Abstract
Introduction: Drug-induced liver injury (DILI) can occur after the use of various drugs, both prescription and over-the-counter, through diverse mechanisms. A high index of suspicion is often necessary to promptly establish the diagnosis. DILI has an estimated annual incidence between 10 and 15 per 10,000 to 100,000 people exposed to prescription medications, accounting for about 10% of all acute hepatitis cases and being the most common cause of acute liver failure in the United States. Alcohol abuse and malnutrition predispose individuals to DILI in some cases. Objectives: This is a case report of drug adverse reaction with hepatotoxicity following the use of Dolutegravir for AIDS treatment in a female patient at a University Hospital in Salvador, Bahia. Method: Observational descriptive interventionist study. Results and Discussion: A 24-year-old patient with a history of dyslipidemia, no other comorbidities, alcohol use, allergies, or prior continuous medication use, was admitted to her local hospital with an infectious condition and tested positive for HIV. She was subsequently referred to the Infectious Diseases Service at the University Hospital Prof. Edgard Santos. Upon admission on February 22, 2017, she presented with an infectious syndrome (intermittent fever, diarrhea, asthenia, pancytopenia, and oral cavity lesions) associated with HIV and received a packed red blood cell transfusion. During her hospitalization at the local hospital, she was treated with ceftriaxone (2g/day, IV, from February 18 to 21, 2017), metronidazole (1500mg/day, PO, from February 17 to 28, 2017), and fluconazole (200mg/day, PO, from February 18 to 28, 2017). Upon admission to HUPES, confirmatory tests for HIV were performed, and azithromycin (1500mg/week, PO) was initiated on February 22, 2017. Initial liver function tests on admission showed: AST 173 U/L, ALT 49 U/L, ALP 290 U/L, GGT 182 U/L. On February 24, 2017, sulfamethoxazole-trimethoprim (800mg + 160mg/day, PO) was initiated. Following viral load results (1,590,438 copies/mL) and CD4+ count (45 cells), an antiretroviral regimen was started on March 2, 2017, including tenofovir (300mg/day, PO), lamivudine (300mg/day, PO), and dolutegravir (50mg/day, PO). A single dose of filgrastim (300mcg, SC) was administered on this date. On March 9, 2017, the patient developed headache, nausea, and vomiting, with subsequent laboratory findings showing elevated canalicular enzymes and transaminases: AST 275 U/L, ALT 197 U/L, ALP 487 U/L, GGT 227 U/L. Peak values were reached on March 14, 2017: AST 445 U/L, ALT 496 U/L, GGT 441 U/L, ALP 2,575 U/L. Dolutegravir was discontinued on this day. Follow-up on March 27, 2017, revealed improvement in liver function tests while maintaining the other medications. Conclusion: According to the causality assessment using Naranjo's algorithm, RUCAM, WHO, and European Union criteria, categorizing the outcome as probable, highly probable, certain or proven, and category A, respectively, it was concluded that the patient's cholestatic liver injury was caused by dolutegravir use.
