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Revista da Sociedade Brasileira de Medicina Tropical 37( 4) 357-358, jul-ago, 2004
CARTA AO EDITOR/LETTER TO THE EDITOR
Recur r ent oedema associated with the co-for mulation
of lopinavir and r itonavir
Edema recorrente associado à co-formulação
de lopinavir e ritonavir
1 . Se r viç o de Ale r gia e Imuno lo gia Clínic a do Ho spital Unive r sitár io Gaffr é e e Guinle da Unive r sidade Fe de r al do Estado do Rio de J ane ir o , Rio de J ane ir o , RJ .
Ad d r e ss to : Pr o f. J o r ge Fr anc isc o C. Pinto . Ho spital Unive r sitár io Gaffr é e e Guinle /1 0a
e nfe r mar ia/UNIRIO. Rua Mar iz e B ar r o s 7 7 5 , 2 0 2 7 0 - 0 0 4 Rio de J ane ir o , RJ . e - mail: pinto j f@ uo l. c o m. b r
Re c e b ido par a pub lic aç ão e m 2 6 /3 /2 0 0 4 Ac e ito e m 3 1 /5 /2 0 0 4
To the Edito r :
Highly active antiretroviral regimens that include the HIV-1 protease inhibitor lopinavir, c o-formulated with ritonavir, have recently been associated with episodes of inflammatory oedema, most frequently of the feet, ankles and legs, in patients with severely advanced HIV-1 disease2 4. One of these previously reported patients
experienced a recurrence of oedema of the feet and ankles seven months after the first episode ( Figure 1 A) . We report a case of remitting and relapsing oedema of the left hand, wrist and fingers in a patient on a lopinavir-including antiretroviral //HAART regimen.
A 3 4 -year old HIV-1 -infec ted male patient with a six-year history of uninterrupted antiretroviral therapy was started on a new regimen c onsisting of stavudine, lamivudine, nevirapine and lopinavir/ritonavir. He had already been exposed to the first three antiretroviral agents, but was naïve to both ritonavir and lopinavir. He had a CD4 c ell c ount of 1 9 5 c ells/mm3 and an HIV-1 plasma
viral load of 1 0 ,0 0 0 c opies/ml. Eight months after starting the new regimen he developed an oedema of moderate intensity of his left hand and wrist that fully rec overed over the ensuing two weeks. One month later, a sec ond and milder episode oc c urred ( Figure 1 B) followed by two other rec urrenc es during the next five months. One year later, he had experienc ed several suc h episodes, oc c asionally involving his left fingertips. These oedema episodes were only mildly painful but sometimes frightening due to their speed of installation. They were not assoc iated with additional clinical or new laboratory abnormalities and invariably remitted spontaneously over the ensuing 2 4 to 7 2 hours without tr e a tm e n t o th e r th a n m a in te n a n c e o f th e a n tir e tr o vir a l medic ations.
Our patient’s c linic al presentation of relapsing and remitting oedema of the hand, wrist and fingers shares a resemblanc e to the r e c e ntly de sc r ib e d syndr o me o f inflammato r y o e de ma asso c iate d with lo pinavir- inc luding antir e tr o vir al//HAART
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Pinto JFC e t a l
regimens. In partic ular, its remitting nature resembles the feet and ankle oedema experienc ed by the patient previously reported in referenc e 2 . The latter patient, however, developed only one, not several, oedema episodes. Due to its benign evolution, we found that these oedema episodes did not justify any c hange in the antiretroviral regimen of the patient reported herein.
Other syndr o mes o f per ipher al o edema asso c iated with antiretroviral agents have also been desc ribed. The protease
inhibitor ritonavir has been assoc iated onc e with ac ute painless o e de ma o f the le gs1. Mo r e r e c e ntly, a syndr o me o f slo wly
developing, severe lower extremity oedema assoc iated with high blood flow of the c ommon femoral arteries has been linked to the use o f the r e ve r se tr ansc r iptase inhib ito r stavudine4.
Physic ians c aring for HIV-1 -infec ted patients should be aware of these syndromes of peripheral oedema, so that appropriate c ounseling and management c an be instituted.
Jor ge Fr ancisco C. Pinto1, Walter A. Eyer- Silva1
and Car los Alber to Mor ais- de- Sá1
REFERENCES
1 . Do l L, Ge ffr ay L, El Kho ur y S, Ce vallo s R, Ve yssie r P. Œdè me s de s me mb e r s infé r ie ur e s c he z un patie nt sé r o po sitif po ur le VIH: e ffe t se c o ndair e du r ito navir ? Pr e sse Mé dic ale 2 8 : 7 5 , 1 9 9 9 .
2 . Eye r- Silva WA, Mo tta RN, Pinto J F, Mo r ais- de - Sá CA. Inflammato r y o e de ma asso c iate d with lo pinavir- inc luding HAART r e gime ns in advanc e d HIV- 1 infe c tio n: r e po r t o f 3 c ase s. AIDS 1 6 : 6 7 3 - 6 7 4 , 2 0 0 2 .
3 . Guyo t S, Hayo z D, Te le nti A, Cavassini M. Pe r iphe r al o e de ma and high ar ter ial b lo o d flo w as a c o mplic atio n o f antir etr o vir al ther apy. AIDS 1 8 :3 5 6 -3 5 8 , 2 0 0 4 .
