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Fatal lactic acidosis and unmasking of previously undiagnosed pulmonary arterial hypertension: case report A 30-year-old woman developed fatal lactic acidosis (LA) and unmasking of previously undiagnosed pulmonary arterial hypertension during treatment with emtricitabine/tenofovir for HIV. The woman, who had HIV, presented 5 days postpartum with worsening dyspnoea on exertion and fatigue. She had been receiving daily darunavir, emtricitabine/tenofovir [route and dosage not stated], raltegravir and ritonavir. Her pre-partum and immediate postpartum course was unremarkable. Physical examination showed tachycardia and pulse oximetry of 98% on 2 L/minute oxygen through a nasal cannula. Laboratory values revealed significant anion gap acidosis with lactic acid levels of 2.2 mmol/L, and mild transaminitis [duration of treatment to reactions onsets not stated]. Echocardiogram showed increased right ventricular pressure with normal left ventricular function. After CAT angiography and ventilator/perfusion scan, pulmonary embolism was ruled out. Right heart catheterisation showed wedge pressure of 10mm Hg and mean pulmonary artery pressure of 80mm Hg. She was diagnosed with pulmonary arterial hypertension. However, transaminitis and lactic acidosis continued to worsen throughout the period of hospitalisation, with lactic acid levels elevating to 8 mmol/L, accompanied by the development of acute renal failure. She exhibited worsening metabolic acidosis with compensatory respiratory alkalosis and near normal oxygenation. The woman was transferred to the higher level of care and was intubated due to increased work of breathing. After intubation, she suffered a cardiac arrest and died following an unsuccessful resuscitation attempt. Pregnancy and female gender were considered as risk factors for development of lactic acidosis secondary to nucleoside reverse transcriptase inhibitor (NRTI). She had an unremarkable peri-partum course prior to the presentation. It was hypothesised that tenofovir (NRTI) might have contributed to the metabolic derangements with post-partum haemodynamic changes leading to unmasking of previously undiagnosed pulmonary arterial hypertension. Sagaslli A, et al. Fatal case of lactic acidosis in a post-partum HIV patient on nucleoside reverse transcriptase inhibitor with new diagnosis of pulmonary arterial hypertension. American Journal of Respiratory and Critical Care Medicine 199: (plus poster) abstr. A4812, No. 9, May 2019. Available from: URL: http://doi.org/10.1164/ajrccm803446491 conference.2019.199.1_MeetingAbstracts.A4812 [abstract]

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Reactions 18 Jan 2020 No. 1787