Case presentation

A 35-year-old male patient with a history of HIV infection, hypertension, amphetamine use, and recent abdominal liposuction presented to the emergency department after intentional ingestion of approximately 90 tablets of Genvoya in a suicide attempt related to psychosocial stressors associated with an ongoing divorce. The patient denied additional co-ingestions. Initial urine toxicology screening was positive for amphetamines. On arrival, the patient was awake, alert, and asymptomatic.

Initial vital signs demonstrated temperature 37°C, heart rate 72 beats per minute, respiratory rate 18 breaths per minute, blood pressure 105/63 mmHg, and oxygen saturation 100% on room air. Physical examination was largely unremarkable aside from anxiety. Initial electrocardiography demonstrated accelerated junctional rhythm with left ventricular hypertrophy and repolarization abnormalities.

Repeat electrocardiography later demonstrated QTc prolongation greater than 480 milliseconds. Initial laboratory studies demonstrated creatinine 1.1 mg/dL, bicarbonate 18 mmol/L, mild hypokalemia, B-type natriuretic peptide (BNP) 113 pg/mL, creatine phosphokinase 445 U/L, and arterial pH 7.25. Pertinent laboratory and clinical findings are summarized in Table 1.

Investigation | Patient values | Reference values
Creatinine | 1.1 mg/dL (baseline 0.8) | 0.7–1.3 mg/dL
Bicarbonate | 18 mmol/L | 22–29 mmol/L
Arterial pH | 7.25 | 7.35–7.45
CPK | 445 U/L | 39–308 U/L
BNP | 113 pg/mL | <100 pg/mL
QTc interval | >480 ms | <450 ms
Ejection fraction | 25–35% | 55–70%
Respiratory support | HFNC required | Room air

Lactate remained within normal limits. Poison control recommended serial blood gas and lactic acid monitoring. Quantitative serum concentrations of EVG/COBI/FTC/TAF were not obtained. Therefore, the observed clinical deterioration could not be attributed to a specific component or definitively attributed to the ingestion alone. Over the following hours, the patient became progressively hypotensive with systolic blood pressures declining into the 60s, requiring initiation of norepinephrine infusion. He subsequently developed acute hypoxic respiratory failure requiring high-flow nasal cannula oxygen therapy. Computed tomography of the chest demonstrated pulmonary edema, periportal edema, and fluid overload. Representative chest computed tomography findings are shown in Figure 1.

Figure 1: Chest computed tomography obtained after onset of hypoxic respiratory failure, demonstrating bilateral interstitial pulmonary edema and volume overload.

Transthoracic echocardiography later demonstrated moderately dilated left ventricular cavity size with severely reduced systolic function and an estimated ejection fraction of 25-35%. Mild right ventricular systolic dysfunction and severe left atrial dilation were also noted. Representative transthoracic echocardiographic findings are shown in Figure 2.

Figure 2: Transthoracic echocardiogram obtained after hemodynamic deterioration, demonstrating a moderately dilated left ventricle with severely reduced systolic function (estimated ejection fraction 25%-35%).

Infectious workup, including respiratory viral panel, remained negative throughout admission. The patient was admitted to the medical intensive care unit for ongoing supportive management. Vasopressor support and oxygen supplementation were gradually weaned over the following days. The patient became medically stable by hospital day three, was transferred to inpatient psychiatry on hospital day four, and discharged from psychiatric care on hospital day seven. The patient's clinical course is summarized in Figure 3.

Figure 3: Clinical timeline showing initially stable presentation after large-volume EVG/COBI/FTC/TAF ingestion, followed by delayed hypotension requiring norepinephrine, acute hypoxic respiratory failure requiring high-flow nasal cannula, and subsequent clinical improvement with supportive care.QTc: corrected QT interval; HFNC: high-flow nasal cannula; EVG/COBI/FTC/TAF: elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide.