CRA17 MANAGING DRUG-INDUCED LIVER INJURY IN SMEAR-POSITIVE PULMONARY TUBERCULOSIS WITH HIV/HEPATITIS B COINFECTION - A DISTRICT HOSPITAL EXPERIENCE

Syahrinnaquiah Samsuddin1, Syaza Naqibah Mohd Noor Rahim 1, Wan Jen Lye2.
1Medical department, Hospital Kuala Kubu Bharu, Selangor
2Respiratory unit, Hospital Selayang, Selangor

Introduction:

HIV patients often have multiple co-infections such as smear-positive PTB and hepatitis B, posing challenges due to drug interactions and a higher risk of drug-induced liver injury (DILI). This case highlights the challenges in managing DILI in a district hospital setting.

Case report:

A 36-year-old gentleman with smear-positive PTB, hepatitis B, and HIV had a history of treatment default. During inpatient DOTS, he developed an acute liver injury, suspected as DILI.  His regimen was changed from EHRZ to SEL then to SHRE after switching Efavirenz (EFV) to Dolutegravir (DTG). He responded well with gradual resolution of liver enzymes.

Discussion:

Differentiating between TB-DILI, ART-DILI, TB iris, and acute viral hepatitis flare-ups can be challenging, requiring liver biopsy confirmation, which is not routine. We identified TB-DILI as the most likely cause rather than hepatitis flare-ups as TDF is a potent antivirus. ART was adjusted by excluding EFV due to its hepatotoxicity risk. Pyrazinamde (PZD) was also excluded due to its known hepatotoxicity in the intensive phase. Identified DILI risk factors included age>35, hypoalbuminemia, and co-infections.

Conclusion:

Mortality is high in HIV-TB coinfected patients with liver injury. Management is challenging, especially in district hospitals with limited resources. Complex drug regimens often worsen liver toxicity, necessitating careful monitoring and medication adjustments. A multidisciplinary approach is crucial to managing such cases and minimizing drug interaction risks.

Keywords:

DILI, tuberculosis, HIV, hepatitis B