FULMINANT, RAPIDLY REVERSIBLE HEPATITIS A ND LIFE-THREATENING ANAPHYLAXIS ENSUING ON RIFAMPICIN IN AN HIV-POSITIVE FEMALE-PATIENT WITH LATENT ADRENAL FAILURE

We report the case of a 28-year-old prostitute from Thailand with HIV infection stage B2 associated with retroperitoneal lymph node tubercul osis. 6 days after the beginning of antituberculous 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 mu mo l/l rising to 238.0; alkaline phosphatase 199 IU/l; glucose 1.8 mmol/l ; prothrombin time 20%). Isoniazid, rifampicin, and pyrazinamid were r eplaced by streptomycin and PAS. A few days after withdrawal the liver profile returned to normal. Hours after the reintroduction of rifampi cin total body erythema, pruritus, vomiting and severe hypotension dev eloped, requiring saline methylprednisolone and epinephrine administra tion. The next reexposure to intravenous rifampicin produced a rash an d was rapidly discontinued. Liver function tests remained normal. Late r mild adverse reactions to streptomycin and pyrazinamid occurred, two drugs which had been well tolerated before. Subsequently the diagnosi s of adrenal insufficiency was established. After initiation of steroi d replacement (50 mg prednisolone) the antituberculous therapy with is oniazid, pyrazinamid and ethambutol was well tolerated. We conclude th at the shock in this HIV-infected patient was either due to severe ana phylaxis 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 in teractions of drug combinations, or an ischemic liver injury during hy potension caused by anaphylaxis. The case illustrates the complex natu re of side effects of antituberculous drugs in HIV patients and their aggravation by adrenal insufficiency.