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Specialist in Hospital Pharmacy Pharmacy Service Hospital de Sagunto Avda Ramon y Cajal s/n. Sagunto 46520, Valencia, Spain fax 34 962659428 jborrasb{at}sefh.es
Specialist in Internal Medicine Internal Medicine Service Hospital de Sagunto
Specialist in Hospital Pharmacy Pharmacy Service Hospital de Sagunto
Specialist in Hospital Pharmacy Pharmacy Service Hospital de Sagunto
Specialist in Hospital Pharmacy Pharmacy Service Hospital de Sagunto
Published Online, July 5, 2006. www.theannals.com, DOI 10.1345/aph.1H036
Case Report. A 42-year-old white woman who had been HIV-positive for 8 years presented to the Internal Medicine Outpatients' Clinic with symptoms of a BMS episode. She had no history of drug allergy. In 1997, she was started on antiretroviral therapy with stavudine, lamivudine, and saquinavir. Doses were in accordance with manufacturers' recommendations. The woman had responded appropriately to highly active antiretroviral therapy (HAART). In order to increase treatment adherence, saquinavir was replaced with efavirenz 600 mg once daily in October 2005. Two weeks after efavirenz was initiated, the patient reported constant, severe, oral burning symptoms including a burning sensation in the tongue, gums, and oral mucosa. She had no history of cigarette smoking or substance abuse and denied the use of any other drugs or herbal remedies. The oral cavity was normal, with no underlying medical causes such as lesions, erythema, or candidiasis. She had undergone no recent dental work and had no specific dental problems.
Results of a complete blood cell count, platelet count, glucose, serum electrolytes, creatinine, and liver function tests were within normal limits. The patient was not coinfected with hepatitis B or C virus. A hormonal etiology was excluded because she was not postmenopausal. A diagnosis of BMS was made. The suspected causative agent was efavirenz, as this was the only drug that had been added to the long-standing regimen the patient was taking before the symptoms appeared. Efavirenz treatment was stopped and a new HAART regimen was started, including stavudine, lamivudine, fosamprenavir, and ritonavir. The BMS symptoms resolved within one week. No relapse was observed with the new HAART regimen and the patient remained asymptomatic.
Discussion. BMS is characterized by burning, stinging, heat,
itching, or pain in the oral cavity and lips, usually in the absence of
clinical and laboratory
findings.1 It
affects women more frequently than men. Many local conditions such as
infections, allergic reactions, and dental procedures have been proposed as
causes; however, this condition is probably multifactorial in origin, and the
etiopathogenesis of BMS remains unclear. Systemic causes of BMS include
menopausal disorders, diabetes mellitus, and nutritional deficiencies.
Psychological factors such as anxiety and depression have been consistently
demonstrated in patients with BMS and have been used to suggest that the
disorder is
psychogenic.1
The treatment of BMS is usually directed at its symptoms. Only 3 interventions
have demonstrated a reduction in BMS symptoms: 
-lipoic acid,
clonazepam, and cognitive behavioral
therapy.2
Case reports have linked BMS to the use of drugs.3,4 A MEDLINE search (1966-May 2006) was performed and we did not find any report of efavirenz as a cause of BMS. In our patient, there was a temporal relationship between the development of symptoms after starting efavirenz therapy. Other potential causes of BMS were ruled out. When efavirenz was discontinued, her symptoms improved and resolved quickly. Furthermore, efavirenz was the only drug added before the BMS symptoms appeared. In our patient, based on the Naranjo probability scale, efavirenz could be considered the probable cause of the BMS.5 To our knowledge, as of May 2006, this is the first report of BMS due to efavirenz therapy. This adverse reaction occurred while the patient was receiving the recommended efavirenz dosage and, although it is not lifethreatening, BMS may be associated with significant poor treatment adherence and morbidity. Clinicians should be aware of this potential adverse effect of a widely used drug.
References
This article has been cited by other articles:
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  J. Borras-Blasco, A. Navarro-Ruiz, C. Borras, and E. Castera Adverse cutaneous reactions associated with the newest antiretroviral drugs in patients with human immunodeficiency virus infection J. Antimicrob. Chemother., July 23, 2008; (2008) dkn292v1. [Abstract] [Full Text] [PDF]
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