Delayed Multisystem Deterioration Following Large-Volume Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide Overdose

Genvoya is a fixed-dose antiretroviral medication commonly used in the treatment of human immunodeficiency virus (HIV) infection and is generally well tolerated. Severe toxicity following Genvoya overdose has not been well described, and currently available reports generally describe mild clinical courses managed with supportive care alone. We present the case of a 35-year-old male with HIV, hypertension, and amphetamine use who presented after intentional ingestion of approximately 90 tablets of Genvoya in a suicide attempt. He was initially awake, alert, and hemodynamically stable. Over the next 24 hours, however, he developed distributive shock requiring vasopressor support, acute hypoxic respiratory failure requiring high-flow nasal cannula oxygen therapy, metabolic acidosis, QTc prolongation, mild acute kidney injury, and newly reduced systolic cardiac function with an estimated ejection fraction of 25-35%. Chest imaging demonstrated pulmonary edema and volume overload. Infectious workup remained negative throughout admission. The patient was managed with supportive care in the medical intensive care unit and gradually improved over the following days. This case adds to the limited literature describing severe multisystem complications following large-volume Genvoya overdose.