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.