An unusual case of underlying rilpivirine resistance in an antiretroviral-naïve man with AIDS

Primary resistance mutations to second generation HIV non-nucleoside reverse transcriptase inhibitors are rare in HIV-infected persons in the US (estimated at 1.8%). We report an antiretroviral treatment (ART)-naïve patient with acquired immunodeficiency syndrome (AIDS) (CD4 cell count 20 cells/mm³, viral load 8439 copies/mL), who was infected with HIV-1 sub-type B virus containing a reverse transcriptase mutation, E138A, associated with rilpivirine resistance. Subsequently, he was initiated on a single tablet ART regimen containing an integrase inhibitor and developed immune reconstitution inflammatory syndrome (IRIS), presenting as Mycobacterium avium cervical adenitis. The patient went on to develop rifamycin-induced neutropenia during treatment of his opportunistic infection but later recovered his counts, and remains well on an integrase-based HIV regimen. His case illustrates the growing importance of archived resistance mutations including the less common E138A mutation, as well as the risk and rapid occurrence of IRIS in AIDS patients initiated on integrase inhibitors.