Efavirenz-Induced Vanishing Bile Duct Syndrome: A Case Report

Abstract

Background: Efavirenz (Sustiva®) is used for the treatment of human immunodeficiency virus (HIV) type 1 infection. Hepatoxicity is a known potential adverse drug event with efavirenz; however, to our knowledge, vanishing bile duct syndrome (VBDS), a type of liver injury, has not been reported with this therapy. Case Presentation: We report the case of a 48-year-old male with HIV and VBDS secondary to antiretroviral therapy. The patient was started on efavirenz, emtricitabine, and tenofovir disoproxil fumarate (Atripla®). Four weeks later, the patient presented with complaints of poor appetite, nausea with emesis, dark urine, and malaise. Labs obtained supported the diagnosis of acute hepatitis, and a liver biopsy confirmed a diagnosis of VBDS. The Naranjo adverse drug reaction probability scale showed that it was probable (score of 7) that the VBDS was related to drug therapy. Efavirenz was assessed to be the most likely cause of VBDS, end-stage liver disease, and the eventual need for liver transplantation. Conclusion: To our knowledge, this is the first reported case of probable efavirenz-induced VBDS in a patient living with HIV. Recognition and awareness of this adverse drug reaction by clinicians for quick diagnosis, discontinuation of therapy, and management are important in patients receiving this regimen.

Chronic Drug-Induced Liver Injury: Updates and Future Challenges

“…Implicated classes of agents comprise antineoplastic drugs, macrolide antibiotics, penicillins, sulfonamides, fluoroquinolones, antifungals, NSAIDs, phenothiazines, tricyclics antidepressants, naproxen and aromatic anticonvulsants ( Flynn and Demling 1982 ; Bethesda 2012 ; Li et al, 2019 ). Drugs related to VBDS reported in the past two years include amoxicillin and clavulanate potassium ( Li et al, 2019 ), ibuprofen ( Park et al, 2020 ), atovaquone/guanine ( Abugroun et al, 2019 ), pembrolizumab ( Doherty et al, 2017 ; Thorsteinsdottir et al, 2020 ), infliximab ( Shah et al, 2019 ), pesidatinib (PLX3397) + paclitaxel ( Piawah et al, 2019 ), meropenem ( Zubarev et al, 2020 ), efavirenz ( Nwaesei et al, 2019 ), trimethoprim/sulfamethoxazole ( Kathi et al, 2020 ) and temozolomide ( Bethesda 2012 ) ( Table 3 ), which provides a clue for the early detection of VBDS in clinical practice.…”