• neuropsychiatric reaction
• clarithromycin

We read with interest the case report by Prime and French¹ describing a person with HIV infection who developed a severe neuropsychiatric reaction during clarithromycin, zidovudine, didanosine, and nevirapine treatment. The authors suggest that this reaction was caused by the clarithromycin and not the antiretrovirals. Indeed, central nervous system (CNS) symptoms are a known side effect of clarithromycin.² CNS adverse effects, however, have also been reported with zidovudine³ and efavirenz.⁴

So far with nevirapine neuropsychiatric side effects have not been described. For this reason we would like to report the case of a patient who developed CNS side effects shortly after starting nevirapine.

A 40 year old woman with HIV infection was initially treated with ritonavir, saquinavir, and stavudine. Because she developed lipodystrophy she was switched to nevirapine, lamivudine, and zidovudine. Shortly after starting this treatment, she started to feel depressed and to experience bad dreams. Her CD4+ lymphocyte count was 727 × 10⁹/l and her viral load was undetectable. She was living under stressful conditions (her husband was also living with HIV) but according to her there was no recent change in her life to explain this depression. The nevirapine was replaced by abacavir and from then on the CNS side effects rapidly disappeared.

This case report strongly suggests that the nevirapine was responsible for the CNS symptoms.

CNS side effects related to antiviral treatment may be caused by high drug levels. Clarithromycin is known to increase nevirapine levels by about 26%.⁵ The fact that in the patient described by Prime and French the neuropsychiatric symptoms disappeared within 72 hours after stopping the clarithromycin suggests this drug was responsible for causing these symptoms. However, it is also possible that after stopping the clarithromycin the nevirapine levels decreased and that therefore potential nevirapine related side effects disappeared. We propose that in HIV clinical trials patients should be monitored more closely for possible neuropsychiatric side effects and that if these side effects appear antiretroviral drug levels should be measured.