Response to Modified Antitubercular Drug Regime and Antiretroviral Therapy in a Case of HIV Infection with Disseminated Tuberculosis with Isoniazid Induced Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a potentially life-threatening disorder characterized by widespread erythema, necrosis, and bullous detachment of the epidermis and mucous membranes. Without proper management,TEN can cause sepsis leading to death of the patient. Though TEN is commonly drug induced, Isoniazid (INH) has been uncommonly associated with TEN. As INH is one of the first line drugs in treatment of tuberculosis, TEN induced INH needs modification of antitubercular therapy (ATT) with withdrawal of INH from the treatment regime along with other supportive treatments. Patients with HIV infection and disseminated tuberculosis need to be urgently initiated on an effective ATT on diagnosis of tuberculosis. However, if the patient develops potential life-threatening toxicity to first line antitubercular drugs like INH, an alternative effective ATT combination needs to be started as soon as the condition of the patient stabilizes as most of these patients present in advanced stage of HIV infection and this is to be followed by antiretroviral therapy (ART) as per guidelines. The present case reports the effectiveness of an ATT regime comprising Rifampicin, Pyrazinamide, Ethambutol, and Levofloxacin along with ART in situations where INH cannot be given in disseminated tuberculosis in HIV patients. 1. Introduction Tuberculosis (TB) in all forms has been associated with all stages of HIV infection. TB is one of the most common coinfections in HIV patients across all continents especially at low CD4 counts [1, 2]. By producing a progressive decline in cell-mediated immunity, HIV alters the pathogenesis of tuberculosis, in coinfected individuals and leading to a more disseminated disease [3]. WHO recommends testing for HIV in newly diagnosed TB patients [4]. HIV patients with TB coinfection are in Stages III or IV depending upon the site of organ involvement [5]. As per the latest international and Indian guidelines, HIV infected patients with TB co-infection need to be initiated with Rifampicin, Isoniazid, Ethambutol, and Pyrazinamide based antitubercular therapy (ATT) urgently in standard dosages followed by antiretroviral therapy (ART) within 2–4 weeks [6, 7] of starting ATT [8]. Drugs used for ATT have their own adverse effects and some of them can be life threatening and need intensive therapy once they develop [9]. HIV infected patients are more prone to the adverse effects of ATT than non-HIV patients [10]. The situation becomes even more serious if the adverse effects of ATT develop in a patient in advanced stages of HIV infection as ATT has to