An 11-year-old patient with a history of connatal HIV was diagnosed at 6 years of age in stage N3 (asymptomatic clinical manifestations N) and corresponds to a child with severe immunosuppression in stage 3.
Highly active antiretroviral therapy was initiated 6 months later.
The patient presented low adherence to treatment, and a high viral load was confirmed 4 years after starting treatment.
Viral resistance was determined which showed the three antiviral drugs used.
It was decided to change therapy to Kaletra® (lopinavir 80/ritonavir 20) (3.5 ml every 12 h), abacavir (300 mg every 12 h) and TDF (300 mg daily), showing good adherence to this therapy.
Eighteen months after starting therapy, the patient presented with loss of strength and pain in the lower limbs, functional disability, difficulty sleeping and weight loss.
Upon admission, the patient had a BMI of 14.5 which is in the 10th percentile (z -1.9) corresponding to his age and height/age z - DS.
Laboratory studies showed hypofatemia, elevated alkaline phosphatase, metabolic acidosis, elevated calcium/creatinine ratio, decreased tubular phosphate, glycosuria and proteinuria.
Brain magnetic resonance imaging and renal ultrasonography were normal.
Bone densitometry showed a significant decrease in bone mineral density.
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This led to proximal renal tubular acidosis (Fannconi syndrome) and secondary hypophosphatemic rachytism.
Treatment was initiated with phosphorus (40 mg/kg/day), vitamin D (1,000 U/day), sodium bicarbonate 1 g every 6 h.
Antiretroviral therapy was continued and the patient was referred for control.
The patient returned 4 months later, complaining of pain while walking and widening of the wrists, maintaining her nutritional status.
The radiographs showed bilateral hip and wrist fractures.
The case was presented to the paediatric AIDS committee, who considered that TDF would have caused secondary tubulopathy and switched therapy to Kaletra ® (lopinavir/ritonavir) (280 mg every 12 hours).
Simultaneously, hip osteosynthesis and orthopedic treatment of wrist fractures were performed.
Two months after therapy the patient gained weight (4 kg) reaching a BMI between p25 to 50 (z-0.5 and 0), showing improvement of phosphate and creatinine normal tubular calcium/ normal urine ratio, reabsorption.
Walking resumed 2 months after surgery.
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Fanconi syndrome is completely diagnosed 4 months after antiretroviral therapy change and its nutritional status remains within the normal curve.
