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Case 5: Antiretroviral Medications and Lactic Acidemia

You answered:

C The patient’s symptoms are consistent with lactic acidemia. If the diagnosis of lactic acidemia is established and it is severe, the most important measure is to immediately prescribe riboflavin.

This answer is incorrect. Indeed the patient’s symptoms strongly suggest lactic acidemia, but the most important aspect of management of severe lactic acidemia is to discontinue the offending drugs, which in this case would be stavudine and didanosine. The patient should also stop all other antiretroviral medications to avoid development of resistance. Although riboflavin could theoretically provide benefit in this situation, its role in the management of lactic acidemia remains unproven.

A The patient’s symptoms are consistent with lactic acidemia, but the normal serum bicarbonate level and normal anion gap effectively rules out lactic acidemia as a diagnosis.
B The patient's symptoms are consistent with lactic acidemia and a serum lactate level should be obtained to establish the diagnosis of lactic acidemia. The likely drugs responsible are stavudine and didanosine.
D The patient’s symptoms are not consistent with lactic acidemia and further laboratory evaluation is not required. Didanosine-induced adrenal insufficiency is a much more likely diagnosis.

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