average BMI of HIV- and leprosy-coinfected patients was 0.34–3.73 kg/m2 higher than HIV carriers (P = 0.019), and this difference increased after sensitivity analysis (0.95-4.20 kg/m2, P = 0.003). | Table 2: Analysis of the changes in body mass index according to the characteristics of coinfection and disease characteristics by HIV or leprosy
Click here to view |
The skinfolds were similar between the groups. It is noteworthy that similar to BMI, the values of skinfold in all three regions were slightly lower in the HIV/AIDS group compared with the other two groups. The clinical characteristics of HIV infection did not seem to influence the skinfold values because no statistically significant differences were observed between the groups [Table 3]. | Table 3: Relationship between the clinical and laboratory variables in HIV and anthropometric values of skin folds (triceps, subscapular and supra-iliac) in HIV-positive and HIV- and leprosy-coinfected patients
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The palmar grip strength was lower in the HIV/leprosy group than in the leprosy and HIV/AIDS groups. After adjusting for sex and age, multiple linear regression revealed that compared with isolated infection, HIV and leprosy coinfection was a possible contributor to the worse prognosis of muscle function, resulting in a bilateral reduction in the palmar grip strength. In this study, palmar grip strength was higher in the leprosy group (right hand: 1.18–7.70 kgf [P = 0.008] and left hand: 1.38–8.78 kgf [P = 0.008]) and the HIV/AIDS group (right hand: 0.14–6.77 kgf [P = 0.041] and left hand: 1.40–8.93 kgf [P = 0.008]) compared with the HIV/leprosy group [Table 4]. | Table 4: Palm grip strength by members, depending on the characteristics of coinfection, sex and age by HIV or leprosy
Click here to view |
Bacillary alterations had a greater effect on palmar grip strength than on the strength resistance test SRTSM, where the individuals with the multibacillary forms obtained lower average values when compared with those who had leprosy exclusively [Table 5]. The resistance of the upper limb strength, measured by SRTSM, was more affected on both sides for HIV/leprosy and leprosy individuals, and the HIV/AIDS group had the best values of muscle strength with an average of 21.1 ± 5.2 and 21.6 ± 5.6, for the right and left upper limbs, respectively. | Table 5: Relationship between clinical forms of leprosy and outcomes of palmar grip strength and upper limb muscle strength in the leprosy and HIV/leprosy groups
Click here to view |
The clinical and laboratory findings revealed that motor damage was more severe in HIV- and leprosy-coinfected patients with an undetectable viral load than in those with HIV alone, as revealed by lower mean palmar grip strength. The SRTSM results did not show significant differences. However, the values of clinical and laboratory parameters were slightly lower in the HIV/leprosy group, both with detectable and undetectable viral load, than in the HIV group [Table 6]. | Table 6: Relationship between clinical and laboratory variables in HIV and palmar grip strength and strength/resistance of upper limbs in HIV and HIV- and leprosy-coinfected patients
Click here to view |
HIV- and leprosy-coinfected patients with a CD4 count of ≥500 cells/μL had lower average palmar grip strength and SRTSM force, especially on the left side. Regarding the duration of use of HAART until the diagnosis of leprosy, it was noticed that among patients who used HAART for up to 5 years, the HIV- and leprosy-coinfected patients presented greater motor damage, considering both palmar grip strength and SRTSM. Interestingly, in individuals with HIV alone, a decrease in palmar grip strength and SRTSM is observed, reflecting greater motor involvement, with longer use of the therapy, differently from HIV- and leprosy-coinfected patients [Table 6].
| Discussion | | |
Peripheral neuropathy in leprosy is a common and widely described disorder in the literature. In a study investigating 41 individuals under the age of 15 years, approximately 32% had some nerve damage and 17% had physical disabilities.[24] The incidence of peripheral neuropathies in HIV carriers increases with the progression of the disease and particularly in individuals with AIDS because of increased immunosuppression and decreased CD4 count.[8],[12]
Zanetti, Manzano and Gabbai (2004)[10] evaluated the frequency of peripheral neuropathy in HIV-positive individuals in Brazil and found peripheral neural damage in 69.4% of the individuals, with the most common complaints being dormancy, paraesthesia and painful dysaesthesia, and alteration of the main neurological signal to distal sensory, mainly in the feet.
Therefore, HIV- and leprosy-coinfected patients may be more susceptible to neural changes because they have two sources of origin for this disease. Machado et al. (2015)[25] studied a clinical cohort and observed that leprosy patients with viral coinfection (e.g., hepatitis B virus (HBV), HIV, human T-cell lymphotropic virus type 1 (HTLV-1) and hepatitis C virus (HCV)) had higher rates of neuritis and nerve function impairment than those without coinfection.
However, few studies have regarding motor damage in HIV- and leprosy-coinfected patients. Bathala et al. (2017)[26] investigated patients with leprosy and reported changes in muscle strength in 93.3% of the patients; however, studies have reported that sensory impairment is more frequent and earlier in patients with leprosy.[27]
In HIV patients, the effects of HAART on preadipocyte proliferation and adipogenesis have been well studied and generally associated with metabolic changes. These metabolic changes culminate in abnormal distribution of fat throughout the body (HIV-associated lipodystrophy syndrome), resulting in generalised muscle weakness.[28],[29] Gouvêa-e-Silva et al. (2016)[30] observed a low frequency of physical activity in patients with HIV/AIDS and lipodystrophy in 37% of the study population, which may contribute to decreased lean body mass, manual grip strength and basal metabolic rate.
Similarly, correlation analysis between motor damage and anthropometric variables in this study revealed that HIV- and leprosy-coinfected patients had a higher average body mass index, as well as slightly higher skinfold values for all three regions, compared with those with HIV alone.
Clinical variables in HIV do not appear to influence the outcomes of both BMI and skin folds. However, Sacilotto et al. (2017)[31] investigated the anthropometric and metabolic alterations in HIV/AIDS patients and found that individuals with lipoatrophy (fat reduction in peripheral regions of the body) had a longer antiretroviral use time (mean time: 14.2 years) and that lipoatrophy may affect muscle strength.
Muscle strength was more altered in HIV- and leprosy-coinfected patients. The coinfection may contribute to a worse prognosis of muscle function. The viral load showed a discrete direct relation with motor damage. Patients with higher viral load (detectable viral load) were more affected and had lower strength. However, compared with patients with HIV/AIDS, those HIV- and leprosy-coinfected patients with undetectable viral load had greater motor damage. In the temporal relationship with the use of HAART until the diagnosis of leprosy, it was observed that among patients who used HAART for up to 5 years, coinfected patients had greater motor damage, both for palmar grip strength and for the SRTSM test. In the present study, individuals with a CD4 count of ≥500 cells/μL, especially those with coinfection, had lower average palmar grip strength and SRTSM strength.
Patil and Patil (2014)[13] evaluated individuals with HIV and neurological implications and found that opportunistic diseases with neurological manifestations are more common in individuals with a low CD4 count; however, they reported no relationship between the use of HAART and the development of neurological diseases. However, it should be considered that the diagnosis of leprosy seems to be directly related to the immune enhancement caused by the use of HAART and consequently to the presence of bacillus, which triggers an inflammatory response resulting in impairment of nerve function. This is because of a phenomenon called immune reconstitution inflammatory syndrome, characterised by the immune system's response to a specific pathogen after the introduction of therapy.[32],[33],[34],[35],[36],[37] This may explain the fact that only HIV- and leprosy-coinfected patients with undetectable viral load and a CD4 count of ≥500 cells/μL presented significant differences compared with those with HIV alone.
HIV- and leprosy-coinfected patients are more likely to experience motor damage, characterised by worse indices of palmar grip strength and resistance strength, measured using the SRTSM, compared with patients with isolated diseases. In this study, anthropometric indices were not found to be the potential causes of muscle weakness in HIV- and leprosy-coinfected patients because they had higher average BMI and skinfolds compared with those with isolated HIV. Hence, motor damage may be related to the sum of the neurological manifestations of the two morbidities. The clinical variables in HIV infection did not seem to influence the anthropometric values. However, regarding motor damage, immune restoration had a greater effect in HIV- and leprosy-coinfected patients, possibly because of the intense inflammation in response to the bacillary presence in the nerves.
This study has potential limitations typical of the observational design of the research, therefore subject to biases and confounding. The study is limited by convenience sampling and no formal sample size calculation a-priori. This limits the power and generalizability of the study. Since the sample is not chosen through random selection, the results do not represent the population being studied. Although both HIV and leprosy infections are highly prevalent in the studied region, and thus their coinfection should not be rare, the recruitment of coinfected patients that meet the inclusion criteria is below the ideal. The broad clinical spectrum of both diseases also adds confounding aspects inside the groups. Finally, sample limitations and operational aspects hindered the proper analysis of the leprosy clinical presentations. New studies with different design approaches are needed to consolidate the findings.
Financial support and sponsorship
This work received funding from Fundação Amazônia de Amparo a Estudos e Pesquisas (FAPESPA), helping with the study costs. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6] |
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