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4 Responses to “M184V: So many options, but does that include TDF/FTC/EFV?”
Paul E. Sax, MD
Associate Editor
NEJM Clinician
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FROM NEJM — Recent Infectious Disease Articles- Scrofuloderma August 29, 2026A 72-year-old man presented with a 2-month history of a painful lump on his neck. Cytologic analysis of fine-needle aspirate was consistent with suppurative lymphadenopathy. The lesion subsequently ulcerated and released purulent discharge.
- Response-Tailored or Standard-Duration Antibiotic Treatment for Infective Endocarditis August 28, 2026Among adults with endocarditis caused by S. aureus, E. faecalis, or streptococcus species, tailored-duration antibiotic therapy led to 13 more days alive without antibiotics than standard therapy, but with a higher incidence of relapse.
- Severe Plasmodium falciparum Malaria August 20, 2026An 82-year-old man was brought to the ED after being “found down.” One week earlier, he had returned from a 1-month visit to Chad. A peripheral-blood smear showed ring-form trophozoites within erythrocytes.
- Case 24-2026: A 74-Year-Old Man with Dyspnea, Proximal Muscle Weakness, and Hypoxemia August 20, 2026A 74-year-old man with myasthenia gravis was evaluated for dyspnea, proximal muscle weakness, hypoxemia, and a painful tongue lesion. Medications included prednisone and mycophenolate mofetil. A diagnosis was made.
- A Regional Measles Outbreak — South Carolina, 2025–2026 August 13, 2026In South Carolina, 997 measles cases occurred in the reported outbreak. In one health care system, 81 cases were identified. Most were in unvaccinated persons; 13 persons were hospitalized, and 2 had measles encephalitis.
- Scrofuloderma August 29, 2026
What about treating her once daily with Atripla + Ziagen —
Would adding abacavir give her the necessary “third drug” in this case and allow her to use Atripla as she desires?
Would the 184V affect the efficacy of the abacavir too much to make it worthwhile?
I would check the hl b 5701 and the trofle assay. If the b 5701 was negative, I would offer her atripla and ziagen. If positive, I would explore twice-daily regimens with her, including isentress, intelence and selzentry as possibilities.
I like Dr. Gallant’s response of ritonavir-boosted PI with tenofovir/FTC even with the M184V. However, instead of a “two-drug regimen,” I would call it a “two and 1/2 drug regimen,” and it makes a lot of sense to me. Perhaps more patients could benefit from this simple regimen.
I would urge the patient to restart therapy using a boosted protease inhibitor based regimen that would be simple (once a day) and relatively fat friendly (such as ritonavir/fosamprenavir or ritonavir/atazanavir or ritonavir/darunavir + Truvada or Epzicom -the latter if HLA B5701 negative). I would be tempted (if the patient was willing) to initially recommend use of another agent (such as raltegravir) to rapidly suppress HIV RNA levels to the detection level and then stop it out of concern about the presence of more extensive NRTI resistance than detected by the genotypic results available and not wanting to use potential monotherapy (just a boosted PI) in a treatment experienced patient with underlying NRTI resistance.