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Aseptic osteonecrosis: a newly diagnosed complication in HIV-infected patients undergoing liver transplantation.

Patients Undergoing Liver Transplantation A septic osteonecrosis (ON) is defined as the death of bone tissue secondary to the compromise of the vasculature with consequent collapse of the bone structure with joint pain and loss of function. It has been associated with numerous conditions, including human immunodeficiency virus (HIV) infection and solid-organ transplantation. Nevertheless, data are scant in HIVinfected populations undergoing solidorgan transplantation. We describe three cases of ON diagnosed in patients coinfected with HIVhepatitis B virus (HBV)/HIV-hepatitis C virus (HCV) undergoing liver transplantation (LT) at the Modena University Transplant Center, Italy. CASE REPORTS Case 1 A 39-year-old white man with alcohol and HCV-related cirrhosis underwent LT in March 2007. HIV infection was diagnosed in 1988, and the patient was categorized as C3 (1993 Centers for Disease Control and Prevention) with a nadir CD4 cell count of 0.038 10/L (38/KL). The first antiretroviral therapy (ART) regimen was started in 1997 with a cumulative exposure of 83 months to protease inhibitors (PIs). He has a medical history of osteopenia, dyslipidemia, and cigarette smoking. On the 13th postoperative day (pod), unboosted atazanavir was resumed with emtricitabine and tenofovir as backbone. Immunosuppressive (IS) regimen was based on cyclosporine and methylprednisolone (cumulative dose of 1972 mg), which was tapered rapidly. During the 10 months, the patient developed progressive bilateral coxalgia. The magnetic resonance imaging (MRI) showed severe ON in the femoral heads (Fig. 1A), for which he underwent a total hip arthroplasty on both joints. Surgery was effective, and the patient went back to his regular job.