Introduction

Genvoya is a fixed-dose antiretroviral regimen containing elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (EVG/COBI/FTC/TAF) used for the treatment of human immunodeficiency virus (HIV) infection. Although generally well tolerated at therapeutic doses, its four pharmacologically distinct components create uncertainty when substantial overdose occurs, particularly because cobicistat can alter drug metabolism through CYP3A inhibition [1]. Published reports of EVG/COBI/FTC/TAF self-poisoning remain limited and have generally described mild or predominantly metabolic abnormalities managed with supportive care [2].

The risk of delayed cardiopulmonary deterioration after large-volume EVG/COBI/FTC/TAF ingestion is therefore poorly defined. This is clinically important because patients may initially appear well despite subsequent development of hemodynamic instability, respiratory failure, or cardiac dysfunction. In addition, coexisting factors, including stimulant exposure and underlying HIV-associated cardiac disease, may complicate attribution of toxicity when drug concentrations and baseline cardiac imaging are unavailable [3-5].

We report a patient who was initially clinically stable after intentional ingestion of approximately 90 tablets of EVG/COBI/FTC/TAF but developed delayed shock requiring vasopressor support, acute hypoxic respiratory failure, metabolic acidosis, corrected QT interval (QTc) prolongation, and newly recognized severe left ventricular systolic dysfunction. This case expands the reported spectrum of EVG/COBI/FTC/TAF overdose and supports close, prolonged observation after large-volume ingestion, even when the initial presentation is reassuring.