A 15 year old girl with HIV since birth had to stop her antiretroviral treatment due to side effects. She started zidovudine monotherapy at the age of six, but continued to deteriorate clinically and immunologically during four years until she started HAART when it became available 1996. At the time she was hospitalized and severely ill with a Mycobacterium avium intracellulare sepsis. After treatment initiation with stavudine (30 mg QD), lamivudine (150 mg QD) and indinavir (600 mg TID) a remarkable recovery took place and her CD4-cell count increased from 10 to 410 in one year, and further to 920 × 106/L during the following three years.
However, the TID dosage of indinavir was inconvenient and to render BID dosing possible, a ritonavir boosted regimen with indinavir (800 mg BID) and ritonavir (100 mg BID) was started about 1.5 months before treatment cessation. It was not known at that time (2001) that such high indinavir dosage very often resulted in nephrotoxic side effects, and the serum creatinine concentration increased from 59 to 132 μmol/L after the change. Consequently, her antiretroviral treatment was stopped and the creatinine concentration normalized again within two months.
Twelve days after the treatment discontinuation she presented with fever (39–39.5°C), lymphadenopathy, splenomegaly and abundant sweating during the nights. Her physical examination was normal and a chest radiography showed clear lung fields. Besides confirmed enlargement of the spleen, nothing abnormal was found with ultrasound or CT-scan of the abdomen. Blood cultures for bacteria, including mycobacteria, were negative. Serological testing for Epstein-Barr Virus (EBV), CMV and toxoplasmosis did not give any evidence of an ongoing infection. Routine laboratory showed discrete leucopenia and thrombocytopenia and slightly increased hepatic aminotransferase levels. Serum lactate and C-reactive protein were normal. Two weeks after treatment interruption the plasma HIV RNA level had increased from <50 copies/mL to >750000 copies/mL and the CD4 cell count decreased from 770 to 210 × 106/L, figure 1.
Treatment with stavudine (30 mg BID), lamivudine (150 mg BID) and efavirenz (600 mg QD) was re-started just over one months after cessation, resulting in decreased HIV RNA and increased CD4 cell count again. The fever disappeared a few days before treatment was re-initiated.