Severe skin rash with lamivudine in HIV infected patients: Some unusual case reports
Antiretroviral therapy (ART) was initiated with zidovudine, lamivudine, and nevirapine in a 30-year-old HIV positive, asymptomatic female with CD4 count of 174 cells/μL. She was already on co-trimoxazole prophylaxis for more than 2 weeks and was tolerating it well. She was hospitalized with diffuse erythematous, maculopapular, pruritic rash, which started from the 8th day after initiation of ART, appearing first on extremities, gradually spreading with systemic symptoms like fever and myalgia. Physical examination revealed increased body temperature, rash on trunk and extremities without any mucosal involvement. Routine laboratory investigations including complete hemogram, liver, and kidney functions were normal. All medications including co-trimoxazole were stopped, and within a few hours, the patient improved and the rash disappeared completely by 10th day. Assuming nevirapine to be the offending agent, a combination of zidovudine, lamivudine, and efavirenz (co-trimoxazole was not started) were initiated 2 weeks following complete resolution of rash but similar type of rash with more extensive distribution re-appeared after second dose of ART. All the antiretrovirals (ARV) were withdrawn and the reaction resolved. The next regimen did not include any NNRTIs; instead, lopinavir/ritonavir was started along with zidovudine and lamivudine. The rash once again reappeared after the first dose and all the drugs were withdrawn. The rash disappeared within 7 days. As zidovudine and lamivudine were the common denominator in all three ARV regimens, lamivudine was suspected and withdrawn, and substituted with didanosine in the next regimen. The patient did not develop any rash with zidovudine, didanosine, and lopinavir/ritonavir. After 2 months, efavirenz was substituted instead of lopinavir/ritonavir.