title: Clinical challenges of thyroid eye disease in HIV-positive patients on highly active antiretroviral therapy.
abstract: BACKGROUND
  Graves' disease (GD) as an immune reconstitution inflammatory syndrome during highly active antiretroviral therapy (HAART) for HIV has previously been reported. However, clinical challenges associated with HIV in the context of thyroid eye disease (TED) are not as well-characterized.
  
  
  OBJECTIVE
  To determine the frequency of coexisting HIV and TED, describe TED presentation and course in the context of HIV, and evaluate management difficulties as well as potential solutions.
  
  
  METHODS
  Cross-sectional study of all patients with coexisting GD and HIV at University Hospitals Birmingham (2003-2014). Retrospective case note review to identify TED with particular reference to HAART regimen, CD4+ T-cell count, HIV viral load, and TED activity and severity.
  
  
  RESULTS
  Of 783 subjects with GD and 1186 with HIV, 11 were identified with both GD and HIV. Of these, three had clinical features of TED; each was of Afro-Caribbean origin, was in their fourth decade, and initially presented with undetectable CD4 T cells and high HIV viral loads. All went on to develop GD >3 years after commencing HAART, with normal CD4 count and undetectable viral load at the time of GD diagnosis. The full spectrum of TED was represented, with two subjects requiring orbital decompression surgery.
  
  
  CONCLUSIONS
  TED in the context of HIV is uncommon. Many challenges exist in such patients, particularly HAART drug interactions with antithyroid and immunosuppressant medications. To better understand TED in HIV and to counsel patients with this copathology most effectively, future multicenter surveillance is required.
authors.affiliation: Birmingham and Midland Eye Centre (M.R.E., F.M., R.L.F.), City Hospital, Birmingham B18 7QH, United Kingdom; School of Clinical and Experimental Medicine (B.T., K.B.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of HIV Medicine (K.M.), University Hospital Birmingham, Birmingham B15 2TH, United Kingdom.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Edmunds
authors.forename: Faye
authors.initials: F
authors.lastname: Mellington
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Ford
authors.forename: Barbara
authors.initials: B
authors.lastname: Torlinska
authors.forename: Kaveh
authors.initials: K
authors.lastname: Manavi
authors.forename: Kristien
authors.initials: K
authors.lastname: Boelaert
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D003430:Cross-Sectional Studies; D005260:Female; D049970:Graves Ophthalmopathy / Q000150:complications* / Q000453:epidemiology* / Q000628:therapy; D006679:HIV Seropositivity / Q000150:complications* / Q000188:drug therapy* / Q000453:epidemiology; D015497:HIV-1 / Q000276:immunology; D006801:Humans; D008297:Male