HIV infection and the pancreas: risk factors and potential management guidelines

Drug-Induced Acute Pancreatitis in Adults: Focus on Antimicrobial and Antiviral Drugs, a Narrative Review

Acute pancreatitis (AP) is an acute inflammation of the pancreas caused by the activation of digestive enzymes in the pancreatic tissue. The main causes of AP are cholelithiasis and alcohol abuse; less commonly, it can be caused by drugs, with a prevalence of up to 5%. Causal associations between drugs and pancreatitis are largely based on case reports or case series with limited evidence. We reviewed the available data on drug-induced AP, focusing on antimicrobial drugs and antivirals, and discussed the current evidence in relation to the classification systems available in the literature. We found 51 suspected associations between antimicrobial and antiviral drugs and AP. The drugs with the most evidence of correlation are didanosine, protease inhibitors, and metronidazole. In addition, other drugs have been described in case reports demonstrating positive rechallenge. However, there are major differences between the various classifications available, where the same drug being assigned to different probability classes. It is likely that the presence in multiple case reports of an association between acute pancreatitis and a drug should serve as a basis for conducting prospective randomized controlled trials to improve the quality of the evidence.

Etiology and severity features of acute pancreatitis in HIV-positive patients with different immune status

Objectives

Acute pancreatitis is common in HIV-infected patients; however, the causes and severity of pancreatitis in HIV-positive patients have a number of significant features that affect both the severity of destruction of the pancreas and the methods of diagnosis and treatment.

Material and Methods

Anamnestic data, results of diagnosis and treatment of two groups of patients with acute pancreatitis were analyzed. The first group included 79 patients with acute pancreatitis combined with HIV infection who were admitted to the clinic for the period from 2017 to 2021. In people living with HIV, drugs and infectious agents caused acute pancreatitis in 11.4% and 24.1% of the cases, respectively. As our study showed, in patients with normal immune status, the drug etiology of pancreatitis prevailed in the structure of the causes of AP, in patients with immunodeficiency, infectious causes of pancreatitis were dominant.

Results

According to the results of data analysis, it is clear that HIV infection is a factor that makes the course of pancreatitis about two times worse regardless of the presence of immunosuppression. The etiological structure of HIV-associated acute pancreatitis directly depends on the patient's immune status and differs in many ways from that of HIV-negative patients or patients receiving ART.

Conclusion

The severity of the disease and the risk of death remain high in acute pancreatitis caused by infectious agents against the background of immunosuppression.

Association between serum amylase levels and CD4 cell counts in newly diagnosed people living with HIV: A case-control study

Serum amylase is a direct reflection of pancreatic injury. Several clinical studies have indicated that antiretroviral therapy may be the main cause of increased serum amylase in people living with human immunodeficiency virus (PLWH). However, other probable causes including direct human immunodeficiency virus infection, opportunistic infections and neoplasms, alcohol abuse, and use of illicit drugs, which can also affect pancreatic amylase levels were not considered in these studies. In our study, we collected clinical data from newly diagnosed PLWH who had not received antiretroviral therapy, and examined the association between serum amylase levels and CD4 cell counts. Between November 2018 and September 2021, a total of 344 newly diagnosed PLWH and 344 healthy controls were recruited at Ningbo Yinzhou No 2 Hospital. Serum amylase levels, CD4 cell counts and other clinical features were measured. Relationships between serum amylase levels and clinical parameters were evaluated using correlation analysis. Multiple linear regression analyses were performed to identify the independent risk factors. Newly diagnosed PLWH had lower CD4 cell counts and higher serum amylase levels than healthy controls (P < .05). Serum amylase levels were negatively correlated with CD4 cell counts (r = -0.506, P < .001). In multiple linear regression analyses, CD4 cell counts (β = -0.327, 95% confidence interval = -0.051--0.022, P < .001) were independently associated with serum amylase levels. CD4 cell counts were independently associated with serum amylase levels in newly diagnosed PLWH. Thus, close monitoring of serum amylase may be significant in preventing opportunistic infections of PLWH, since low CD4 cell counts are associated with an increased risk of opportunistic infections.

[The prospects for the use of drugs based on the phenomenon of RNA interference against HIV infection]

The human immunodeficiency virus (HIV) is currently one of the most pressing global health problems. Since its discovery in 1978, HIV has claimed the lives of more than 35 million people, and the number of people infected today reaches 37 million. In the absence of highly active antiretroviral therapy (HAART), HIV infection is characterized by a steady decrease in the number of CD4+ T-lymphocytes, but its manifestations can affect the central nervous, cardiovascular, digestive, endocrine and genitourinary systems. At the same time, complications induced by representatives of pathogenic and opportunistic microflora, which can lead to the development of bacterial, fungal and viral concomitant infections, are of particular danger. It should be borne in mind that an important problem is the emergence of viruses resistant to standard therapy, as well as the toxicity of the drugs themselves for the body. In the context of this review, of particular interest is the assessment of the prospects for the creation and clinical use of drugs based on small interfering RNAs aimed at suppressing the reproduction of HIV, taking into account the experience of similar studies conducted earlier. RNA interference is a cascade of regulatory reactions in eukaryotic cells, which results in the degradation of foreign messenger RNA. The development of drugs based on the mechanism of RNA interference will overcome the problem of viral resistance. Along with this, this technology makes it possible to quickly respond to outbreaks of new viral diseases.

Pancreas and Adverse Drug Reactions: A Literature Review

Adverse drug reactions (ADRs) affecting the pancreas are a heterogeneous group of side effects that cause damage to pancreatic cells. Various mechanisms such as hypersensitization, sphincter of Oddi constriction, direct cytotoxic and metabolic effects on pancreatic cells, and dose-dependent idiosyncrasy lead to intrapancreatic activation of pancreatic enzymes resulting in drug-induced acute pancreatitis. Several medications have been linked with the development of pancreatic cancer. Pancreatic cancer may result from proinflammatory, proliferative, and antiapoptotic effects. Diabetogenic effect of drugs, which is understood as impairment of insulin secretion, may occur due to direct destruction of β cells, systemic toxicity affecting pancreatic islets and cell membrane glucose transporters, induction of Th1-type autoimmune response, and impairment of voltage-gated calcium channels in β cells, endoplasmic reticulum stress, and insulin signaling. A better understanding of ADRs that affect the pancreas may contribute to improving the awareness of clinicians and patients and reducing potential harmful side effects of implemented therapies.

Gastrointestinal Diseases in Children Living with HIV

Thanks to the advances in antiretroviral therapies (ART) and early diagnosis, pediatric HIV has turned into a chronic infection that requires the collaboration of all pediatric subspecialists for holistic patient management. Gastrointestinal complaints are a frequent reason for seeking access to medical care in all pediatric patients worldwide. Intestinal involvement is present in virtually all children with HIV infections. In high-prevalence settings, up to 25% of children accessing the hospital for diarrhea are diagnosed with HIV. More than half of patients with advanced disease present with gastrointestinal symptoms, from mild infectious diarrhea to severe gastrointestinal impairment, malabsorption and failure to thrive. Gastrointestinal disorders do not spare children on ART, particularly in the initial months of therapy. ART-associated pancreatitis and hepatitis are rare but potentially severe adverse events, whereas lower abdominal symptoms have been reported in more than a third of patients. The latter are usually mild and transient, but may limit ART adherence; a correct framing of the problem is necessary to minimize therapy switches while optimizing the quality of life of children on ART. This review aims to provide state-of-the-art guidance for the initial approach to gastrointestinal diseases in children living with HIV.

Clinical profile of acute pancreatitis following treatment with protease inhibitors: a real-world analysis of post-marketing surveillance data

BACKGROUNDS

Acute pancreatitis (AP) has been reported in patients treated with protease inhibitors (PIs), but there are few real-world studies comparing the occurrence and characteristics of AP after different PI regimens.

RESEARCH DESIGN AND METHODS

Disproportionality analysis and Bayesian analysis were utilized for data mining of the Food and Drug Administration's Adverse Event Reporting System (FAERS) database for suspected adverse events involving AP after PI. The times to onset and fatality rates of AP following different PI regimens were also compared.

RESULTS

Based on 33,832 reports related to PIs, 285 cases were associated with AP, involving with 12 out of the 15 studied PIs. Of all the reported AP events related to PIs, 64.56% occurred in men and the median time to onset of AP was 103 (IQR: 26-408) days after the initiation of PI treatment with a fatality rate of 14.02%. Among all PI therapies, indinavir was notably associated with AP, and ritonavir and lopinavir/ritonavir-induced AP cases appeared to be associated with a higher risk of death.

CONCLUSIONS

Most of PIs were associated with AP-related adverse events, among which indinavir has a stronger association with AP but there is no significant difference in fatality rates.

Impact of the Human Immunodeficiency Viruses Status on Outcomes in Patients Hospitalized With Acute Pancreatitis: A Propensity-Matched Analysis

OBJECTIVES

We aimed to examine the clinical characteristics and outcomes of patients admitted for acute pancreatitis (AP) in the population with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).

METHODS

The National Inpatient Sample from 2010 to 2014 was used to identify adult patients admitted with AP. Patients were grouped based on the HIV status. Primary outcomes were mortality, length of stay (LOS), disposition and total hospitalization charges. Secondary outcomes included acute kidney injury, septic shock, respiratory failure and pancreatic procedures.

RESULTS

After matching and weighting, a total of 14,152 HIV-positive patients (6904 with AIDS and 7248 with asymptomatic HIV [aHIV]) with AP were identified. Acute pancreatitis with AIDS were associated with a higher rate of acute kidney injury, longer LOS, higher hospitalization charges, and less routine disposition compared with HIV-negative AP. Patients with aHIV had less septic shock, shorter LOS, and less hospitalization charges compared with HIV-negative patients and less respiratory failure, shorter LOS, and less hospitalization charges compared with AIDS patients.

CONCLUSIONS

Patients admitted for AP with AIDS have worse outcomes. On the contrary, aHIV status was not only associated with better outcomes when compared with AIDS, but to HIV-negative status as well.

Hypertriglyceridaemia and the risk of pancreatitis six months post lopinavir/ritonavir initiation

Background

Hypertriglyceridaemia (HTG) is an important risk factor for pancreatitis and cardiovascular disease (CVD), depending on severity. Hypertriglyceridaemia is common in human immunodeficiency virus (HIV) infection and is also a common complication of lopinavir/ritonavir (LPV/r).

Objectives

To evaluate the risk of pancreatitis associated with HTG in patients six months post initiation of LPV/r-based therapy in a regional public hospital.

Methods

Triglyceride (TG), serum amylase (s-amylase) and CD4+ count values were retrospectively investigated six months post LPV/r-based initiation. Age, gender, previous antiretroviral regimen and period since HIV diagnosis were also recorded.

Results

The final sample consisted of 194 patients, 50 males and 144 females; mean (± standard deviation [s.d.]) age was 39.52 (± 9.98) years, and the mean (± s.d.) period since HIV diagnosis was 91.32 (± 25.18) months. Normal TG levels (< 1.70 mmol/L) were detected in only 55% of patients and the rest presented with some degree of HTG. The mean (± s.d.) TG for the entire sample was elevated at 1.94 (± 1.30) mmol/L with the mean (± s.d.) of the males at 2.36 (± 1.74) – statistically higher compared to the females at 1.79 (± 1.08) mmol/L (p = 0.034). No cases of pancreatitis were recorded and the time since HIV diagnosis did not indicate any statistically significant differences in the means of the TG, serum amylase or CD4 count values.

Conclusion

Triglyceride levels were not substantially elevated to induce pancreatitis at six months post initiation of LPV/r, but were elevated above the accepted upper normal limit of 1.70 mmol/L which may have implications for cardiovascular risk.

Emerging reverse transcriptase inhibitors for HIV-1 infection

INTRODUCTION

There are 36.7 million people living with HIV with 20.9 million having access to antiretroviral therapy (ART). Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) remain the 'backbone' of ART. However, the currently available nine NRTIs and five non-nucleoside reverse transcriptase inhibitors (NNRTIs) have significant side effects and resistance profiles. Areas covered: We summarize the mechanisms of resistance and other limitations of the existing NRTIs/NNRTIs. GS-9131, MK-8591, Elsulfavirine and Doravirine are four new agents that are furthest along in development. Expert opinion: ART development has evolved with several new promising agents. Longer-acting agents, like MK-8591 are extremely attractive to enhance drug adherence and patient satisfaction. Doravirine offers an NNRTI effective against common mutations that has fewer side effects, limitations on dosing and drug interactions. GS-9131 is very potent and active against a variety of NRTI mutants but it is too early in its development to understand its full risks and benefits. Finally, Elsulfavirine has a long half-life and preliminary data suggests fewer side effects than the most commonly used NNRTI, efavirenz. Each of these new agents shows promise and potential to improve ART in the future. The newer generation of reverse transcriptase inhibitors have longer half-lives, more favorable adverse effect profiles, and fewer drug interactions.

Frequency of Pancreatic Hyperamylasemia in Human Immunodeficiency Virus-Positive Patients in the Highly Active Antiretroviral Therapy Era

OBJECTIVES

Increased frequency of hyperamylasemia has previously been reported in human immunodeficiency virus (HIV)-positive patients, but studies determined total amylase activity and were performed before the introduction of highly active antiretroviral therapy (HAART). We evaluated the frequency of pancreatic hyperamylasemia in a large HIV+ population mostly treated with HAART.

METHODS

The upper reference limit (URL) for pancreatic amylase (P-AMY) was derived from 299 healthy blood donors. A cross-sectional study was then performed on samples obtained from 1,548 consecutive patients referred to our infectious disease clinic to assess serum P-AMY and lipase concentrations. Of the patients, 94% were HIV+, and most (92%) were taking HAART (HIV+Tx+).

RESULTS

P-AMY URL was 51 U/L. The frequency of P-AMY increase did not significantly differ between HIV+ and HIV - populations (14.2% vs 15.2%, P = .91) or between HIV+Tx+ and HIV+Tx - (14.7% vs 8.9%, P = .11). In almost half (48.3% of HIV+ and 42.9% of HIV -) of hyperamylasemic patients, lipase was normal, indicating a non pancreatic origin of their P-AMY increase. Markedly elevated P-AMY (>3 times the URL) was found in six HIV+ patients and in one HIV - patient: two had macroamylasemia, one acute pancreatitis, three (including the HIV - patient) chronic pancreatitis, and one chronic hyperamylasemia of undefined origin.

CONCLUSIONS

In our study, both HIV+ and HIV+Tx+ do not show an increased frequency of P-AMY elevation. Frank pancreatic disease is rare in this clinical setting.

Searching for biomarkers of comorbidities in sera of treated HIV-infected patients by isoelectric focusing

Based on their characteristics, we hypothesized that the following parameters, namely collagen IV, glutathione S-transferase, secretory component (SC), and AMP-activated protein kinase α1α2 may be useful serum markers in the detection of comorbidities in treated HIV-infected patients. These parameters were determined in 204 HIV-infected patients and 35 controls by using IEF and densitometry. Collagen IV was undetectable in controls and the majority of HIV-infected patients. Twenty-two HIV-infected patients presented significantly elevated levels of collagen IV, most of them were coinfected with hepatitis C virus and/or hepatitis B virus. SC was undetectable in controls. SC was significantly increased in 81 HIV-infected patients and significantly correlated with aspartate aminotransferase (r = 0.267, p = 0.0049), alkaline phosphatase (r = 0.309, p = 0.0011), and γ-glutamyl-transferase (r = 0.264, p = 0.0054). Glutathione S-transferase levels of HIV-infected patients were significantly higher than the controls (3779 ± 5860 vs. 785 ± 71 DU, p = 0.0007) and significantly correlated with serum urea (r = 0.204, p = 0.0038), triglycerides (r = 0.209, p = 0.0033), and lipase (r = 0.219, p = 0.0025). AMP-activated protein kinase α1α2 levels of HIV-infected patients were significantly higher than the controls (5676 ± 6248 vs. 1189 ± 6248 DU, p = 0.0009). Further studies are needed to demonstrate the relevance of these results to diagnose non-AIDS-related illnesses in HIV-infected patients.

Antiretroviral drugs and acute pancreatitis in HIV/AIDS patients: is there any association? A literature review

In HIV-seropositive individuals, the incidence of acute pancreatitis may achieve 40% per year, higher than the 2% found in the general population. Since 1996, when combined antiretroviral therapy, known as HAART (highly active antiretroviral therapy), was introduced, a broad spectrum of harmful factors to the pancreas, such as opportunistic infections and drugs used for chemoprophylaxis, dropped considerably. Nucleotide analogues and metabolic abnormalities, hepatic steatosis and lactic acidosis have emerged as new conditions that can affect the pancreas. To evaluate the role of antiretroviral drugs to treat HIV/AIDS in a scenario of high incidence of acute pancreatitis in this population, a systematic review was performed, including original articles, case reports and case series studies, whose targets were HIV-seropositive patients that developed acute pancreatitis after exposure to any antiretroviral drugs. This association was confirmed after exclusion of other possible etiologies and/or a recurrent episode of acute pancreatitis after re-exposure to the suspected drug. Zidovudine, efavirenz, and protease inhibitors are thought to lead to acute pancreatitis secondary to hyperlipidemia. Nucleotide reverse transcriptase inhibitors, despite being powerful inhibitors of viral replication, induce a wide spectrum of side effects, including myelotoxicity and acute pancreatitis. Didanosine, zalcitabine and stavudine have been reported as causes of acute and chronic pancreatitis. They pose a high risk with cumulative doses. Didanosine with hydroxyurea, alcohol or pentamidine are additional risk factors, leading to lethal pancreatitis, which is not a frequent event. In addition, other drugs used for prophylaxis of AIDS-related opportunistic diseases, such as sulfamethoxazole-trimethoprim and pentamidine, can produce necrotizing pancreatitis. Despite comorbidities that can lead to pancreatic involvement in the HIV/AIDS population, antiretroviral drug-induced pancreatitis should always be considered in the diagnosis of patients with abdominal pain and elevated pancreatic enzymes.

The impact of alcohol on HIV prevention and treatment for South Africans in primary healthcare

BACKGROUND

Antiretroviral treatment (ART) has substantially reduced morbidity and mortality for HIV patients. In South Africa, with the largest ART programme globally, attention is needed not only on the further expansion of ART coverage, but also on factors which undermine its effectiveness, such as alcohol use.

OBJECTIVE

Given the decentralised approach of nurse-initiated and -sustained ART in the South African primary health sector, it is important to document key aspects of alcohol use to be conveyed to HIV-positive individuals and those at risk for HIV.

METHOD

This study comprised a narrative review of relevant literature.

RESULTS

Alcohol acts through both behavioural and physiological pathways to impact on the acquisition, further transmission and then progression of HIV disease. Besides links to risky sex, alcohol undermines the immune system, raising susceptibility to contracting and then countering HIV and other infections. There are important drug interactions between alcohol and ART, or therapies for opportunistic infections and other co-morbidities. Moreover, alcohol undermines adherence to the medication which is essential for effective ART.

CONCLUSION

Primary healthcare clinic attendees need evidence-based information on the detrimental effects of alcohol consumption on HIV infection, which ensue throughout the clinical course of HIV. This spans the role of alcohol consumption as a risk factor for HIV infection, HIV replication in infected individuals, a person's response to HIV infection and HIV treatment. Primary healthcare workers, especially nurses and HIV counsellors, require training in order to screen for and provide appropriate interventions for HIV-positive patients, those on treatment and treatment-naïve patients, who will benefit from reduced alcohol consumption or the cessation thereof.

Acute pancreatitis in HIV/AIDS patients: an issue of concern

Pancreatitis is a well-described complication of human immunodeficiency virus (HIV) itself and its combination antiretroviral therapy. Historically, this has been predominantly associated with the usage of nucleoside reverse transcriptase inhibitors such as didanosine and stavudine, but only rarely with the usage of protease inhibitors via the induction of hypertriglyceridemia. Pancreatitis rates in HIV/AIDS population may have been exceedingly high because of the comorbid conditions prevalent in HIV/AIDS patients (e.g. ethanol use and biliary disease), and the use of non-combination antiretroviral therapy medications such as pentamidine, corticosteroids, ketoconazole, sulphonamides, metronidazole, isoniazid and opportunistic infections (e.g. cytomegalovirus, cryptosporidiosis, mycobacterial disease). In resource limited settings, where didanosine and stavudine are widely available in cheaper generic fixed dose combinations it is likely that their usage will remain in the first line HIV treatment in common. In such settings management or estimation of a patient's risk of pancreatitis still remains an issue of concern.

Pancreatic insufficiency in HIV: is it possible?

Pancreatic involvement in AIDS is very important and common, but there are few studies in the literature concerning the pancreas in AIDS. Therefore, our research involves an important issue in the pancreatic field. The objective of the study was to evaluate the profile of HIV-infected patients with probable exocrine pancreatic insufficiency and its relation to the degree of human immunodeficiency virus (HIV) infection. This is a cross-sectional study carried out at Faculdade de Medicina do ABC in partnership with the basic health care unit Vila Guiomar in Santo André. We selected 118 individuals divided into four groups (a control group and three other groups composed of AIDS patients, separated according to CD4 levels); participants had an interview, completed a questionnaire, and had laboratory and imaging tests. The only clinical variables with significant differences among the studied groups were the use of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections, the administration of chemoprophylaxis, and weight loss. There were no differences in the amylase, lipase, and steatocrit dosages among the groups. Levels of fecal elastase 1 were lower in the HIV patient groups (2, 3, and 4) when compared with the control group, although all of them showed average levels that were much higher than the cutoff point (200 μg/g). Only nonalcoholic individuals showed a relationship between diarrhea and alterations in elastase levels. A relationship between the use of HAART and exocrine pancreatic insufficiency in different phases of HIV infection could not be verified.

Alcohol Consumption, Progression of Disease and Other Comorbidities, and Responses to Antiretroviral Medication in People Living with HIV

The present paper describes the possible connection between alcohol consumption and adherence to medicine used to treat human deficiency viral (HIV) infection. Highly active antiretroviral therapy (HAART) has a positive influence on longevity in patients with HIV, substantially reducing morbidity and mortality, including resource-poor settings such as South Africa. However, in a systematic comparison of HAART outcomes between low-income and high-income countries in the treatment of HIV-patients, mortality was higher in resource-poor settings. Specifically, in South Africa, patients often suffer from concomitant tuberculosis and other infections that may contribute to these results. Alcohol influences the use of medicine for opportunistic infections (e.g., pneumonia, tuberculosis), or coinfections HIV-hepatitis viruses-B (HBV) and C (HCV), cytomegalovirus, or herpes simplex virus. Furthermore, alcohol use may negatively impact on medication adherence contributing to HIV progression. The materials used provide a data-supported approach. They are based on analysis of published (2006–2011) world literature and the experience of the authors in the specified topic. Intended for use by health care professionals, these recommendations suggest approaches to the therapeutic and preventive aspects of care. Our intention was to fully characterize the quality of evidence supporting recommendations, which are reflecting benefit versus risk, and assessing strength or certainty.

HIV-Antiretroviral Therapy Induced Liver, Gastrointestinal, and Pancreatic Injury

The present paper describes possible connections between antiretroviral therapies (ARTs) used to treat human immunodeficiency virus (HIV) infection and adverse drug reactions (ADRs) encountered predominantly in the liver, including hypersensitivity syndrome reactions, as well as throughout the gastrointestinal system, including the pancreas. Highly active antiretroviral therapy (HAART) has a positive influence on the quality of life and longevity in HIV patients, substantially reducing morbidity and mortality in this population. However, HAART produces a spectrum of ADRs. Alcohol consumption can interact with HAART as well as other pharmaceutical agents used for the prevention of opportunistic infections such as pneumonia and tuberculosis. Other coinfections that occur in HIV, such as hepatitis viruses B or C, cytomegalovirus, or herpes simplex virus, further complicate the etiology of HAART-induced ADRs. The aspect of liver pathology including liver structure and function has received little attention and deserves further evaluation. The materials used provide a data-supported approach. They are based on systematic review and analysis of recently published world literature (MedLine search) and the experience of the authors in the specified topic. We conclude that therapeutic and drug monitoring of ART, using laboratory identification of phenotypic susceptibilities, drug interactions with other medications, drug interactions with herbal medicines, and alcohol intake might enable a safer use of this medication.

HIV/AIDS cholangiopathy: clinical spectrum, cholangiographic features and outcome in 30 patients

BACKGROUND AND AIMS

AIDS cholangiopathy is presently considered rare and has been reported mainly from the West. With the HIV epidemic in India, we have encountered an increasing number of patients. We aimed to study these patients and determine differences from earlier experiences.

METHODS

We describe the clinical presentation, cholangiographic features, and outcome and determine differences reported in Western literature.

RESULTS

From Jan 1999 to May 2009, 30 patients (27 men) with AIDS cholangiopathy were seen. The most common mode of transmission was heterosexual (n = 28) followed by blood transfusion (n = 2). Abdominal pain (n = 20) of biliary origin, was the commonest manifestation followed by an asymptomatic group (n = 6) and a third group (n = 3) with pain due to pancreatitis. Ultrasonography of the abdomen was abnormal in all patients. Papillary stenosis (n = 23) was the most common cholangiographic feature followed by sclerosing cholangitis (n = 5). Abdominal pain resolved reliably and promptly after endoscopic sphincterotomy. Cholangiographic abnormalities regressed during follow up on antiretroviral therapy in 10 patients. Seven patients on anti retroviral therapy developed de novo cholangiopathy, with a precipitous drop in CD4 count of whom two had a worse prognosis. None had Kaposi's sarcoma.

CONCLUSIONS

In contrast to Western literature, HIV cholangiopathy was seen predominantly in patients who acquired HIV by heterosexual transmission. De novo development of cholangiopathy on antiretroviral therapy may indicate the occurrence of resistance. Papillary stenosis is the most common feature. Abdominal pain resolved with sphincterotomy. Regression of cholangiographic abnormality occurred with anti retroviral medications. Median survival following cholangiopathy diagnosis was 34 months, higher than reported in previous studies.

Metabolic and hepatobiliary side effects of antiretroviral therapy (ART)

Although antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been in use since 1987, the initiation of highly active ART has produced an increase in adverse drug reactions. This is a new challenge as many of the adverse drug reactions attributable to ART may be indistinguishable from non-drug-related illnesses. The emergency physician must be aware of the potential complications of ART as affected patients may present with nonspecific symptoms. The focus of this article is the metabolic and hepatobiliary adverse effects of ART.