CASE 2 54 yo man…HIV + 1997 PCP Cryptospordiasis Chronic HepC Genotype 1a Biopsy… 2/4 activity, 3/4scarring CD4 40 No baseline genotype.

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Presentation transcript:

CASE 2 54 yo man…HIV PCP Cryptospordiasis Chronic HepC Genotype 1a Biopsy… 2/4 activity, 3/4scarring CD4 40 No baseline genotype

CASE D4T/3TC/Indinavir initiated CD4 30 → 400 Viral load undetectable

CASE 2 U/A - ++ WBC + IDV crystals Creatinine – 80 → 115 Indinavir crystal induced interstitial renal disease felt to be responsible

CASE D4T/3TC/Nelfinavir Mild intermittent diarrhea Successfully treated for Hepatitis C with 48 wks of Peg Interferon/RBV CD VL <50

CASE D4T/3TC/Nelfinavir Ongoing diarrhea Increasing recognition of dorsocervical fat pad Switched to TDF/FTC/Efavirenz

CASE 2 TIMEASTALTOTHER 10/083331Etoh 6 beers/day x yrs 11/085586No increase in Etoh; HepA IgG (+); HepBsAb (+) 12/084159Workup for secondary liver disease (-); HCV RNA (-); U/S… fatty liver 04/ Repeat HCV RNA (-); Urinary Drug Screen (UDS) (-); 06/ UDS (-) WHAT WOULD YOU DO?

CASE 2 June 2009 TDF/FTC/Efavirenz switched to TDF/FTC/Etravirine to attempt to r/o Efavirenz as cause of hepatitis

CASE 2 TIMEASTALTOTHER 07/ month post-switch 08/ months post switch WHAT WOULD YOU DO?

CASE 2 TDF/FTC/Etravirine switched to D4T/3TC/Etravirine to attempt to r/o TDF/FTC as rare cause of hepatitis

CASE 2 Sept/09 D4T/3TC/Etravirine TIMEASTALTOTHER 08/ TDF/FTC/ETV 09/ / / WHAT WOULD YOU DO?

CASE 2 Switched back to TDF/FTC/Etravirine as patient concerned about lipodystrophy and unclear whether liver improving at all from Etravirine or TDF/FTC switch

CASE 2 TIMEASTALTOTHER 11/ D4T/3TC/Etravirine 03/ TDF/FTC/Etravirine… No increase in Etoh 06/ WHAT IS HAPPENING? WHAT WOULD YOU DO?

CASE 2 Patient self-discontinues meds TIMEASTALT 06/ /104769

CASE 2 Restarted TDF/FTC/Efavirenz for simplicity/convenience TIMEASTALTOTHER 07/104769No Meds 07/ wks 08/ wks 09/ wks NOW WHAT?

CASE 2 Late September 2010 Switched to D4T/3TC/Raltegravir as previously had normal liver enzymes for years on D4T/3TC/Nelfinavir and need to get rid of TDF/FTC and NNRTI class. Refused PI due to lipohypertrophy STAY TUNED!!!