HIV in Children
GRAND ROUNDS AND TEACHING FILES
Multidrug resistant Tuberculosis in HIV infected child
Ira Shah
Consultant in Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati Hospital, Mumbai, India
Incharge, Pediatric HIV and TB Clinic, B J Wadia Hospital for Children, Mumbai, India

A 9 years old boy was detected to be HIV infected In 2008 in view of chronic diarrhea. He was started on antiretroviral therapy (ART) consisting of stavudine (d4T), lamivudine (3TC) and nevirapine (NVP). He was alright till February 2013 when he developed cough that did not respond to antibiotics. Chest X-ray showed left upper zone consolidation. His mantoux test was positive (15mm). Sputum for acid fast bacilli (AFB) was negative. Sputum TB MGIT culture was sent. In the meantime, he was started on 4 drug anti-tuberculous therapy (ATT) consisting of isoniazid (H), rifabutin (RBT), ethambutol (E) and pyrazinamide (Z). In the meantime, his CD4 count was done which was 254 cells/cumm and HIV viral load was done which was 23,000 copies/ml. Complete hemogram showed anemia with hemoglobin of 8.4gm/dl. His ART was shifted to tenofovir (TDF), emtricitabine and atazanavir-ritonavir. Six weeks later, culture was positive for M.tuberculosis (MTB). Drug sensitivity showed resistance to HRZS and sensitive to ethionamide, ethambutol, PAS, ofloxacin, Moxifloxacin, Amikacin, Kanamycin, Clofazimine and Capreomycin. His ATT was changed to ethambutol, ofloxacin, PAS, Ethionamide, Cycloserine and kanamycin. On follow up after 2 months, HIV viral load was 87 copies/ml.

Are there any drug interactions between ART and second line ATT?
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