Ann Stewart, David Wong and Soo Chan Carusone
Complex patients with multiple comorbidities are rarely included in large randomized studies. As a result, little is known about the optimal management of these cases. The following two cases occurred within a six month period in 2013 and were seen at Casey House, a community-based facility specializing in HIV/AIDS in Toronto, Canada. Both cases involved a serious assault to the liver believed to be drug induced liver injury (DILI) caused by darunavir. In the first case, Patient A, a 50 year-old male with a CD4 count of 454 cells/mm3 presented with tense ascites, jaundice and pedal edema. He had recently started a new anti-retroviral combination including darunavir. The ARV medications were stopped, liver function improved and his ascites was reduced with paracentesis and infusions of albumin. Chronic hepatitis B was identified. The patient was started on a new anti-retroviral regimen effective for hepatitis B. His liver failure resolved and he continues to live well in the community. In Patient B, a 49 year-old woman with CD4 count of 20 cells/mm3 and Mycobacterium Avium Complex (MAC) and hepatitis C was started on a darunavir-based regimen. She developed abdominal pain, jaundice, elevated liver function tests and anemia. HIV medications were held, and then restarted. Her symptoms worsened. Eventually all medications were stopped. Although the patient’s liver began to recover, her CD4 count remained very low and the patient developed pneumocystis pneumonia (PJP) and died. These cases are presented with a view to better understanding darunavir and its potential toxicity. The literature concerning darunavir toxicity in the setting of complex comorbidity will be reviewed.
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