Treatment of recurring cutaneous drug reactions in patients with human immunodeficiency virus 1 infection: a series of 3 cases.

Abstract

A 41-year-old man, who was diagnosed as having human immunodeficiency virus (HIV) infection 2 weeks previously, presented to the San Francisco General Hospital emergency department, San Francisco, Calif, with acute generalized exanthematous pustulosis. The patient had begun antiretroviral therapy (ART) with stavudine, didanosine, and nelfinavir mesylate 10 days prior to presentation. His CD4 cell count was 501/μL, with a viral load of 20 copies/mL. He was admitted to the inpatient service for management. His cutaneous eruption resolved with discontinuation of all antiretroviral medications. The patient received a 10-day course of oral prednisone at 60 mg/d, which was then tapered to 30 mg/d for an additional 10 days. One month after discharge, ART was reattempted with nevirapine, zidovudine, and lamivudine. After 10 days, he again developed acute generalized exanthematous pustulosis, which again cleared when medications were discontinued. No corticosteroid therapy was given at that time. Three months later, he was prescribed stavudine, lamivudine, and efavirenz. Within 10 days he developed an urticarial reaction, and his ART was terminated. The following month, a decision was made between the primary care physician and the dermatology service to initiate an 8-week course of oral prednisone at 30 mg/d and simultaneously introduce ART. The goal was to use the anti-inflammatory effects of the corticosteroids to minimize any adverse medication reactions during the first 8 weeks of ART. The patient was started on lamivudinezidovudine, indinavir sulfate, and ritonavir therapies and the 8-week course of prednisone. The patient was finally able to tolerate his much-needed ART, and no adverse reactions were observed through 4 weeks of follow-up after prednisone therapy was discontinued. CASE 2