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Elevated Liver Enzymes Following Initiation of Antiretroviral Therapy
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To the Editor: Dr Sulkowski and colleagues1 described hepatotoxicity associated with antiretroviral treatment (ART), but the finding of liver abnormalities following ART does not necessarily imply drug toxicity. Recent reports have suggested that protease inhibitor therapy may be associated with transient "flares" of chronic viral hepatitis, which represent a reactivation of the host inflammatory response following the "immune reconstitution" associated with successful ART. Similar inflammatory reactivations of clinically silent infections have been described for other opportunistic infections after human immunodeficiency virus (HIV) ART.2 Indeed, anecdotal reports have shown that the flare of hepatitis may be followed by full clearance of the hepatitis B virus.3-4
Mild to severe hepatotoxicity may be the initial sign of immune reconstitution. If ART is discontinued at this point, such cases may be indistinguishable from those of drug toxicity. Sulkowski et al reported that in 6 of 31 cases with severe hepatotoxicity, ART was continued without . . . [Full Text of this Article]
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