Page 94 - SAHCS HIVMed Journal Vol 20 No 1 2019

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 3 Case Report

Emtricitabine-induced pure red cell aplasia

Authors: Introduction: Anemia is common in HIV. Parvo B19 infection is a well-recognised cause of red
Nithendra Manickchund cell aplasia. Other causes of persistent pure red cell aplasia (PRCA) include anti-retroviral
1,2
Camille du Plessis
1,2
Melanie-Anne A. John 2 drugs such as zidovudine and lamivudine. We describe a case of PRCA that strongly implicates
Thandekile C. Manzini 2 emtricitabine as the probable cause.
Bernadett I. Gosnell
1,2
Richard J. Lessells 2,3,4 Patient presentation: Patient was HIV positive and on treatment with a fixed drug combination
Yunus S. Moosa consisting of tenofovir, emtricitabine and efavirenz for 3 months when she developed severe
1,2
transfusion dependent anemia. The anemia, attributed to PRCA, was persistent and transfusion
Affiliations:
1 King Edward VIII Hospital, dependent for about one year.
Durban, South Africa Management and outcome: Replacement of emtricitabine with abacavir resulted in a prompt,
complete and lasting resolution of the anaemia, suggesting an etiologic role of emtricitabine in
2 Department of Infectious
Diseases, University of the PRCA.
KwaZulu-Natal, Durban,
South Africa Conclusion: Emtricitibine is a rare cause of pure red cell aplasia.
Keywords: emtricitabine; pure red cell aplasia; drug induced; rare drug toxicity; adverse drug
3 KwaZulu-Natal Research
and Innovation Sequencing reaction; antiretroviral.
Platform (KRISP), University
of KwaZulu-Natal, Durban,
South Africa Introduction
1
4 Centre for the AIDS There are 7.9 million people living with HIV in South Africa. Anaemia in the HIV infected is
Programme of Research in common, affecting 60% – 80% with advanced disease. There are several causes of anaemia,
South Africa, University of including HIV itself, opportunistic infections, malignancies, drug toxicities and malnutrition.
2
KwaZulu-Natal, Durban, Often a combination of factors contributes to anaemia.
South Africa
Corresponding author: Nucleoside reverse transcriptase analogues, such as zidovudine and lamivudine, are well-
Nithendra Manickchund, established causes of red cell aplasia. 3,4,5,6 Considering the close structural and functional similarity
[email protected]
between lamivudine and emtricitabine, it is not surprising that emtricitabine was recently
7
Dates: implicated as a cause of pure red cell aplasia (PRCA) in a case series of four patients. We describe
Received: 10 May 2019 a case of PRCA that strongly implicates emtricitabine as the probable cause.
Accepted: 10 June 2019
Published: 23 Sept. 2019
Case report
How to cite this article:
Manickchund N, Du Plessis C, A 35-year-old HIV-infected, pregnant woman developed a severe anaemia following initiation of
John MA, et al. Emtricitabine- anti-retroviral treatment (ART) consisting of a fixed drug combination of tenofovir, emtricitabine
induced pure red cell aplasia. and efavirenz (Atroiza). She was diagnosed with HIV infection at 17 weeks gestation in August
S Afr J HIV Med. 2019;20(1), 2014 and was promptly started on ART. Her baseline CD4 cell count and haemoglobin (Hb) were
a983. https://doi.org/10.4102/ 3
sajhivmed.v20i1.983 83 cells/mm and 8.2 g/dL respectively.
Copyright: Three months later, she was admitted with a symptomatic, normochromic, normocytic anaemia
© 2019. The Authors. with Hb of 2.2 g/dL and a normal white blood cell and platelet count. Haemolysis was excluded
Licensee: AOSIS. This work
is licensed under the and an autoimmune screen was negative. There was no suggestion of ongoing blood loss.
Creative Commons Electrolytes and liver function tests were normal. Epstein-Barr virus, Cytomegalovirus and
Attribution License. hepatitis A, B and C serology were all negative. She received six units of packed red cells with post-
transfusion Hb of 8.9 g/dL. She subsequently required an emergency caesarean section for foetal
distress. Following surgery, her Hb repeatedly dropped, requiring frequent blood transfusions. A
bone marrow aspirate and trephine biopsy, done 3 months later, revealed adequately represented
myeloid series and megakaryocytes, but a marked reduction in erythropoiesis with maturation
arrest at the pronormoblast stage. Overall findings were consistent with PRCA. Coupled with a
Read online: positive qualitative serum parvovirus B19 (PVB19) polymerase chain reaction (PCR) (Parvovirus
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Scan this QR R-GENE® assay, Argene range, bioMérieux S.A., Verniolle France), a diagnosis of PVB19-induced
code with your
code with your
smart phone or
smart phone or PRCA was made even though giant pronormoblasts, which are pathognomonic for PVB19
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mobile device marrow infection, were not observed. She was treated with a single course of 400 mg/kg/day
8
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to read online.
of intravenous immunoglobulin (IVIG) over 5 days, but remained transfusion-dependent.
http://www.sajhivmed.org.za 87 Open Access