Fatal Tenofovir-Associateacd Lactic Acidosis: A Case Report

Abstract

Introduction:The introduction of highly active antiretroviral therapy (HAART), in 1996, has resulted in marked reductions in the rate of illness and death, due to HIV infection. The HAART has transformed HIV infection into a manageable chronic disease. However, although many regimens lower plasma viral load, to below the limit of detection, in most patients, maintaining viral load suppression remains challenging, because of adverse effects and toxicity in the long term, which can lead to non-adherence, virologic failure and drug resistance. Although rare, lactic acidosis often develops fatal complications, as reported in several human immunodeficiency virus infected patients treated with nucleoside reverse transcriptase inhibitors (NRTIs). The purpose of this paper is to report a case of tenofovir induced lactic acidosis and review the literature.Case Presentation:A 52-year-old Malay gentleman, with hepatitis C virus and HIV infection was admitted to the intensive care unit for severe lactic acidosis, with concurrent Escherichia coli bacteremia with multiorgan dysfunction. The patient was started on highly active antiretroviral therapy, which included tenofovir, 5 weeks before presentation. Antimicrobial therapy, continuous veno-venous hemofiltration, and other supportive treatments were instituted. However, the patient eventually succumbed to his illness.Conclusions:It is essential for clinicians to be able to recognize the signs and symptoms of lactic acidosis in NRTIs treated HIV patients, as an early diagnosis is important to institute treatment.

Tenofovir Induced Hepatitis

“…(5) In another case reported by Hashim et al, there was underlying HCV infection, E. coli bacteraemia and hypotensive episodes. (6) Contrary to this in the present case, none of the identifiable risk factors were present and patient's baseline investigations were all normal.…”

Tenofovir alafenamide associated fatal lactic acidosis in an autologous hematopoietic stem cell transplant recipient

“…The combination of antiretroviral medications might have made those patients more prone to developing mitochondrial dysfunction & lactic acidosis. We also found a single case report of a patient infected with HCV & HIV on tenofovir, emtricitabine, and efavirenz developing fatal lactic acidosis . Last, there currently is a single case report in the literature of fatal lactic acidosis in a patient with chronic HBV treated with single‐drug agent TDF .…”

Recurrent Anion Gap Metabolic Acidosis

“…The etiology of NALA involved mitochondrial toxicity, leading to impairment of mitochondrial aerobic metabolism and accumulation of lactic acid. The incidence of NALA is around 1% and it generally develops between 1 to 20 months after initiation of highly active antiretroviral therapy [13]. Given the timeline and recurrent nature, NALA although unlikely in our patient’s case, could be contributing or triggering to the underlying acidosis.…”

“…Of note, our patient had been taking tenofovir for the past fifteen years. There has been reported cases of nucleoside reverse transcriptase inhibitors (NRTIs) associated lactic acidosis (NALA) [13,14]. The etiology of NALA involved mitochondrial toxicity, leading to impairment of mitochondrial aerobic metabolism and accumulation of lactic acid.…”