Abstract

We present a case of Acute Intermittent Porphyria (AIP) exacerbated by HAART and review the complications of managing these two conditions. Only one previous case of these two conditions has been published. AB is a middle aged man who was diagnosed with HIV with baseline CD4 of 518. He was well until 2011 when he was admitted to our department with severe abdominal pain, hypotension and a penile ulcer. CT, MRCP, OGD and ultrasound were normal but syphilis serology was positive. He was treated with benzathine, his pain reduced and was discharged. He was then started on Atripla with a CD4 of 162. After 3 weeks he developed severe abdominal pain, hypertension and complained of ‘bloody’ urine but no blood on analysis. Biochemistry showed a sodium of 117. With these new symptoms urinary porphyrins were requested which were elevated at 4002 nmol/l representing an acute episode of AIP. It was felt this second admission was triggered by HAART which was stopped and he was treated with haem arginate and his symptoms improved. On further discussion with AB he admitted to taking a ‘legal high’ prior to the first admission which may have triggered this episode. There have been no reported cases of AIP due to syphilis. AIP is a disorder of the haem pathway and is known as the Little Imitator in contrast to syphilis the Great Imitator as it is often misdiagnosed. While it is a rare condition its importance with HIV is that it is triggered by most drugs needed in managing HIV. Drugs which induce cytochrome p450, anti PCP, TB and fungal agents have all been implicated. NRTI's are thought to be safe while Saquinavir is the only PI recommended for use and there is no evidence of newer HIV agents. AB was started on Truvada and boosted Saquinavir and 4 months on his symptoms are controlled with no further AIP attacks and viral load is 42 c/ml. Reports such as this are important in increasing the limited knowledge of safely co-treating HIV and AIP.