A 41-year-old female patient with human immunodeficiency virus (HIV) infection, on regular antiretroviral therapy (tenofovir, lamivudine, and dolutegravir), was hospitalized following a recent diagnosis of pulmonary tuberculosis, persistent fever, abdominal pain, and lower limb edema. She reported chronic cocaine use. She evolved with headache, polyuria, urinary tenesmus, abdominal distension, jaundice, moderate anemia (hemoglobin between 6.5–7.9 g/dL), and signs of immune reconstitution inflammatory syndrome. Tuberculosis therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol was initiated; however, after seven days, transaminase levels increased, and drug-induced hepatitis was diagnosed. She received blood component transfusions, antimicrobials (ceftriaxone and azithromycin), and amphotericin B. Laboratory tests revealed leukopenia, thrombocytopenia, hyponatremia, hypokalemia, AST 109, ALT 90, and alkaline phosphatase 2229. Brain CT was normal; chest CT showed tree-in-bud opacities and septal thickening in the left upper lobe. Histoplasmosis serology (urinary antigen) was reactive, and antifungal treatment was initiated (amphotericin B followed by itraconazole), with progressive improvement. Attempts to reintroduce tuberculosis medications resulted in recurrence of jaundice. The relevance of the interaction between drugs, especially rifampicin, and antiretrovirals is highlighted, as it reduces the serum concentration of dolutegravir and requires therapeutic adjustments. Management required temporary suspension of rifampicin and modification of ART. After clinical stabilization, the patient was discharged with oral itraconazole and outpatient follow-up. This case illustrates the challenges in managing HIV/tuberculosis coinfection in the presence of opportunistic histoplasmosis and drug-induced hepatotoxicity. The importance of pharmacovigilance is reinforced, as well as the joint involvement of infectious diseases, pulmonology, and pharmacology, and the early recognition of endemic mycoses in vulnerable populations. The integration of clinical, laboratory, and pharmacological approaches contributes to safer and more individualized therapeutic decisions in contexts of advanced immunosuppression.
Santos et al. (Sun,) studied this question.