Cautionary tales on the treatment of HIV

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Two cautionary notes about HAART for children with HIV infection are published in this issue of The Journal. Johnson et al present the cases of a 12-year old and a 15-year old adolescents who received Ritonavir plus Lopinavir as HAART and who required inhaled fluticasone for management of asthma. Both developed cushingoid appearance and evidence of adrenal suppression. The authors point out that a large portion of the fluticasone dose is deposited in the oropharynx and is swallowed. Inhibition of cytochrome P450 3A4 enzyme system by Ritonavir then can lead to systemic accumulation. Children with lipodystrophy secondary to protease inhibitor therapy may make recognition of cushingoid features more difficult in those who use fluticasone, but the authors suggest that rapid weight gain, new striae, or hirsutism are clues to adrenal suppression.

Vigano et al report the case of a neonate whose mother was treated with nevirapine and zidovudine, intrapartum, and the infant with zidovudine peripartum, and then zidovudine, lamivudine and nevirapine beginning in the first week of life. All virologic, immunologic, and serologic markers of HIV reverted to negative. Tonsillar tissue was examined by histologic and virologic techniques and was negative. Despite these findings, HIV virologic, immunologic, and serologic markers all became positive within one month of discontinuing HAART at 18 months. HIV is able to hide and persist despite HAART immediately after birth, and despite test results suggesting that it has been eradicated.