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 .