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Bictegravir/emtricitabine/tenofovir-alafenamide

Immune reconstitution inflammatory syndrome in the form of granulomatous interstitial nephritis: case report A 32-year-old man developed immune reconstitution inflammatory syndrome (IRIS) in the form of granulomatous interstitial nephritis during antiretroviral therapy with bictegravir/emtricitabine/tenofovir-alafenamide for HIV infection. The man presented with weight loss, blurry vision and odynophagia. He was eventually diagnosed with advanced HIV infection. Additionally, he was also found to have various other infections, i.e. cytomegalovirus (CMV) retinitis, candida oesophagitis and disseminated Mycobacterium simiae infection. He then started receiving antiretroviral therapy with bictegravir/emtricitabine/ tenofovir-alafenamide [dosages and routes not stated] for HIV infection. His concomitant medications included azithromycin, moxifloxacin, tedizolid, valganciclovir and fluconazole. Within three months of initiating anti-retroviral therapy, his HIV condition improved. However, six weeks later, he presented with lower extremity oedema, abdominal discomfort and fatigue. Laboratory tests revealed the following: creatinine 3.72 mg/dL (baseline creatinine 0.9 mg/dL), sodium 129 mmol/L, bicarbonate 21 mmol/L and blood urea nitrogen 35 mmol/L. Liver function tests revealed elevated alkaline phosphatase and normal transaminases. Urine protein/creatinine ratio was 2.2, which was consistent with nephrotic range proteinuria. Urinalysis revealed white cell casts. An antibody test for Treponemal pallidum was found to be negative. An abdominal CT-scan revealed hepatosplenomegaly with diffuse retroperitoneal lymphadenopathy. The man’s all the medication were consequently discontinued, and adequate hydration was administered. However, his creatinine continued to elevate, peaking at 4.6 mg/dL. A renal biopsy revealed multiple non-caseating granulomas in the renal parenchyma. Based on the results of the investigations, he was diagnosed with IRIS in the form of granulomatous interstitial nephritis (GIN), which caused acute renal failure. It was suspected that the IRIS was caused by antiretroviral therapy (bictegravir/ emtricitabine/tenofovir-alafenamide). Prednisone was therefore initiated. Within five days of initiating prednisone, his creatinine decreased by half. The man’s drug therapy for HIV and disseminated M. simiae was restarted without further complications. Salas NM, et al. Granulomatous interstitial nephritis in the setting of disseminated Mycobacterium simiae: a rare presentation of immune reconstitution inflammatory syndrome. International Journal of STD and AIDS 31: 911-913, No. 9, 01 Aug 2020. Available from: URL: http://doi.org/10.1177/0956462420926881

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Reactions 10 Oct 2020 No. 1825