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Johns Hopkins University AIDS Service, New York State DOH AIDS Institute, The CORE Center, Cook County Hospital



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Lactic Acidosis and Hepatic Steatosis Associated with Use of Stavudine: Report of Four Cases [Miller KD, et al. Ann Intern Med 2000; 133: 192]: This is a report of four cases of lactic acidosis and hepatic steatosis ascribed to HIV treatment with d4T. Salient features in these cases include the following:

  • The duration of therapy with d4T varied from three months to 15 months.
  • All patients presented with nausea, vomiting and abdominal pain, which varied in duration from three days to three months.
  • Lactate levels ranged from 4.3 to 13.6 mmol/L and ALT levels ranged from 43 to 356 U/L.
  • CT scans of the abdomen showed liver density consistent with diffuse fatty infiltration in all four patients and pancreatic inflammation in two.
  • Liver biopsies in two patients showed "severe microvesicular and macrovesicular steatosis." Two patients had biopsy-proven myopathy with prominent lipid accumulations ascribed to mitochondrial dysfunction.
  • All four patients had resolution of symptoms with discontinuation of d4T without recurrence, including three who received other nucleosides.
Comment: This is a topical issue concerning a potentially lethal complication of nucleosides that is commonly ascribed to mitochondrial toxicity. These data should alert physicians to this complication in patients receiving nucleosides with GI complaints regardless of the duration of treatment. The authors also recommend that with routine monitoring of CD4 cell counts and viral loads at three to four month intervals there should also be measurements of ALT and AST levels in patients who are receiving nucleosides. Patients with elevations of the transaminase levels or unexplained GI symptoms should have creatine kinase, amylase and/or lipase levels. CT scans or US reliably detects fatty liver when this diagnosis is suspected. posted 8/11/2000







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