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Browse ATS 2021 Abstracts

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ATS 2021 will feature presentations of original research from accepted abstracts. Mini Symposia and Thematic Poster Sessions are abstract based sessions.

Please use the form below to browse scientific abstracts and case reports accepted for ATS 2021. Abstracts presented at the ATS 2021 will be published in the Online Abstract Issue of the American Journal of Respiratory and Critical Care Medicine, Volume 203, May 3, 2021.

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Fanconi Syndrome with Multi-Organ Failure Secondary to Tenofovir Use in Chronic Hepatitis B

Session Title
TP57 - TP057 NON-PULMONARY CRITICAL CARE CASE REPORTS
Abstract
A2919 - Fanconi Syndrome with Multi-Organ Failure Secondary to Tenofovir Use in Chronic Hepatitis B
Author Block: T. N. Anderson1, E. W. Green2, M. H. Taylor3, L. M. Benson4, S. P. Giovanni4; 1Oregon Health & Science University, Portland, OR, United States, 2Internal Medicine, Oregon Health & Science University, Portland, OR, United States, 3Nephrology, Oregon Health & Science University, Portland, OR, United States, 4Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, United States.
Introduction
Fanconi syndrome is a rare, but known side effect of tenofovir, a nucleoside reverse transcriptase inhibitor used in the treatment of HIV and hepatitis B infections. This clinical phenomenon is characterized by proximal tubular wasting of protein, glucose, electrolytes, and bicarbonate leading to a profound non-gap metabolic acidosis.
Case Description
A 76-year-old Vietnamese woman with a history of chronic hepatitis B on tenofovir presented to her physician with two weeks of cloudy urine and bilateral lower extremity edema. Urine culture was positive for Escherichia coli, and she was subsequently treated with furosemide for the edema and ciprofloxacin for presumed cystitis. Over the next week, she developed malaise, nausea, vomiting, and altered mental status, prompting presentation to the emergency department. Exam on arrival was notable for hypothermia (31.3°C) and profound encephalopathy. Laboratory evaluation demonstrated pancytopenia (WBC 1.83 K/mm3, RBC 1.78 M/mm3, platelets 36 K/mm3), severe electrolyte disturbances, and mixed gap metabolic acidosis with relative hyperchloremia (Figure 1). Urine studies were notable for proteinuria (4146 mg/dl) and euglycemic glycosuria (≥500 mg/dl). Head CT was unremarkable, and an abdominal CT triggered by elevated lipase demonstrated peri-pancreatic fat stranding and acute-on-chronic iliac wing and vertebral fractures. On hospital day 1, the patient developed intermittent episodes of sinus arrest necessitating temporary transcutaneous and transvenous pacing that resolved with aggressive electrolyte correction; however, bicarbonate wasting persisted, warranting initiation of continuous renal replacement therapy (CRRT) on hospital day 8. The patient subsequently developed hypoxemic respiratory failure due to an aspiration event requiring intubation and mechanical ventilation. Course was further complicated by development of Acute Respiratory Distress Syndrome (ARDS), further reducing respiratory compensation. The patient was ultimately transitioned to comfort care and passed away on hospital day 28. After an extensive infectious, toxic, hematologic, and neoplastic workup with no contributory findings, her clinical presentation was ultimately attributed to proximal tubular acidosis of Fanconi syndrome secondary to chronic use of tenofovir, which was discontinued on day 3 of hospitalization.
Discussion
This case illustrates a complex clinical presentation of tenofovir-associated Fanconi syndrome requiring intensive care management and renal replacement therapy, not previously described in the literature. The constellation of mixed gap metabolic acidosis, pancytopenia, and multiorgan dysfunction observed in this patient should be recognized as a severe manifestation of this phenomenon. This case highlights the importance of thorough medication review and supports the use of CRRT as a treatment strategy for severe metabolic disturbances in Fanconi syndrome.