Rhabdomyolysis in an HIV cohort: epidemiology, causes and outcomes

Rhabdomyolysis in Acute HIV Infection

Rhabdomyolysis is a rare but potentially life-threatening complication of acute HIV infection. We present a case report of a young adult male who presented with fever, myalgia, and elevated creatine phosphokinase levels, ultimately diagnosed with acute HIV infection-associated rhabdomyolysis. This case highlights the importance of considering HIV infection in the differential diagnosis of rhabdomyolysis, particularly in at-risk populations, even in the absence of typical HIV-related symptoms.

Rhabdomyolysis and Resultant Acute Renal Failure due to Legionella Pneumonia in a Patient with Human Immunodeficiency Virus

Legionnaires' disease is a severe pneumonia caused by Legionella that results in laboratory abnormalities including hyponatremia and elevated liver enzymes. Rarely skeletal muscle and renal abnormalities occur. This case report describes a case of Legionella pneumonia complicated by rhabdomyolysis and acute renal failure in a patient with the human immunodeficiency virus.

Acute HIV presenting as rhabdomyolysis

A man, in his early 30s, with no significant medical history presented with a 2-week history of fatigue, chest and abdominal pain, associated with anorexia and vomiting. Initial laboratory testing was suggestive of rhabdomyolysis with acute renal failure and transaminitis. The aetiology of his rhabdomyolysis initially remained unexplained as there were no clear risk factors or inciting events. An extensive workup revealed acute HIV as the precipitant of rhabdomyolysis.

Genvoya-Associated and Simvastatin-Associated Noninflammatory and Nonautoimmune Myopathy: A Case Report and Literature Review

Patients with HIV have a higher incidence of rhabdomyolysis compared with the HIV negative population because of medication-related myotoxicity and drug-drug interactions. Statins and antiretroviral therapy have been previously reported to cause myopathy in patients with HIV when used alone or in combination. In this study, we describe a case of biopsy-proven noninflammatory and nonautoimmune myopathy associated with the use of simvastatin and Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide fumarate) and review 3 previously reported similar cases. Our patient presented with acute proximal limb weakness and significantly elevated serum creatine kinase. Muscle biopsy revealed scattered degenerating and regenerating muscle fibers without evidence for an inflammatory process. She did not respond to empiric treatment with high-dose intravenous steroids and intravenous immunoglobulin. Her creatine kinase only began to downtrend after discontinuation of both simvastatin and Genvoya, and she returned to baseline function at 2-month follow-up. Our case highlights the importance of recognizing drug-drug interactions between HIV and statin medications in causing significant noninflammatory myopathy. In these patients, both categories of medications need to be discontinued for recovery.

Human Immunodeficiency Virus (HIV) Masquerading as Myopathy and Rhabdomyolysis

Human immunodeficiency virus (HIV) characteristically presents as a mononucleosis-like prodrome; rhabdomyolysis as a sole manifestation remains a rare finding from infection to seroconversion. A young male with a vague sexual history presented with myopathy progressing rapidly to rhabdomyolysis and renal failure. Acute HIV rarely presents with classic features, and rhabdomyolysis seems to manifest more in younger patients. Our case also demonstrates the importance of keeping a strong suspicion for HIV in the right setting despite false-negative results in the pre-seroconversion phase. The variability in HIV presentation and stigma of sexual history taking represents a diagnostic challenge. The astute clinician must be privy to these peculiarities to formulate a prompt diagnosis.

Risk factors for severe acute kidney injury among patients with rhabdomyolysis

BACKGROUND

Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). The aim of the present study was to assess patients at high risk for the occurrence of severe AKI defined as stage II or III of KDIGO classification and in-hospital mortality of AKI following RM.

METHODS

We performed a retrospective study of patients with creatine kinase levels > 1000 U/L, who were admitted to the West China Hospital of Sichuan University between January 2011 and March 2019. The sociodemographic, clinical and laboratory data of these patients were obtained from an electronic medical records database, and univariate and multivariate regression analyses were subsequently conducted.

RESULTS

For the 329 patients included in our study, the incidence of AKI was 61.4% and the proportion of stage I, stage II, stage III were 18.8, 14.9 and 66.3%, respectively. The overall mortality rate was 19.8%; furthermore, patients with AKI tended to have higher mortality rates than those without AKI (24.8% vs. 11.8%; P < 0.01). The clinical conditions most frequently associated with RM were trauma (28.3%), sepsis (14.6%), bee sting (12.8%), thoracic and abdominal surgery (11.2%) and exercise (7.0%). Furthermore, patients with RM resulting from sepsis, bee sting and acute alcoholism were more susceptible to severe AKI. The risk factors for the occurrence of stage II-III AKI among RM patients included hypertension (OR = 2.702), high levels of white blood cell count (OR = 1.054), increased triglycerides (OR = 1.260), low level of high-density lipoprotein cholesterol (OR = 0.318), elevated serum phosphorus (OR = 5.727), 5000<CK ≤ 10,000 U/L (OR = 2.617) and CK>10,000 U/L (OR = 8.093). Age ≥ 60 years (OR = 2.946), sepsis (OR = 3.206) and elevated prothrombin time (OR = 1.079) were independent risk factors for in-hospital mortality in RM patients with AKI.

CONCLUSIONS

AKI is independently associated with mortality in patients with RM, and several risk factors were found to be associated with the occurrence of severe AKI and in-hospital mortality. These findings suggest that, to improve the quality of medical care, the early prevention of AKI should focus on high-risk patients and more effective management.

It's complicated: A case report on a COVID-19-positive HIV patient presenting with rhabdomyolysis and acute kidney injury

The SARS-Cov-2/COVID-19 pandemic in early 2020 has had a devastating impact on health systems around the world. While viral pneumonia remains the most common complication, reports are surfacing of cases with neurological, cardiac, and renal involvement. Even less is known about the implications in special high-risk populations. In this report, we discuss a unique case of an HIV-positive patient in New York City who presented with a 2-week history of worsening fatigue, cough, dyspnea, and myalgias and was found to have COVID-19 pneumonia and acute kidney injury. He was managed for severe uremic metabolic acidosis and electrolyte abnormalities with emergent hemodialysis and supportive therapy with subsequent improvement. Direct involvement of SARS-CoV-2 and pneumonia-induced rhabdomyolysis were identified as the precipitating factors of his acute kidney injury. The pathophysiologic mechanisms of acute kidney injury, SARS-CoV-2 renal tropism, and the impact of highly active antiretroviral therapy on COVID-19 pneumonia are discussed. We highlight the importance of clinician awareness of this potentially fatal complication of COVID-19 pneumonia, particularly in the HIV-positive population as early recognition and management can have favorable outcomes.

Severe rhabdomyolysis and acute asymptomatic pancreatitis following the concomitant use of Biktarvy in the setting of hyperosmolar diabetic crisis

Biktarvy (bictegravir/emtricitabine/tenofovir alafemanide), which has been recently approved for the treatment of HIV, is a single-pill regimen that associates bictegravir and a novel integrase strand transfer inhibitor (INSTI) with a combination of two nucleoside reverse transcriptase inhibitors (NRTI) of emtricitabine and tenofovir alafemanide. Among treatment complications, rhabdomyolysis has been reported in association with some NRTI and INSTI but never with bictegravir. Acute pancreatitis has also been reported recently with another INSTI, dolutegravir. We report here a 62-year-old man with diabetes and HIV infection, and receiving Biktarvy for 1 month. He presented to the emergency department for muscular pain and fatigue. He was on treatment with Descovy (tenofovir alafenamide/emtricitabine) and Viramune (nevirapine) for 2 years but he recently asked for a regimen simplification. Severe rhabdomyolysis and acute pancreatitis were diagnosed. Although the aetiology of these events could be multifactorial, it cannot be ruled out that this episode could be linked to a potential side effect of bictegravir.

Acute HIV in an Adolescent Male With Fever and Rhabdomyolysis

We report the case of a young adolescent male who presented with persistent fever and rhabdomyolysis and was ultimately diagnosed with acute HIV. Rhabdomyolysis is an unusual manifestation of acute HIV that has been rarely reported. However, in the absence of another etiology, we propose that HIV should be considered in the differential for rhabdomyolysis, particularly in association with fever and pharyngitis. Young people, especially men who have sex with men of color and younger adolescents, are at increased risk of HIV and may not disclose any sexual history. Opportunities to identify risk factors and test for HIV are often missed in young people. A high level of suspicion and routine screening for HIV is needed in youth, especially in light of the benefits of early diagnosis and treatment of acute HIV. Pre-exposure prophylaxis is highly effective for the prevention of HIV and is underutilized in adolescents.

Kidney Disease in HIV Infection

Antiretroviral therapy (ART) has significantly improved life expectancy of infected subjects, generating a new epidemiological setting of people aging withHuman Immunodeficiency Virus (HIV). People living with HIV (PLWH), having longer life expectancy, now face several age-related conditions as well as side effects of long-term exposure of ART. Chronic kidney disease (CKD) is a common comorbidity in this population. CKD is a relentlessly progressive disease that may evolve toward end-stage renal disease (ESRD) and significantly affect quality of life and risk of death. Herein, we review current understanding of renal involvement in PLWH, mechanisms and risk factors for CKD as well as strategies for early recognition of renal dysfunction and best care of CKD.

Drug-drug interactions and clinical considerations with co-administration of antiretrovirals and psychotropic drugs

Psychotropic medications are frequently co-prescribed with antiretroviral therapy (ART), owing to a high prevalence of psychiatric illness within the population living with HIV, as well as a 7-fold increased risk of HIV infection among patients with psychiatric illness. While ART has been notoriously associated with a multitude of pharmacokinetic drug interactions involving the cytochrome P450 enzyme system, the magnitude and clinical impact of these interactions with psychotropics may range from negligible effects on plasma concentrations to life-threatening torsades de pointes or respiratory depression. This comprehensive review summarizes the currently available information regarding drug-drug interactions between antiretrovirals and pharmacologic agents utilized in the treatment of psychiatric disorders-antidepressants, stimulants, antipsychotics, anxiolytics, mood stabilizers, and treatments for opioid use disorder and alcohol use disorder-and provides recommendations for their management. Additionally, overlapping toxicities between antiretrovirals and the psychotropic classes are highlighted. Knowledge of the interaction and adverse effect potential of specific antiretrovirals and psychotropics will allow clinicians to make informed prescribing decisions to better promote the health and wellness of this high-risk population.

Case report of Triumeq (abacavir/dolutegravir/lamivudine) associated rhabdomyolysis in a human immunodeficiency virus (HIV) infected patient

RATIONALE

With the existence of the human immunodeficiency virus (HIV) infection as a chronic disease, more often adverse effects of its treatment with the various antiretroviral therapies (ARTs) available have been recognized. Going further, Triumeq has been associated with a myriad of adverse effects, of which rhabdomyolysis is rarely reported in the literature.

PATIENT CONCERNS

The patient presented with muscle tenderness over the lower limbs and dark brown-to-red colored urine.

DIAGNOSIS

Given the presenting symptoms, as well as the laboratory testing, including elevated serum creatine kinase and liver enzymes, the diagnosis of rhabdomyolysis was made.

INTERVENTIONS

Improvement was achieved rapidly after starting intravenous fluid therapy and with discontinuation of Triumeq.

OUTCOMES

After discharge, repeated creatine kinase levels in the clinic have been normal and decision was made to initiate another ART and until now, no further episodes of rhabdomyolysis have developed. Regular outpatient follow-up has been ongoing for over 1 year and no complications have been identified.

LESSONS

This case aims to recognize rhabdomyolysis as a rare, but possible adverse effect associated with the use of Triumeq for HIV-infected patients and therefore clinicians prescribing this combination should be aware of this potential side effect and counsel their patients accordingly.

Severe rhabdomyolysis-induced acute kidney injury following concomitant use of Genvoya® (EVG/COBI/FTC/TAF) and simvastatin; a case report

Background

Genvoya® (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide) is a recent single regimen for the treatment of Human Immunodeficiency Virus (HIV). However, because of its complexity, it is difficult to predict drug interactions, especially when associated with HMG-CoA reductase inhibitors and/or in the setting of other comorbidities. We discuss the mechanisms of these potential drug interactions as the cause of rhabdomyolysis and acute kidney injury in the context of prior and current medication therapy with possible underlying liver and kidney dysfunction.

Case presentation

We describe the case of a 54-year-old man diagnosed with HIV who developed severe rhabdomyolysis-induced anuric acute kidney injury (AKI) requiring renal replacement therapy following introduction of Genvoya® concomitantly with simvastatin, in the context of recently diagnosed hepatitis C and hepatitis A. Haemodialysis was continued over 5 weeks followed by progressive clinical and biological improvements. Five months later, a new antiretroviral regimen was started and has been well tolerated.

Conclusion

Simvastatin, as well as lovastatin, because of their CYP3A4 metabolism, and to a lesser extent atorvastatin, which is only partially metabolized by CYP3A4, are the HMG-CoA reductase inhibitors with the greatest risk of drug interactions and should not be used in patients under HIV-therapy. Patients receiving HMG-CoA reductase inhibitors should be monitored regularly for the occurrence of muscular adverse effects and drug interactions should be considered with each new prescription or change in clinical status. There are many online tools that enable clinicians to rapidly check for drug interactions. We recommend the one from the University of Liverpool for patients under HIV-therapy (https://www.hiv-druginteractions.org/checker), while for patients under hepatitis C-therapy, we advise to consult http://www.hep-druginteractions.org/. This case illustrates the importance of multidisciplinary collaboration in the treatment of HIV-positive patients because of their complexity, associated comorbidities and the potential of multiple drug-drug interactions potentially exacerbated by underlying liver and/or kidney dysfunction.

Acute kidney injury in HIV-infected patients: a critical review

Acute kidney injury (AKI) is characterized by a rapid decline of renal function associated with worse outcomes. The purpose of the authors is to perform a critical review of the incidence, risk factors, pathogenesis and outcome of AKI in HIV-infected patients. Human immunodeficiency virus (HIV)-infected patients have an increased risk of developing AKI, to which contribute both HIV-dependent and HIV-independent factors as well as the nephrotoxicity of drugs used. The increased risk of AKI in HIV-infected patients and its negative impact on prognosis highlights the need for identification of patients at risk, creation of prevention strategies and management. HIV-infected patients have an increased risk of developing AKI, to which both HIV-dependent and HIV-independent factors contribute, as well as the nephrotoxicity of drugs used. The increased risk of AKI in HIV-infected patients and its negative impact on prognosis highlight the need for identification of patients at risk, creation of prevention strategies and management.

Severe Rhabdomyolysis as an Unusual Presentation of Primary Human Immunodeficiency Virus Infection

Rhabdomyolysis is characterized by muscle necrosis and leakage of toxic intracellular contents into the circulatory system. It is most commonly caused by trauma, physical exertion, drugs, toxins, and a variety of infections; only rarely is it associated with acute human immunodeficiency virus (HIV) infection alone. The severity of illness ranges from asymptomatic elevations in serum muscle enzymes to life-threatening electrolyte imbalances and acute kidney injury. High HIV viral load is associated with higher muscle breakdown that increases the incidence of severe acute kidney injury and sometimes the need for renal replacement therapy. The introduction of highly active antiretroviral therapy (HAART) revolutionized the treatment of HIV infection and increased the life expectancy of such patients by suppressing viral replication. Myopathy is one of the neuromuscular manifestations of HIV. It can occur either as a result of a complication of HIV itself or as a result of medicines used to control HIV. Muscle involvement of HIV infection ranges from asymptomatic muscle enzyme elevation to severe, HIV-associated polymyositis or pyomyositis. Here we report a case of acute retroviral syndrome presenting as severe non-traumatic rhabdomyolysis.

Association between infection and severe drug adverse reactions: an analysis using data from the Japanese Adverse Drug Event Report database

PURPOSE

It has been reported recently that immune reactions are involved in the pathogenesis of certain types of adverse drug reactions (ADRs). We aimed to determine the associations between infections and drug-induced interstitial lung disease (DILD), rhabdomyolysis, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), or drug-induced liver injury (DILI) using a spontaneous adverse drug event reporting database in Japan.

METHODS

The reported cases were classified into three categories (anti-infectious drug group, concomitant infection group, and non-infection group) based on the presence of anti-infectious drugs (either as primary suspected drug or concomitant drug) and infectious disease. We assessed the association between four severe ADRs and the presence and seriousness of infection using logistic regression analysis.

RESULTS

We identified 177,649 cases reported in the study period (2009-2013). Logistic regression analysis showed significant positive associations between infection status and onset of SJS/TEN or DILI (SJS/TEN: anti-infectious drug group: odds ratio (OR) 2.04, 95% CI [1.85-2.24], concomitant infection group: OR 2.44, 95% CI [2.21-2.69], DILI: anti-infectious drug group: OR 1.27, 95% CI [1.09-1.49], concomitant infection group: OR 1.25, 95% CI [1.04-1.49]), compared to the non-infection group. By contrast, there were negative or no associations between infection and DILD or rhabdomyolysis. A significantly positive association between infection and SJS/TEN seriousness (OR 1.48, 95% CI [1.10-1.98]) was observed.

CONCLUSIONS

This study suggested that infection plays an important role in the development of SJS/TEN and DILI. For the patients with infection and/ or anti-infectious drugs, careful monitoring for severe ADRs, especially SJS/TEN, might be needed.