nevirapine is a dipyrido - diazepinone non - nucleoside reverse transcriptase inhibitor ( nnrti ) . it was the first nnrti approved by the us food and drug administration for the treatment of human immunodeficiency virus ( hiv ) infection in 1997 . nevirapine based regimens of highly active antiretroviral therapy have been widely used in resource limited countries because of their efficacy , accessibility and comparatively low cost . nevirapine binds directly to reverse transcriptase ( rt ) and blocks the ribonucleic acid - dependent and deoxyribonucleic acid ( dna)-dependent dna polymerase activities by causing a disruption of the enzyme 's catalytic site . rt and eukaryotic dna polymerases ( such as human dna polymerases  ,  ,  , or  ) are not inhibited by nevirapine . efavirenz , nevirapine and delavirdine exhibit a class effect with regard to cutaneous adverse reactions . the spectrum of drug rash can vary from a mild urticarial , morbilliform rash to stevens - johnson syndrome ( sjs ) or toxic epidermal necrolysis ( ten ) . sjs and ten are variants of the same spectrum presenting as severe mucosal erosions with widespread erythematous maculopapular rashes with atypical targetoid lesions . the cutaneous lesions often become confluent and show a positive nikolsky 's sign and epidermal detachment . ten is defined by epidermal detachment greater than 30 percent of body surface area . here we report the case of a patient infected with hiv-1 manifesting the entire spectrum of drug reactions associated with nevirapine . incidentally , this patient also had non - hodgkin lymphoma ( nhl ) stage iv of the anal canal with lung and bone metastasis . written informed consent was taken from the patient for collection of his data and photographs . a 44-year - old businessman , diagnosed hiv positive 4 years ago , was started initially on zidovudine , lamivudine and efavirenz based antiretroviral therapy ( art ) . three months ago , his art regimen was modified to tenofovir , lamivudine and efavirenz for unknown reasons . a month later , at his art centre twenty days after starting the modified regimen of tenofovir , lamivudine and nevirapine , he developed itching with maculopapular rash for which he was treated symptomatically with antihistamines and art was continued . fifteen days later , he presented to us with a severe maculopapular rash all over the body with targetoid lesions over the limbs [ figure 1 ] along with mucosal lesions in the oral and genital areas . patient was hospitalized and art was stopped . over the next three days , he developed severe bullous lesions and extensive exfoliation involving more than 90 percent of the body surface [ figure 2 ] , including the palms and soles . oral and genital lesions were severely erosive [ figures 3 and 4 ] and the nikolsky 's sign was positive . initially , all his hematologic and biochemical parameters were normal with a cd4 count of 17/cu mm . over the next 4 - 5 days , he developed leucopenia of 750 cells / cu mm . his alanine aminotransferase and aspartate aminotransferase levels were 220 iu / l ( n : 10 - 40 iu / l and gamma glutamyl transferase was 116 iu / l , showing 2 - 3 fold rise above normal . targetoid lesions over the forearms as initial manifestation epidermal necrolysis over the back epidermal necrolysis involving the oral cavity he was placed on fourth generation cephalosporin cefpirome 1 g twice daily for 10 days . intravenous hydrocortisone 100 mg twice daily was given for two days , changed to dexamethasone 8 mg twice daily when he started developing ten lesions . after one week , dexamethasone was tapered to once - daily dosage over the next week and then stopped . granulocyte colony stimulating factor filgrastim , 5 mcg / kg was administered subcutaneously for 5 days along with adequate hydration and meticulous nursing care . over the next 10 days , the patient 's condition improved dramatically with reepithelialization of entire body surfaces except for a small erosion in the sacral region , which also healed later [ figure 5 ] . later , he developed lower respiratory tract infection for which linezolid was administered after culture and sensitivity reports . after one month , he recovered completely and art was restarted with tenofovir , lamivudine and efavirenz . healed lesions over the back after treatment two years prior , the patient was diagnosed to have nhl stage iv , of the anal canal . immunohistochemistry showed features of plasmablastic lymphoma , neoplastic cells expressing mum-1 , cd138 , cd56 ( focal ) and ki-67 ( 80% ) . he was treated with external beam radiation therapy at a dose of 40 gy in 20 fractions to the pelvic bone and 3d conformal radiotherapy to the lung lesions . patient was also treated with two cycles of chemotherapy with cyclophosphamide , vincristine and prednisolone . a wholebody positron emission tomography scan showed multiple bone lesions destroying the pelvic bone with soft tissue lesions in the lungs and adrenal glands , suggesting secondary metastasis . there were also new lesions in the calvaria and left hilar lymph nodes , suggestive of progressive disease . the patient was advised admission to the oncology department for further management of his nhl and discharged on art . he was followed up by the medicosocial worker for one month and found to tolerate the new art regimen well . recent advances in treatment and modified lifestyle have prolonged the life span of hiv infected patients . but adverse drug reactions to art continue to be a matter of concern , as they inflict significant morbidity and mortality . in our case , the patient suffered severe cutaneous adverse reaction to nevirapine , whose course and morphology varied from maculopapular rash to targetoid lesions , to extensive erosions of the skin , leading to ten along with hepatotoxicity and leucopenia . in a study conducted by euroscar study group on 246 sjs - ten patients , 18 were hiv positive of whom 15 were on nevirapine . therefore , treating physicians need to keep in mind the risk of life - threatening cutaneous reactions while prescribing nevirapine - based art regimens . further , our patient had nhl as a comorbidity , which must have contributed to the severity of ten by compounding the profound immunosuppression of hiv . there have been comparative studies on the severity of ten among hiv patients with and without comorbid malignancies . there has not been any conclusive data whether the former has any increased risk of mortality as compared to the latter . thus all the known adverse reactions of nevirapine were present in our patient , which has been rarely reported . several reports on the hepatotoxicity due to nevirapine show that the abnormalities of liver function tests are reversible upon discontinuation of the drug . this happened in our patient too where the liver enzyme levels normalized four weeks after discontinuation of nevirapine . though ten is associated with severe morbidity and mortality , close observation , timely intervention with meticulous nursing care and support could prevent a fatal outcome in our patient . thus , managing hiv infection is a double edged sword the benefits of art have to balanced against the risks of drug toxicity . a strict vigil during the initial two months of an art regimen is mandatory to prevent such serious life - threatening reactions .
nevirapine , a non - nucleoside reverse transcriptase inhibitor ( nnrti ) is one of the important components of highly active antiretroviral therapy . 
 it is sometimes associated with life - threatening adverse reactions . here 
 we report one such patient who developed toxic epidermal necrolysis ( ten ) , leucopenia and hepatotoxicity secondary to intake of nevirapine . 
 this patient was also diagnosed to have non - hodgkin lymphoma grade iv of anal canal for which he was given radiotherapy and two cycles of chemotherapy . 
 the treating physicians should carefully monitor patients on nnrti - based antiretroviral therapy so that fatalities due to adverse drug reactions can be prevented with timely intervention .