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Management of Complex Comorbidities in an HIV-Positive Patient with Hepatitis C and Cardiac Issues

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This case study details the clinical management of a 52-year-old man, HIV-positive for 5 years, with a complex medical history including coronary artery disease (CAD), hypertension, and hypothyroidism. Treatment consisted of antiretrovirals Tenofovir, FTC, and Raltegravir, achieving excellent virological suppression. He developed hypercholesterolemia and started on atorvastatin and fenofibrate while preparing for hepatitis C treatment. Despite initial therapy success, he experienced fatigue and myalgias, prompting a reevaluation of his medication regimen.

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Management of Complex Comorbidities in an HIV-Positive Patient with Hepatitis C and Cardiac Issues

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  1. CASE 2 • 52 yo man • HIV positive 5 yrs ago • CAD with previous MI 3 yrs ago/Hypertensive/Hypothyroidism • Tenofovir/FTC/Raltegravir x 4 yrs • CD4 700 HIV Viral Load<40

  2. CASE 2 • Hypercholesterolemia and Hypertriglyceridemia on combination therapy with Atorvastatin 80mg/day and Fenofibrate 145mg/day • Hypertension controlled on Amlodipine 10mg/day • Hypothyroidism controlled on 0.125 mg L-Thyroxine

  3. CASE 2 • Genotype 1a chronic hepatitis C • Naïve to therapy • F2-3/4 scarring • Ready to start triple therapy with PEG INF/RBV/Boceprevir • Atorvastatin decreased to 40mg/day • Baseline HCVRNA 1.66X10E6

  4. CASE 2 • Week 0 HCVRNA 1.66x10E6 • Week 4 HCVRNA (lead in) 2.37x 10E2 • Week 8 HCVRNA <12 • At week 10 begins to feel tired/weak/constipated/muscle cramping • TSH noted to be 18.91…L-T4 increased to 0.15mg/d in response

  5. CASE 2 • At week 11 notes increasingly prominent myalgias, more predominant post interferon injection but lasting all week long as opposed to a few hrs post injection, along with increasing weakness • Hb stable at 105g/l over last few weeks with RBV dose reduction to 600mg/d • AST noted to be increasing while ALT has been normalizing over the last few weeks…also increasing swelling of ankles • ?Cause…Hepatic Decompensation?

  6. CASE 2 • CK measured at 83,700 • BP noted to be low at 90/55 and swelling of ankles worsened now to mid calf…no ascites noted clinically • Cause?

  7. CASE 2 • Atorvastatin and Fenofibrate discontinued!!! • CK fell over the next few weeks as did AST • The symptomatic myalgias and weakness improved over the subsequent month • Amlodipine discontinued…BP normalized to 130/80 and SOAs disappeared over the next month

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