Nucleoside Reverse Transcriptase Inhibitor Associated Lactic Acidosis and Delayed Intubation Daria Falkowitz DO1,2, Benjamin Kessler MD 1,2, Nima Majlesi DO2 1Department of Emergency Medicine, Division of Toxicology, North Shore University Hospital, Manhasset, New York 2Departtment of Emergency Medicine, Staten Island University Hospital, Staten Island, New York INTRODUCTION DISCUSSION

• Treatment of HIV consists of a regimen with multiple classes of • This is one of the only cases reported in which severe metabolic medications. acidosis was delayed, despite a profoundly elevated lactate STAVUDINE STRUCTURE concentration with therapeutic NRTI use. • Nucleoside reverse transcriptase inhibitors (NRTI) are among the first line of treatment. • Clinicians should not be reassured by minimal initial changes in blood pH or clinical symptoms. • Toxicity after an acute NRTI overdose causes acidemia and elevated lactate concentration due to decreased production of human DNA • Patients can develop profound acidemia, may have a prolonged electron transport proteins and inhibition of oxidative phosphorylation. clinical course, and mortality is between 33-57%.

• We present an unusual case of delayed acidemia and clinical • It has been demonstrated that L-carnitine, thiamine, vitamin C and deterioration despite initial severely elevated lactate and minimal riboflavin may accelerate resolution of the acidosis. symptoms. • Life threatening acidemia can be delayed despite early elevated lactate concentration in therapeutic use of NRTI. Clinicians should CASE be aware of this complication and adjunctive treatments.

• 38-year-old female with HIV, and dyslipidemia presented for 10 days of bilateral leg pain treated as cellulitis with clindamycin. REFERENCES

• Home medications included stavudine, darunavir, ritonavir, raltegravir, atorvastatin, aspirin, iron, and vitamins. • Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014;10(1):26-39. • Blood pressure was 128/75 mmHg, heart rate 105 bpm, and she was afebrile. PROPOSED MECHANISM • Dragovic G, Jevtovic D. The role of nucleoside reverse • Exam: lower extremities were diffusely tender without edema, warmth, transcriptase inhibitors usage in the incidence of hyperlactatemia crepitus or skin lesions. and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012;66(4):308-11. • Labs : pH was 7.31 with pCO2 of 32 mm/Hg, lactate was 7.4 mmol/L. • Pedrol E, Ribell M, Deig E, et al. [Treatment of symptomatic • Her electrolytes, renal function and CBC were normal. Intravenous hyperlactatemia and lactic acidosis in HIV+ patients under saline was administered and repeat lactate was 5.9 mmol/L. nucleoside reverse transcriptase inhibitors]. Med Clin (Barc). 2005;125(6):201-4. • Vascular studies showed no evidence of lower extremity ischemia.

• The patient was started on thiamine, carnitine, multivitamins, and For more information contact Daria Falkowitz @ [email protected]. admitted to the ICU.

• On hospital day 6 she developed respiratory failure requiring mechanical ventilation coinciding with her pH nadir of 7.06 and lactate peak of 7.8mmol/L.

• Vitamin therapy and supportive care were continued and she was extubated on hospital day 10. She was discharged on hospital day 16 without an NRTI.