Antiretroviral/immunosuppressants interaction
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Antiretroviral/immunosuppressants interaction Strongyloides hyperinfection and tacrolimus toxicity resulting in delayed graft function: case report.
A 58-year-old man developed tacrolimus toxicity following concomitant administration of tacrolimus and lopinavir/ritonavir, resulting in delayed graft function. Additionally, he developed Strongyloides hyperinfection during treatment with basiliximab, methylprednisolone, mycophenolate mofetil, prednisolone and tacrolimus [routes and dosages not stated]. The man, who had a history of HIV, developed focal segmental glomerulosclerosis requiring a renal transplant. His immunosuppression induction was carried out with methylprednisolone and basiliximab, followed by maintenance with mycophenolate mofetil, prednisolone and tacrolimus. His antiviral regimen consisted of antiretrovirals including lopinavir/ritonavir. However, after the transplant, he developed delayed graft function owing to severe tacrolimus toxicity following an interaction between tacrolimus and lopinavir/ritonavir. The man’s antiretroviral therapy was changed to raltegravir, didanosine and lamivudine and his graft function improved. After 5 months of transplant, he presented with anorexia, abdominal pain, diarrhoea and weight loss from 2 weeks. He was also concurrently diagnosed with acute kidney injury. His stool and blood cultures were negative. Further faecal testing for Salmonella, Shigella, Clostridium difficile, Campylobacter and other bacterial pathogens were also negative. His serum Strongyloides antibody testing was negative. He continued to experience watery diarrhoea. A gastroscopy revealed active chronic inflammation with erosive duodenitis;frequent larvae and parasites at the mucosal surface and in duodenal crypts were noted. Based on the morphology of the parasites, he was diagnosed with Strongyloidiasis. He was initiated on treatment with ivermectin. However, he experienced increasing dyspnoea. A CT scan of the chest showed infiltration in the right lower lobe. A bronchoalveolar lavage and bronchoscopy were unremarkable. He underwent a CT-guided biopsy of the affected area, which revealed a single helminth and inflammatory cells, suggestive of Strongyloides hyperinfection. Ivermectin was continued. He exhibited deconditioning and required total parenteral nutrition for an unspecified period. After several weeks of ivermectin treatment, he gradually improved with resolution of the diarrhoea and abdominal pain. A repeat chest x-ray did not show consolidation. Subsequently, he was able to maintain body weight with an increased oral intake. He was discharged after 54 days of hospitalisation. Lai C, et al. Strongyloides hyperinfection in an HIV-positive kidney transplant recipient: a case report. BMC Infectious Diseases 20: 613, No. 1, 18 Aug 2020. Available from: 803502384 URL: http://doi.org/10.1186/s12879-020-05333-8
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Reactions 26 Sep 2020 No. 1823
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