Herbert Cushing

Acute tubulointerstitial nephritis attributable to indinavir therapy.

Indinavir sulfate has been reported to cause asymptomatic crystalluria and nephrolithiasis in patients with human immunodeficiency virus (HIV) infection. Patients taking indinavir may present with asymptomatic crystalluria, nephrolithiasis with frank renal colic and obstruction, flank pain in the absence of nephrolithiasis, and dysuria or urgency. Asymptomatic crystalluria has been described as benign. Discontinuation of the drug has not been recommended in the absence of nephrolithiasis. We report two HIV-positive patients receiving indinavir who developed acute interstitial nephritis with foreign body giant cell reaction on renal biopsies. Both patients had asymptomatic crystalluria, although crystals were associated with clumps of white blood cells (WBCs) on urinalysis in one patient. Both cases show that the inflammatory response was significant enough to lead to tubular injury and acute renal impairment. Our findings suggest that asymptomatic crystalluria attributable to indinavir may illicit an inflammatory response with acute renal insufficiency, warranting monitoring of renal function, especially in patients with crystalluria.

Therapeutic Failure of Trimethoprim/Sulfamethoxazole in the Treatment of Pneumocystis Carinii Pneumonia

OBJECTIVE: To report a case of failure of treatment of Pneumocystis carinii pneumonia (PCP) with trimethoprim/sulfamethoxazole (TMP/SMX) in a patient with HIV infection, despite an adequate serum SMX concentration. CASE SUMMARY: A 52-year-old white man was treated with TMP/SMX for PCP. After discharge he returned to the hospital with worsening of the PCP despite a serum SMX concentration of 60 μg/mL 18 hours after his last dose of TMP/SMX. DISCUSSION: PCP is one of the most common complications of HIV infection. TMP/SMX is the drug of choice for prophylaxis and treatment. The causes of therapeutic failure with this agent are not well documented. CONCLUSIONS: Alternative therapies to TMP/SMX should be seriously considered if the serum concentrations are therapeutic and the patient is not clinically improved.