International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
Bootstrap Slider

Indexed and Abstracted in: SCOPUS, Crossref, CAS Abstracts, Publons, CiteFactor, Open J-Gate, ROAD, Indian Citation Index (ICI), Indian Journals Index (IJINDEX), Internet Archive, IP Indexing, Google Scholar, Scientific Indexing Services, Index Copernicus, Science Central, Revistas Medicas Portuguesas, EBSCO, BOAI, SOROS, NEWJOUR, ResearchGATE, Ulrich's Periodicals Directory, DocStoc, PdfCast, getCITED, SkyDrive, Citebase, e-Print, WorldCat (World's largest network of library content and services), Electronic Journals Library by University Library of Regensburg, SciPeople.

Search Articles

Track manuscript

Readers around the world

Full Html

IJCRR - vol 06 issue 01, January, 2014

Pages: 89-94

Date of Publication: 30-Nov--0001


Print Article   Download XML  Download PDF

STUDYING ANTI RETRO VIRAL THERAPY A CAUSATIVE FACTOR FOR OSTEONECROSIS IN HIV INFECTED PATIENTS

Author: Vetrivel Chezian Sengodan

Category: Healthcare

Abstract:Background and Objectives: Avascular necrosis of femoral head is a common entity. Avascular necrosis of femoral head due to anti-retroviral therapy is an emerging health problem in the world. In India, avascular necrosis of femoral head due to anti-retroviral therapy is not yet reported. We report a case of bilateral avascular necrosis of femoral head as a complication of anti-retroviral therapy. Material and methods: A 41 year old female, a known case of pulmonary tuberculosis had anti tuberculous treatment. While she was on anti tuberculous treatment, she was diagnosed for human immune deficiency infection and put on stavudine, lamivudine and efavirenz [transcriptase inhibitors] and continued for one year. Results: In the follow up period of our patient, she was found to have low back pain and pain in right hip and limp and she was diagnosed of having bilateral avascular necrosis of the femoral head. The diagnosis was confirmed by biopsy of both the femoral heads which revealed avascular necrosis. Interpretation and conclusion: Till date avascular necrosis of the bone due to anti-retroviral therapy is not yet reported from India. We report this case for its rarity and to stress the role of MRI in early detection of avascular necrosis of hip in patients with anti-retro viral therapy.

Keywords: Anti-retroviral therapy, avascular necrosis, Nucleoside and Non-Nucleoside reverse transcriptase inhibitors.

Full Text:

INTRODUCTION

Avascular necrosis is termed as “osteonecrosis” indicates ischemic death of the bone as a result of insufficient arterial blood supply.[1] Risk factors associated with avascular necrosis have included corticosteroid use, alcoholism, intravenous drug use, smoking, antiphospholipid antibodies, hyperlipidemia, sickle cell anemia, radiation exposure and systemic lupus erythematosus. Metabolic factors such as hyperlipidaemia have also been strongly associated with use of protease inhibitors, nucleoside and non nucleoside reverse transcriptase inhibitors. Regardless of the aetiology avascular necrosis has become an emerging manifestation within the Human immuno deficiency virus population. [1, 2]

MATERIAL AND METHODS

A forty one year old female, presented with history of pain over the lower back for three months and pain in the right hip for one month. She had pulmonary tuberculosis three years back, and was treated with antituberculous treatment under category one of Revised National Tuberculous Control Programme. While she was on anti tuberculous treatment, patient was diagnosed to have Human immuno deficiency virus Infection and was started on antiretroviral drugs stavudine, lamivudine and efavirenz. At one year follow up after anti retroviral therapy she presented with pain in the lower back and right hip. There was no history of steroid intake, cardiac disease and radiation exposure. On clinical examination patient was found to have tenderness over the lower lumbar spine. There was no obvious deformity or swelling. There was no distal neurological deficit. On examination of both the lower limbs, tenderness was present over the scarpa’s triangle on right side with no fixed deformity. Extremes of movements were painful and restricted on the right hip joint. There was no limb length discrepancy. The left hip was clinically normal. Antalgic gait was noted. Laboratory parameters showed that there is no raise in acute phase reactants. CRP and ESR were normal. Complete blood count was within normal limits. CD4 count was 590 cells/mm3 . Lipid profile showed high triglyceride level (420mg/dl) and high cholesterol level (364mg/dl). Peripheral smear was also normal.

RESULTS

Radiograph of the pelvis showed increased density on the right hip joint, slight flattening of the weight bearing zone of the femoral head more on right side. MRI of the lumbar spine and screening of the pelvis showed minimal disc bulge at L4 L5 level with bilateral lateral recess stenosis[figure 1] and avascular necrosis involving both femoral heads[figure 2] which was confirmed by biopsy [figure 3 and 4]. As per Ficat and Arlet classification, it was stage 3 on right and stage 2 on left side [figure 5].

DISCUSSION

Anti retroviral therapy is the only treatment option available for human immuno deficiency infected individuals. Normally combinations of anti retroviral drugs are used. In our country, nucleoside and non nucleoside reverse transcriptase inhibitors are used as a first line of drugs for the diseased individuals. Whereas in western countries protease inhibitors is used as a part of regimen. Both protease inhibitors and nucleoside and non nucleoside reverse transcriptase inhibitors causes’ hyperlipidaemia. The Incidence rate of avascular necrosis have been reported to be 0.135% in the general population, although incidence rates ranging 0.3-0.45% have been observed in human immuno deficiency virusinfected patients. [3].The femoral head is the main location of avascular necrosis and is bilateral in approximately 80% of the cases. Other sites of avascular necrosis involved are knee, ankle, shoulder and wrist. [4, 5] Previously, avascular necrosis has been infrequently described in human immuno deficiency virus -infected patients; but in recent reports, its incidence in these patients has grown between 45–58 times over the rate expected in the general population. [6, 7] A retrospective chart review conducted from 19 human immuno deficiency virus clinics in Spain reported 23 cases of avascular necrosis over a 10- year period with a notable increase in frequency of avascular necrosis from 1.6 per 1,000 AIDS patients during 1993-1996 to 14 per 1,000 patients during 1997-2000. [1] Elevation of cholesterol has been observed with the use of efavirenz and nucleoside reverse transcriptase inhibitors such as stavudine. [8, 9] More recently, higher triglycerides levels were reported in subjects taking stavudine, compared with tenofovir-based regimen. [10] A prospective, randomized, double blind study assessed 602 antiretroviral-naive patients who received tenofovir or stavudine, in combination with lamivudine and efavirenz, and who were observed for 144 weeks. [10] A significant increase in the triglyceride level was observed among stavudine-treated patients. [10] Osteonecrosis was seen in patients with different levels of immune status. In most patients, CD4 counts at diagnosis of osteonecrosis were above 200 cells/mm3 . In some of the reported cases, although the average CD4 count was 501 cells/mm3 and the human immune viral RNA was suppressed (<50 cell/mm3 ), many patients still developed avascular necrosis.[1] In our case, CD4 level was 590 cells/mm3 . The mechanisms by which highly active antiretro viral therapy could cause osteonecrosis are unclear, but they involve increased production of anti–protein S or antiphospholipid antibodies as a result of enhanced humoral immunity and hyperlipidaemia. [4] Alteration in lipid metabolism is one of the mechanisms even involved in glucocorticoid-associated osteonecrosis. [10] Osteonecrosis is reported to occur most often in association with advanced human immuno deficiency virus disease. [2] Moreover, in most of the human immuno deficiency virus infected patients, known predisposing factors are lacking, which suggests a possible role of antiretroviral therapy. [3] Till date avascular necrosis of the bone due to anti retroviral therapy is not yet reported from India.

CONCLUSION

In western countries, protease inhibitors are commonly used in multiple drug regimens. All the reported cases of avascular necrosis due to anti retro viral therapy are mainly focusing the role of protease inhibitors causing avascular necrosis of femoral head. Whereas in India, nucleoside and non nucleoside reverse transcriptase inhibitors are used as per National Aids Control Organisation (NACO) as the main drug in combination therapy without protease inhibitors. We want to enlighten the medical fraternity that first line of drugs like stavudine, lamivudine and efavirenz used as per Indian National AIDS Control Organisation (NACO) is known to cause avascular necrosis as in our case. We report this case report for the following reasons. 1. The first case of avascular necrosis of the bone in India due to anti retroviral therapy. 2. To highlight the significance of screening the hips in the MRI study of lumbo sacral spine in ART therapy patients with low back pain.

 

References:

REFERENCES

1. Ramani Reddy MD, Monika ND, Robert D, Arjun Dutta, Jacquay Oliver, and Winston Frederick. Avascular Necrosis and Protease Inhibitors. Journal of the National Medical Association. November 2005; 97: no.11.1543- 1546.

2. Paul Monier, Kevin McKown, Michael S. Bronze. Osteonecrosis Complicating Highly Active Antiretroviral Therapy in Patients Infected with Human Immunodeficiency Virus.CID 2000; 31 (December).1488-1492

3. Fe´lix Gutie´rrez, eT al. Osteonecrosis in Patients Infected with HIV: Clinical Epidemiology and Natural History in a Large Case Series from Spain .J Acquir Immune Defic Syndr .July 2006; Vol 4:No3.

4. Aurélie C Molia, Christophe Strady, Christine Rouger, Isabelle M Beguinot, Jean-Luc Berger, and Thierry C Trenque. Osteonecrosis in Six HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy. The Annals of Pharmacotherapy. 2004 December; Volume 38:2050-2054.

5. Gerster JC, Camus JP, Chave JP, et al. Multiple site avascular necrosis In HIV infected patients. J Rheumatol 1991; 18:300– 2.

6. Wolfe Cj, Taylor-Butler Kl. avascular necrosis. A case history and literature review. Arch FAM Med. 2000; 9:291–294.

7. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis) N Engl J Med. 1992; 326:1473–1479.

8. Calza L, Manfredi R, Mastroianni A, Osteonecrosis and highly active antiretroviral therapy during HIV infection: report of a series and literature review. AIDS Patient Care STDS. 2001 Jul; 15(7):385-9.

9. Hamilton D, Rivaldo VC and Anamaria MM Paniago. Dyslipidaemia Associated with the Highly Active Antiretroviral Therapy in AIDS Patient: Reversion after Switching (Stavudine to Tenofovir and Lopinavir/Ritonavir to Atazanavir/Ritonavir). The Brazilian Journal of Infectious Diseases 2007; 11(2):290-292.

10. Gallant JE, Staszewski S, Pozniak AL, et al. Efficacy and safety of tenofovir DF vs. Stavudine in combination therapy in antiretroviral-naïve Patients: a 3-year randomized trial. JAMA 2004; 292:266–8.

Research Incentive Schemes

Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
Late to bed everyday? You may die early, get depression
Egg a day tied to lower risk of heart disease
88 Percent Of Delhi Population Has Vitamin D Deficiency: ASSOCHAM Report

List of Awardees

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


RSS feed

Indexed and Abstracted in


Antiplagiarism Policy: IJCRR strongly condemn and discourage practice of plagiarism. All received manuscripts have to pass through "Plagiarism Detection Software" test before forwarding for peer review. We consider "Plagiarism is a crime"

IJCRR Code of Conduct: We at IJCRR voluntarily adopt policies on Code of Conduct, and Code of Ethics given by OASPA and COPE. To know about IJCRRs Code of Conduct, Code of Ethics, Artical Retraction policy, Digital Preservation Policy, and Journals Licence policy click here

Disclaimer: International Journal of Current Research and Review (JICRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



Company name

International Journal of Current Research and Review (JICRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

Contact

148, IMSR Building, Ayurvedic Layout,
        Near NIT Complex, Sakkardara,
        Nagpur-24, Maharashtra State, India

editor@ijcrr.com

editor.ijcrr@gmail.com


Copyright © 2020 IJCRR. Specialized online journals by ubijournal .Website by Ubitech solutions