title: [Fulminant, rapidly reversible hepatitis and life-threatening anaphylaxis following rifampicin in an HIV-positive female patient with latent adrenal cortex insufficiency].
abstract: We report the case of a 28-year-old-prostitute from Thailand with HIV infection stage B2 associated with retroperitoneal lymph node tuberculosis. 6 days after the beginning of anti-tuberculous therapy (isoniazid, rifampicin, pyrazinamid and ethambutol) the temperature rose to 40.5 degrees C, diarrhea, vomiting, and tachycardia developed and systolic blood pressure fell to 80 mm Hg. Liver function tests revealed acute hepatic failure (ALT 800 IU/l rising to 1500; serum bilirubin 89 mumol/l rising to 238.0; alkaline phosphatase 199 IU/l; glucose 1.8 mmol/l; prothrombin time 20%). Isoniazid, rifampicin, and pyrazinamid were replaced by streptomycin and PAS. A few days after withdrawal the liver profile returned to normal. Hours after the reintroduction of rifampicin total body erythema, pruritus, vomiting and severe hypotension developed, requiring saline methylprednisolone and epinephrine administration. The next reexposure to intravenous rifampicin produced a rash and was rapidly discontinued. Liver function tests remained normal. Later mild adverse reactions to streptomycin and pyrazinamid occurred, two drugs which had been well tolerated before. Subsequently the diagnosis of adrenal insufficiency was established. After initiation of steroid replacement (50 mg prednisolone) the antituberculous therapy with isoniazid, pyrazinamid and ethambutol was well tolerated. We conclude that the shock in this HIV-infected patient was either due to severe anaphylaxis to rifampicin or acute adrenal insufficiency ensuing on this drug. The reversible fulminant acute hepatic failure represents either an adverse effect of antituberculous drugs, especially hepatotoxic interactions of drug combinations, or an ischemic liver injury during hypotension caused by anaphylaxis. The case illustrates the complex nature of side effects of antituberculous drugs in HIV patients and their aggravation by adrenal insufficiency.
authors.affiliation: Medizinische Klinik, Kantonsspital Chur.
authors.forename: C R
authors.initials: CR
authors.lastname: Canova
authors.forename: M
authors.initials: M
authors.lastname: Kuhn
authors.forename: U
authors.initials: U
authors.lastname: Zellweger
authors.forename: W H
authors.initials: WH
authors.lastname: Reinhart
mesh_terms: D000309:Adrenal Insufficiency / Q000188:drug therapy / Q000209:etiology*; D000328:Adult; D000707:Anaphylaxis / Q000139:chemically induced*; D000904:Antibiotics, Antitubercular / Q000009:adverse effects*; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D017093:Liver Failure / Q000139:chemically induced*; D011239:Prednisolone / Q000627:therapeutic use; D012293:Rifampin / Q000009:adverse effects*
chemical_list: D000904:Antibiotics, Antitubercular; D011239:Prednisolone; D012293:Rifampin
vernacular_title: Fulminante, rasch reversible Hepatitis und lebensgefährliche Anaphylaxie nach Rifampicin bei einer HIV-positiven Patientin mit latenter Nebennierenrinden-Insuffizienz.