Zusammenfassung
Schwere Hepatotoxizität ist eine seltene, aber lebensbedrohliche Komplikation der antiretroviralen Therapie bei Patienten mit einer humanen Immundeffizienzvirus (HIV)-Erkrankung. In dieser Kasuistik berichten wir über eine HIV-positive Patientin, welche 18 Monate nach Einleitung einer antiviralen Therapie (Stavudine und Didanosine) mit Zeichen der schweren Pankreatitis an unserer Abteilung stationär aufgenommen wurde. Kurze Zeit später entwickelte die Patientin eine Laktatazidose in Kombination mit einem akuten Lebersowie Nierenversagen. Eine Nierenersatztherapie (Hämofiltration) musste für drei Tage durchgeführt werden. Zusätzlich entwickelte die Patientin eine Encephalopathie Grad III, sowie einen ausgedehnten Pleuraerguss und einen deutlichen Aszites. Im weiteren Verlauf erholte sich unsere Patientin nach sofortigem Absetzen der antiviralen Therapie und unter intensivmedizinischer Betreuung vollschändig, obwohl Fallberichte über Leberversagen unter antiretroviraler Therapie durchwegs eine hohe Mortalität beschreiben. Die Leberbiopsie zeigte eine mikrovesikuläre Steatose und Riesenmitochondrien, die typischen Zeichen der Mitochondrienschädigung ausgelöst durch eine antiretrovirale Toxizität. Mehr als drei Jahre nach Entlassung ist der Gesundheitszustand der Patientin ausgezeichnet und die HIV-Infektion stabil, obwohl keine weitere antiretrovirale Therapie verabreicht wurde.
Diese Kasuistik soll zudem das Bewusstsein für das potentielle Auftreten eines Leberversagens unter antiretroviraler Therapie, welche in zunehmendem Maße eingesetzt wird, wecken.
Summary
Severe hepatotoxicity is a rare but potentially life-threatening side effect of antiretroviral therapy. In this case report we describe an HIV-positive patient who was admitted to our clinic with evidence of severe acute pancreatitis 18 months after the introduction of antiretroviral treatment, which included stavudine and didanosine. Shortly afterwards, she developed lactate acidosis and acute hepatic failure associated with renal failure. Renal support (hemofiltration) was required for three days. The patient subsequently developed grade III encephalopathy, as well as a large pleural effusion and ascites. Although the reported outcome of patients with liver failure due to antiretroviral treatment is poor, with a high mortality rate, our patient fully recovered after intensive supportive care and cessation of the antiretroviral agents. Liver biopsy revealed microvesicular steatosis and giant mitochondria, which are the typical hallmarks of mitochondrial damage, the presumed mechanism of antiretroviral drug toxicity. More than three years later he patient has an excellent clinical status with a stable HIV infection and no need for antiretroviral treatment.
This case report indicates the need for increased awareness of the potential hepatotoxicity of an antiretroviral therapy, as severe side effects may occur more frequently with increasing use of such treatment.
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This work was supported by “Verein zur Förderung der Forschung in Gastroenterologie und Hepatologie an der Universität Inssbruck”
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Koch, R.O., Granziadei, I.W., Zangerle, R. et al. Acute hepatic failure and lactate acidosis associated with antiretroviral treatment for HIV. Wien Klin Wochenschr 115, 135–140 (2003). https://doi.org/10.1007/BF03040295
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DOI: https://doi.org/10.1007/BF03040295