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Case report. This is the case of a 15-year-old male patient with a history of hemophilia A and secondary blood product-related human immunodeficiency virus infection. He was first diagnosed with HIV infection in August, 1991, with a CD4+ count of 12 cells/ml. He was maintained on zidovudine 100 mg four times daily from 1991 to 1995. Therapy was changed to didanosine 200 mg twice daily in 1995 which he took until January, 1996, but this was discontinued because of gastrointestinal intolerance. He was then prescribed a combination therapy of zalcitabine 0.75 mg and zidovudine 200 mg three times daily. His therapy also included monthly intravenous immunoglobulin for recurrent pneumonias and pentamidine 300 mg nebulized for Pneumocystis prophylaxis. He is a severe hemophiliac with <1% activity of Factor VIII. His last spontaneous bleed requiring Factor VIII was in 1994, and he reports only one untreated left elbow bleed in March, 1996. His past medical history was significant for asthma, frequent pneumonia and otitis media, but no opportunistic infections. He has had no surgeries, his immunizations are up to date and he has an allergy to trimethoprim-sulfamethoxazole.
In August, 1996, while receiving the above combination antiretroviral therapy of zidovudine and zalcitabine, he had a viral load of 95 488 RNA copies of HIV-1 per ml and his absolute CD4+ count was 8 cells/ml. In November, 1996, the regimen was changed to zidovudine 200 mg three times daily, lamivudine 150 mg twice daily and ritonavir (Norvir®). The dosage of ritonavir was incrementally increased during 3 weeks to a dose of 600 mg twice daily. During his 12 weeks on this therapy he had 7 spontaneous active bleeding episodes which required Factor VIII. The first episode was within 1 week of starting ritonavir. The sites of hemarthrosis included his right elbow and right knee with soft tissue bleeding in his right thigh, right gastrocnemius and left gastrocnemius. He received 50 units per kilogram of Factor VIII product intravenously daily for up to 3 days for each bleed. It is difficult to determine whether retreatment was necessary because he would frequently have bleeding in a different location when finishing 3 days of treatment. He has no history of an inhibitor. There was no change in his physical activity, life style or general health.
During this time his viral load decreased to <200 RNA copies of HIV-1 per ml and his absolute CD4+ count increased to 98 cells per ml. Treatment with ritonavir was then discontinued after 4 months in February, 1997, because of frequent bleeding.
