From the Guidelines
The next step in managing this 50-year-old CKD patient with HIV who has been experiencing fever for 7 days despite negative diagnostic tests would be to evaluate for abacavir hypersensitivity reaction (HSR) and consider alternative antiretroviral regimens due to potential nephrotoxicity associated with certain medications, as suggested by guidelines for the management of chronic kidney disease in HIV-infected patients 1. Given the patient's recent initiation of abacavir, dolutegravir, and lamivudine, and the presence of fever without evidence of infection, abacavir hypersensitivity reaction should be considered as a potential cause.
- The patient should immediately discontinue the current antiretroviral regimen and be tested for HLA-B*5701, a genetic marker associated with abacavir hypersensitivity.
- While awaiting HLA-B*5701 results, the patient should be switched to an alternative antiretroviral regimen such as tenofovir alafenamide (adjusted for CKD), emtricitabine, and dolutegravir, considering the potential nephrotoxicity associated with tenofovir, especially when used in combination with ritonavir-containing regimens 1.
- If abacavir HSR is confirmed, the patient must never be rechallenged with abacavir as this could lead to life-threatening reactions.
- Additionally, a comprehensive evaluation for other opportunistic infections should be conducted, including blood cultures, CD4 count, and HIV viral load measurement to assess immune status and treatment effectiveness.
- The timing of fever coinciding with antiretroviral initiation strongly suggests a medication-related adverse effect, with abacavir hypersensitivity being the most concerning possibility given the clinical presentation and negative infectious workup.
- It is also essential to monitor the patient's renal function closely, as certain antiretroviral medications, such as tenofovir, can cause nephrotoxicity, particularly in patients with preexisting renal dysfunction 1.
From the Research
Next Steps in Management
Given the patient's symptoms and test results, the next steps in management could include:
- Further diagnostic testing to determine the cause of the fever, as the current test results (MP, dengue widal, sputum truenaat, X-ray, and urine complete) are negative or within normal limits.
- Consideration of opportunistic infections, such as toxoplasma pneumonia, which can occur in immunocompromised patients, including those with HIV/AIDS 2.
- Review of the patient's medication regimen, including abacavir, dolutegravir, and lamivudine, to ensure that it is not contributing to the fever.
- Monitoring of the patient's condition and adjustment of the treatment plan as needed.
Opportunistic Infections
Opportunistic infections, such as Pneumocystis carinii pneumonia, cerebral toxoplasmosis, and Mycobacterium avium complex, are a major cause of morbidity and mortality in HIV-infected patients 3.
- These infections can occur in patients with compromised immune systems, and their incidence rates have decreased significantly since the introduction of highly active antiretroviral therapy.
- However, they still represent a significant public health problem, particularly in low/middle-income settings.
Comprehensive Patient History
Taking a comprehensive patient history is essential for accurate diagnosis and effective management of health conditions 4.
- This involves gathering relevant information from patients through a structured but flexible process, using important communication skills such as active listening, empathetic communication, and cultural sensitivity.
- A thorough patient history can help identify potential causes of the fever and guide further diagnostic testing and treatment.