45
45
Clinical Practice Pearls
P R O B E
• V o l . L I I I • N o . 3 • A p r – J u n 2 0 1 4
Drug Alert
Recurrent Nephrolithiasis Associated With
Atazanavir Use
Wang LC, et al
BMJ Case Rep
. January 8, 2014 (doi: 10.1136/bcr-2013-
201565).
A 64-year-old man with HIV on antiretroviral therapy
(including atazanavir, a protease inhibitor) presented
with left flank pain, nausea, and vomiting. A kidney
stone was suspected, and a CT scan demonstrated left
hydronephrosis, but failed to demonstrate nephrolithiasis
or extrinsic compression. The patient had a ureteral stent
placed, which relieved his symptoms. A few months later,
he underwent left ureteroscopy and a large ureteral calculus
was found. The stone was removed and analysis showed
43% atazanavir and 57% calcium oxalate. Several months
later, the patient developed flank pain on the opposite side.
A renal ultrasound suggested right-sided nephrolithiasis
and he subsequently underwent ureteroscopy with laser
lithotripsy of 2 stones. Stone analysis showed that they were
composed of 100% atazanavir. This case highlights the
fact that patients treated with protease inhibitors remain
at risk for developing nephrolithiasis. Ultrasonography
can be a useful diagnostic tool in the setting of these
radiolucent calculi.
Acute Focal Dystonia Induced by
a Tricyclic Antidepressant in a Patient With
Wilson Disease: A Case Report
Litwin T, et al
Neurol Neurochir Pol
. 2013;47(5):502–506.
A case of Wilson disease (WD) was presented in a
19-year-old patient who developed symptoms of acute focal
dystonia of the left hand (a “starfish” hand presentation)
shortly after treatment with the tricyclic antidepressant
clomipramine. The diagnosis of WD was made 8 months
earlier based on abnormal copper metabolism parameters
and was confirmed by genetic testing. Initially, the patient
presented with akathisia, sialorrhea, oromandibular
dystonia (occasionally grimacing) and slight dysarthria.
The patient’s symptoms diminished after treatment with
d-penicillamine was initiated. No further deterioration was
observed after copper-chelating therapy was started. Acute
focal dystonia induced by clomipramine was diagnosed.
Botulinum toxin and intensive rehabilitation was initiated;
complete regression of hand dystonia was observed.
Based on the case, the authors suggest that care should be
exercised with regard to starting medications that could
potentially impact the extrapyramidal system in WD
patients.
