CASE PRESENTATION
A 35-year-old male from Boudha, Kathmandu, was diagnosed with HIV on
14th September 2016. As a result, his first Antiretroviral Therapy (ART)
clinic visit occurred on 13th March 2017, and his CD4 count was measured
at 500 cells/mm3. He started ART on 16th March 2017 with the Tenofovir
Disoproxil Fumarate (TDF), Lamivudine (3TC), and Efavirenz (EFV)
regimen.
During the initial days of treatment, he developed a rash as a side
effect of Efavirenz (EFV). To manage the rash, Cortilone
(corticosteroid) was prescribed for a week and the symptoms subsided. He
underwent a complete blood count (CBC), renal function tests (RFT), and
liver function tests (LFT) as part of his initial follow-up on March 29,
2017. The results showed a WBC count of 5400
cells/mm3, Hb of 14.30 g/dL, platelet count of 21800
cells/mm3, CD4 count of 525
cells/mm3, Creatinine (Cr) of 1.0 mg/dL, and ALT
(SGPT) of 57 U/L.
Every six months, viral load testing was carried out, and the initial
result on September 20, 2017, showed less than 20 copies, demonstrating
effective viral suppression. He was started on Isoniazid Preventive
Therapy on 24th August 2018 to prevent opportunistic tuberculosis
infection. After six months of unremarkable therapy, it was
discontinued.
EFV is known to be associated with neuropsychiatric symptoms like
delirium, anxiety, acute psychosis, and an increased risk of suicidal
thoughts. Following the national protocol guidelines, EFV was replaced
with a similar drug from the same category i.e. Dolutegravir to avoid
potential side effects on 10th June 2020.
After two months of continuing the TDF, 3TC, and DTG regimen, the
patient came to OPD complaining of generalized fatiguability, dizziness,
and headache for one week. Upon admission, the patient exhibited slight
pallor without hepatosplenomegaly or lymphadenopathy. CBC revealed Hb
4.5 gm/dl, MCV of 68.6 fl, and MCH of 23.6 pg. PBS showed microcytic
hypochromic red cells. Pencil cells were also seen. Any atypical
cells/hemoparasites were not present. The stool for occult blood was
negative. A blood transfusion was done and Hb was raised to 7.7gm/dl.
Iron deficiency anemia was suspected and the patient was prescribed iron
tablets. On follow-up after a week, the patient complained the symptoms
did not subside. Hb was reduced to 3.6 gm/dl. Hematocrit was 9.9% and
MCV of 80 fl. PBS revealed hypochromasia with anisopoikilocytosis with
few polychromatic cells, smudge cells, and atypical white blood cells.
LDH was 1600 U/L with total bilirubin and direct bilirubin of 2.7 mg/dl
and 0.9 mg/dl respectively. The iron profile showed serum iron of 182
ug/dl, TIBC of 251 ug/dl, %Transferrin saturation of 72.5%, and serum
ferritin of 1950 ng/ml. Antinuclear antibodies were 4.8 ODI (negative)
and double-stranded DNA was 6.0 IU/ML (negative). The Direct Coombs test
was negative. Hematological disorders and malignancies were not detected
by chromosome analysis
via karyotyping in bone marrow. Myelodysplastic syndrome with ring
sideroblasts (>15%) was seen in bone marrow aspirate as
shown in Figure 1. Mildly hypercellular marrow with erythroid
hyperplasia was present in bone marrow biopsy as shown in Figure 2. The
combination of these findings, along with the presence of marked
myelofibrosis on bone marrow biopsy, led to a suspected diagnosis of
idiopathic acquired sideroblastic anemia with a pre-leukemic state.
According to Naranjo’s Adverse Drug Reaction (ADR) Assessment Scale, it
received the ”probable” level rating after scoring 5 points, as shown in
Table 1.
As a result, Dolutegravir was replaced with Raltegravir and the new ART
regimen was started.
Follow-up laboratory investigations conducted one month after
discontinuing Dolutegravir is compared with those conducted before
discontinuing the drug as shown in Table 2.The patient’s symptoms of
fatigue and weakness also improved significantly. Subsequent monitoring
over a period of six months demonstrated sustained hematologic recovery
without the recurrence of anemia.