CASE REPORT
We present a case of a 50-year-old black African female on management of
HIV for the last 12 years who presented to our hospital with complaints
of longstanding generalized body aches and bone pains for a duration of
2 years. These symptoms got worse 3 weeks prior to admission and were
associated with muscle weakness of both the upper and lower limbs. In
addition, she had joint pains worsened by activity but not associated
with stiffness. A year prior to admission she suffered a trivial fall
without a fracture that rendered her unable to walk. She denied any of
history of cough, weight loss, night sweats, back pain or paraesthesia.
Moreover, she had normal bladder and bowel control without polydipsia,
polyuria or even polyphagia.
Our patient was initiated on HAART in 2011 and has been on drugs with
excellent adherence since then. She was on TDF/3TC/EFV, however in 2019
she was transferred to TDF/3TC/DTG as part of a Nationwide optimization
program.
She has a history of pulmonary TB treatment 13 years ago but no history
of any other opportunistic infection, hypertension or diabetes.
General exams revealed a middle-aged female who was alert and
responsive, groaning and moaning in pain. She was wasted with a BMI of
17.8 kg/m2 and a weight of 48 Kgs. There was no
pallor, jaundice, dehydration, oedema or lymphadenopathy. Her vital
signs were within the normal ranges. On musculoskeletal exams she had
reduced muscle bulk, reduced muscle power graded at 3/5 and tenderness
on palpation of the muscles and along the long bones. Range of motion of
the right hip joint was also restricted. The other systemic exams were
normal.
Laboratory investigations done at admission revealed reduced
GFR at 35.80 ml/min/1.73m2 (CKD- EPI) with raised
creatinine levels of 152.58 umol/l. Her Calcium and Uric acid levels
were low at 1.8 mmol/l and 2.26 mg/dl respectively. She had normal
HBA1c of 4.6% with a normal random blood sugar of 6.7
mmol/L. Abnormal urinalysis findings that included glycosuria of
250mg/dl, proteinuria of 100 mg/dl and urine pH of 7.0. She had normal
full hemogram and electrolytes, and a negative Rheumatoid factor.
KUB ultrasound was normal, but the Bone survey x-rays (attached)
revealed features of osteoporosis and osteoarthritis of the Hip joints.
A diagnosis of Fanconi syndrome secondary to Tenofovir
nephrotoxicity was made based on clinical symptoms of generalized body
aches and bone pains and supporting laboratory findings of elevated
creatinine levels, proteinuria, glycosuria, hypouricemia, osteoporosis
and a urine pH of >5.
Our patient was then switched from TDF based regimen to an Abacavir
based one, Abacavir/Lamivudine/ Dolutegravir. Serial creatinine levels
were done, See table 1 .