Chaparala Swethapriya, Da Silva Rafael C, Papadopoulos John Paul
Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA.
Cureus. 2021 Oct 24;13(10):e19008. doi: 10.7759/cureus.19008. eCollection 2021 Oct.
A 46-year-old female with a history of generalized anxiety disorder was admitted after intentional ingestion of an unknown amount of emtricitabine/tenofovir alafenamide (Descovy®) in a suicidal attempt. Patient was emergently intubated secondary to severe agitation and inability to protect airways. Patient developed severe lactic acidosis early in the admission, secondary as to a possible mitochondrial toxicity. Failed attempts to fluid resuscitation with Lactate Ringer®, eventually warranted to start the patient on norepinephrine infusion. Metabolic acidosis remained refractory to bicarbonate bolus and infusion. Hypothermia and hypoglycemia were corrected. Despite the initial approach, the patient remained acidotic, and the nephrology was consulted for emergent continuous renal replacement therapy (CRRT). After three days of intensive care unit stay and CRRT, the patient improved and was successfully decannulated. Her metabolic profile also showed remarkable improvement and the metabolic lactic acidosis resolved. The previous formulation of tenofovir with disoproxil fumarate is associated with severe lactic acidosis due to inhibition of mammalian mitochondrial DNA polymerase. Risk factors include liver cirrhosis, chronic kidney disease, hepatitis B and C coinfection, and metformin use. The new pharmaceutical formulation of tenofovir with alafenamide (TAF) has caused a significant decrease in the incidence of lactic acidosis. However, its real incidence and the usual plasma level to induce toxicity and mitochondrial dysfunction are unknown. The aim of this report is to highlight the risk of severe lactic acidosis with the use of TAF.
一名有广泛性焦虑症病史的46岁女性，因企图自杀故意摄入未知量的恩曲他滨/替诺福韦艾拉酚胺（Descovy®）后入院。患者因严重躁动和无法保护气道而紧急插管。患者入院早期出现严重乳酸酸中毒，可能继发于线粒体毒性。使用乳酸林格氏液进行液体复苏失败，最终不得不开始给患者输注去甲肾上腺素。代谢性酸中毒对碳酸氢盐推注和输注仍无反应。体温过低和低血糖得到纠正。尽管采取了初始治疗方法，患者仍处于酸中毒状态，于是咨询肾病科进行紧急连续性肾脏替代治疗（CRRT）。在重症监护病房住院并进行CRRT三天后，患者病情好转并成功拔管。她的代谢指标也有显著改善，代谢性乳酸酸中毒得到缓解。以前的替诺福韦富马酸替诺福韦酯制剂因抑制哺乳动物线粒体DNA聚合酶而与严重乳酸酸中毒有关。危险因素包括肝硬化、慢性肾病、乙肝和丙肝合并感染以及使用二甲双胍。新的替诺福韦艾拉酚胺（TAF）药物制剂使乳酸酸中毒的发生率显著降低。然而，其实际发生率以及诱导毒性和线粒体功能障碍的通常血浆水平尚不清楚。本报告的目的是强调使用TAF导致严重乳酸酸中毒的风险。
