Systemic necrotizing vasculitis in a patient co-infected with human immunodeficiency virus and hepatitis C

Systemic vasculitis is a rare but devastating problem in patients with huma n immunodeficiency virus (HIV). The coinfection with hepatitis C virus (HCV ) further complicates the clinical management. We report a 46-year-old woma n coinfected with HCV and HIV with a CD4 count of 950/mm(3) who presented w ith a life-threatening vasculitis of the lungs, kidneys, and skin and who i nitially responded after use of corticosteroids and then 2 monthly pulses o f i.v. cyclophosphamide. Her condition deteriorated when she was switched t o azathioprine. Ultimately, the patient died of neutropenic sepsis. On the basis of our experience and an analysis of the literature, we suggest that monthly pulsed i.v. cyclophosphamide and steroids might be used as an induc tion therapy, followed by antiviral treatment for patients with HIV, HCV, a nd a life-threatening ischemic vasculitis if the CD4 count is >400/mm(3). F or patients in this complex condition who are receiving immunosuppressants close surveillance for signs of secondary infection, and prophylactic trime thoprim/sulfamethoxazole, are advised. The use of interferon alpha, ribavir in, i.v. immunoglobulin, and plasmapheresis are alternatives for patients w ith milder vasculitis.