A 20-year-old HIV infected male with a baseline CD4 count of 17 cells/mm3 was referred with cholestatic jaundice. He had recently commenced a fixed dose combination of emtricitabine, tenofovir DF, and efavirenz and was well prior to initiating ART. He developed jaundice two weeks after initiating these drugs. The ART drugs were discontinued by the referring physician as drug induced liver injury was suspected. He was asymptomatic prior to initiating ART. On examination he was emaciated, had yellow sclera and pale conjunctiva, and had a liver span of 18 cm and splenomegaly measuring 5 cm below the costal margin.
His baseline and follow-up blood investigations are shown in Table 1. Hepatitis A, B, and C serologies were negative. The chest radiograph was normal. Ultrasound of the abdomen showed an enlarged "fatty" liver and splenic hypodensities suggestive of granulomas.
The liver ultrasound failed to detect biliary obstruction and a liver biopsy was undertaken to rule out an infiltrative cause of the cholestatic jaundice such as mycobacterial, fungal, or nonbenign infiltration. A gastroscope was performed to investigate the normocytic, normochromic anaemia, and the suspicious lesions noted at gastroscopy were biopsied. In view of the bicytopenia and the absence of a plausible cause, a bone marrow aspiration and biopsy were also performed. The liver biopsy showed multiple acid fast bacilli; however the SD Bioline MPT64 TB Antigen Rapid was negative.
The duodenal biopsy and bone marrow trephine biopsy also showed AFBs. The TB culture was negative for mycobacteria tuberculosis, and microscopy was suggestive of Mycobacteria avium complex; however polymerase chain reaction was unable to identify the species.  Figure 1 shows clumping of acid fast bacilli seen in the liver biopsy sample.  Figure 2 shows a poorly formed granuloma commonly seen in nontuberculous mycobacteria infection.
He was commenced on rifampicin, isoniazid, ethambutol, pyrazinamide, and clarithromycin because a definitive microbiological diagnosis of TB or NTM was difficult to attain. After a two-month period of treatment, the patient showed significant clinical improvement.
The baseline HIV viral load was not done; however his viral load at 2 weeks of ART and following discontinuation of the drug for suspected drug induced hepatitis was 227 226 copies/mL. A HIV viral load, after 5 months of antiretrovirals, in June 2014 was 756 copies/mL.