Septic Bursitis, a Potential Complication of Protease Inhibitor Use in Hepatitis C Virus

TO THE EDITOR—Telaprevir and bocepre-vir are protease inhibitors approved by the Food and Drug Administration for use in the treatment of genotype 1 chronic hepatitis C virus (HCV) infection. Common adverse events associated with boceprevir are anemia and dysgeusia, whereas rash and anemia are associated with telaprevir [1, 2]. We report 2 cases of infectious bursitis in patients undergoing therapy with protease inhibitors, and propose that this adverse event may be associated with this class of medication. Patient 1 is a 57-year-old Hispanic man coinfected with human immuno-deficiency virus (HIV) and HCV. He is currently on tenofovir, emtricitabine, and raltegravir and has a CD4 count of 356 cells/mm 3 and undetectable HIV load. His HCV genotype 1a is complicated by cirrhosis. He started telaprevir, pegylated interferon (peg-IFN), and ri-bavirin (RBV) in March 2012 and HCV was undetectable by week 4. At week 8, he developed an erythematous maculo-papular rash on his trunk and extremities without mucosal involvement (Figure 1). He did not improve on topical clobetasol and triamcinolone and was prescribed a 5-day course of methyl-prednisolone. Telaprevir was discontinued. At week 9, the rash became consistent with erythema multiforme. The patient reported right knee erythema, edema, and tenderness but was able to bear weight. He was instructed to discontinue peg-IFN and RBV and was started on oral prednisone 60 mg/day and amoxicillin–clavulanic acid for suspected cellulitis. At week 10, exam and knee radiographs demonstrated suprapatellar joint effusion and the patient underwent incision and drainage of pus, which grew methicillin-sensitive Staphylococcus Figure 1. Patient 1 targetoid lesions consistent with erythema multiforme.