Bilateral pathologic hip fractures associated with antiretroviral therapy: a case report

Fanconi Syndrome in Patients With Human Immunodeficiency Virus Treated With Tenofovir-Based Antiretroviral Therapy: A Systematic Literature Review

OBJECTIVE

Several cases of Fanconi syndrome (FS), a severe form of nephrotoxicity, have been reported in patients with HIV on tenofovir-containing antiretroviral therapy. A systematic review of the published literature on tenofovir-related FS in patients with HIV was conducted.

DATA SOURCES

PubMed and Embase were queried to identify articles in English published between January 2005 and June 2023, reporting tenofovir-related FS in adults with HIV. Preclinical studies, conference/poster abstracts, commentaries and responses, and review papers were excluded.

STUDY SELECTION AND DATA EXTRACTION

Of the 256 articles screened, 57 met the inclusion criteria. These comprised 37 case reports, 11 case series, 1 cross-sectional study, 1 case-control study, 4 cohort studies, 1 single-arm open-label clinical trial, 1 sub-analysis of clinical trials, and 1 pooled analysis of clinical trials.

DATA SYNTHESIS

Among 56 cases on which information was abstracted, median age at FS diagnosis was 50 years, 51.8% were men, and duration of tenofovir use ranged from 6 weeks to 11 years. Ritonavir was co-prescribed in almost half the cases. In observational and interventional studies, incidence of FS was low. Many studies reported resolution of FS symptoms after tenofovir discontinuation. All FS occurrences were identified in those on tenofovir disoproxil fumarate (TDF), except for one patient on tenofovir alafenamide (TAF).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Continuous monitoring of signs and symptoms of renal and bone toxicity is essential for patients with HIV on tenofovir-containing therapy.

CONCLUSIONS

Occurrence of FS is low in patients with HIV treated with tenofovir-based regimens. Concomitant use of ritonavir may increase risk of FS. TAF may be a safer alternative than TDF in terms of nephrotoxicity.

Symphyseal plating for pelvic fracture in a morbidly obese patient: operative challenges and innovation of a novel 'wire-ramp plate-sliding method'

We are describing a case report of a morbidly obese patient (body mass index 41) in his mid-40s with Young and Burgess Anteroposterior Compression type II injury (AO Foundation/Orthopaedic Trauma Association type B1.2) managed by symphyseal plating. Morbid obesity made working at a depth very difficult; hence, we adopted a novel 'wire-ramp plate-sliding method'. In this method, two strong sturdy K-wires inserted through the medial-most plate holes into the pubis acted as a ramp over which the plate was pushed/slid distally. During this manoeuvre, the K-wires passing through the plate holes were used as a reduction tool. The patient also had a wedge fracture of the distal femoral shaft which was managed by retrograde femoral nailing. At 1-year follow-up, the pelvic continuity is maintained and the fracture has united. The patient is able to do full weight-bearing and is back to his normal life.

Surface bone sarcomas: an update on current clinicopathological diagnosis and treatment

Surface bone sarcomas are rare malignant bone tumours. Osseous and cartilaginous surface bone sarcomas are the most common, with parosteal and periosteal osteosarcomas, periosteal chondrosarcomas and secondary peripheral chondrosarcomas being the most frequent.

Their clinical symptoms are non-specific and include pain for several months, swelling and limited range of motion of the adjacent joints.

Prompt diagnosis is important, as biological behaviour, imaging and histopathologic characteristics, treatment and prognosis differ considerably from their conventional intramedullary counterparts. Moreover, their imaging characteristics are not infrequently non-characteristic and may be misinterpreted as juxtacortical benign lesions leading to incorrect diagnosis and treatment, with life-threatening repercussions. Molecular studies and histopathological sampling are essential for accurate diagnosis.

There are still numerous issues regarding the biology, pathophysiology and treatment options of these entities due to their rarity.

Cite this article: EFORT Open Rev 2021;6:905-917. DOI: 10.1302/2058-5241.6.210064

Pelvic injury is not just pelvic fracture

Pelvic trauma is complex, most of current work centres around pelvic haemorrhage and fractures. It is important to remember that there is more anatomy in the pelvis than bones and vessels. A 29-year-old male patient was admitted after an Road Traffic Collision (RTC) where his motorbike T-boned a car. He was noted to have a traumatic dislocation of his right testicle, which spontaneously reduced in the emergency department and he was admitted for scrotal exploration and observation. Due to difficulty in mobilising postoperatively, he underwent an MRI, which showed diastasis of his pubis symphysis as well as left-sided adductor tendon rupture, not evident on his initial CT scan, and underwent pelvic fixation. Why should an emergency physician be aware of this? This case emphasises the alternate differentials with pelvic trauma in a haemodynamically stable patient, and the requirement for continuous reassessment in patients failing to improve.

Non-traumatic Unilateral Femur Neck Fracture in a Human Immunodeficiency Virus-Positive Septuagenarian Indian Male: A Unique Case Report

Introduction

Antiretroviral drugs are known to cause osteoporosis making the bones susceptible to fracture. Osteoporotic fractures are majorly seen in the vertebral bodies. Pathological fractures need to be fixed without much delay to start mobilization of the patients.

Case Report

The present case describes a 72-year-old male who was diagnosed to be human immunodeficiency virus-positive 11 months back for which the patient was on a combination of antiretroviral therapy for 11 months. The patient was a farmer by occupation. The patient presented to us with left sided hip pain for1 week with no history of trauma or fall. The patient was able to walk approximately 100m with the help of a height adjustable walker. However, activities such as squatting and sitting cross-legged were restricted for1 week. Radiographic examination revealed a fracture of the left neck of the femur. The patient was evaluated for metastasis the investigations for which were negative. Bipolar hemiarthroplasty of the hip was done since radiographically and intraoperatively no changes were noted in the acetabulum which would have changed the plan to total hip replacement. Following the surgery, patient started walking full-weight bearing from the very next day after surgery.

Conclusion

This case concludes the potential of antiretroviral drugs such as abacavir, lamivudine and efavirenz to cause pathological fractures which has never been described in literature before.

Bilateral Hip Fracture in Adolescents With Antiretroviral Treatment

Tenofovir is a nucleotide reverse transcriptase inhibitor, a commonly prescribed antiretroviral as part of initial therapy. It is widely used and has been recognized as a cause of acquired Fanconi syndrome, a disorder characterized by renal tubular dysfunction, which leads to hypophosphatemia, hypokalemia, and metabolic acidosis, as well as symptoms of polyuria and dehydration, which can ultimately lead to defects in bone mineralization and increase risk of fracture.

Fibroblast growth factor 23 is elevated in tenofovir-related hypophosphatemia

In human immunodeficiency virus (HIV)-infected patients, tenofovir disoproxil fumarate (TDF) may cause hypophosphatemia leading to osteomalacia due to renal phosphate wasting. Fibroblast growth factor 23 (FGF23) may play a role in this setting. We present an HIV-infected patient with TDF-induced profound hypophosphatemia, Fanconi syndrome, osteomalacia, and bilateral hip fracture. Routine serum biochemistry was assessed by standard methods. The plasma FGF23 concentration was measured at Mayo Laboratories (Scottsdale, AZ, USA). Bone mineral density (BMD) was measured using a Hologic Discovery densitometer. At presentation, the patient's plasma C-terminal FGF23 was 2,760 reference units (RU)/mL (15 times upper limit of normal; reference interval [RI] ≤ 180 RU/mL), serum phosphate was 0.58 (RI 0.8-1.6 mmol/L), and TmPO4/GFR was 95%. DXA at the lumbar spine showed a Z score of -4.0. Vitamin D3 and oral phosphate were administered, and TDF was discontinued. After 4 months off TDF, lumbar spine BMD significantly increased by 12% (Z score -3.5); by 6 months the plasma C-terminal FGF23 declined to 1.8 times the upper limit of normal, and both urine and serum phosphate levels normalized. By its marked elevation and subsequent near normalization, FGF23 may be responsible for a component of the phosphate wasting syndrome in these patients. The time course of resolution was 6 months. As expected, with calcium, vitamin D, and phosphate management, BMD significantly improved with resolution of osteomalacia. Clinicians should be aware of this side effect of TDF and the time course of its resolution.