S3450 When the Therapy Bites Back: Drug-Induced Necrotizing Pancreatitis in an HIV Positive Patient

Introduction: Medication-induced pancreatitis remains a relatively uncommon etiology of acute pancreatitis, composing 0.1-2% of reported cases, and is considered a diagnosis of exclusion. Drug-induced triggers of pancreatitis warrant careful consideration particularly in HIV positive patients due to a higher incidence of disease compared to the general population. We present the case of an HIV-positive man who developed necrotizing pancreatitis complicated by pancreatic pseudocyst secondary to the initiation of the antiretroviral drug, darunavir/cobicistat/emtricitabine/tenofovir alafenamide (DRV/COBI/FTC/TAF). Case Description/Methods: A 27-year-old man with a past medical history of HIV presented with 2 days of worsening abdominal pain. On admission, computed tomography abdomen/pelvis with contrast revealed necrosis of up to 40% of pancreatic parenchyma, ascites, and cholelithiasis. The patient was initially admitted to the intensive care unit for septic shock secondary to acute necrotizing pancreatitis with a Ranson’s score of 3. The patient had no history of pancreatic or liver disease, gallstones, hypertriglyceridemia, or alcohol, tobacco, or illicit drug use. Two months prior to admission, the patient's antiretroviral therapy had been switched from dolutegravir/lamivudine to DRV/COBI/FTC/TAF due to weight gain. The patient endorsed progressive nausea and heartburn since starting the new therapy. The patient’s clinical course was complicated by encephalopathy and recurrent decompensation despite fluid resuscitation, antibiotics, and elective cholecystectomy. The patient was determined to have necrotizing pancreatitis secondary to antiretroviral therapy and DRV/COBI/FTC/TAF was discontinued. Two weeks after discharge, the patient returned to the hospital with worsening pancreatic necrosis and a 24 cm pancreatic pseudocyst with significant mass effect on the splenic vein and adjacent structures. The patient had complete recovery following esophagogastroduodenoscopy with cystogastrostomy and Axios stent placement, and 2 pancreatic necrosectomies. Discussion: Though necrotizing pancreatitis is an extremely uncommon complication related to DRV/COBI/FTC/TAF therapy, a small number of cases were reported in phase III drug trials. Drug-induced pancreatitis was determined to be the cause of severe necrotizing pancreatitis in our patient after other causes were ruled out. As novel antiretroviral therapies emerge, HIV positive patients should be closely monitored for rare complications following initiation or modification of therapy.