Case 6: Protease Inhibitor-Associated Hyperbilirubinemia

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You answered:

	The patient’s chronic hepatitis B predisposes him to the isolated atazanavir-associated hyperbilirubinemia. Approximately 50% of patients with chronic hepatitis B virus infection will develop hyperbilirubinemia when starting atazanavir.

This answer is incorrect. There is no clear evidence that patients coinfected with chronic hepatitis B or C have an increased frequency of developing isolated hyperbilirubinemia when taking atazanavir. The atazanavir-associated hyperbilirubinemia is not associated with hepatocellular injury.

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	The patient’s presentation is most consistent with atazanavir-associated hyperbilirubinemia. The ritonavir should be discontinued and the hyperbilirubinemia should then completely resolve.
	Atazanavir causes hyperbilirubinemia via competitive inhibition of a key enzyme involved in bilirubin conjugation; patients with Gilbert’s syndrome are more likely to develop jaundice and severe hyperbilirubinemia when exposed to atazanavir or indinavir than those who do not have Gilbert’s syndrome.
	The differential for the jaundice includes hemolytic anemia from dapsone. The diagnosis of dapsone-associated hemolytic anemia can be made with certainty if the bilirubin is fractionated and found to be mostly unconjugated.

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