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Metabolic Acidosis in a Woman With Stable HIV/AIDS

Metabolic Acidosis in a Woman With Stable HIV/AIDS

An asymptomatic 42-year-old woman who has HIV/AIDS presents for a routine check-up. She denies abdominal pain, nausea, vomiting, diarrhea, paresthesias, and muscle weakness. HISTORY
Her most recent CD4+ cell count was 298/L, and her viral load was less than 50 copies/mL. Her medications include didanosine, stavudine, nelfinavir, and trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jiroveci (formerly Pneumocystis carinii) prophylaxis. PHYSICAL EXAMINATION
Vital signs are stable, and the results of a physical examination are normal. LABORATORY RESULTS
Sodium level is 136 mEq/L; potassium, 3.9 mEq/L; chloride, 102 mEq/L; and bicarbonate, 13 mEq/L. Blood urea nitrogen level is 15 mg/dL; serum creatinine, 1.1 mg/dL; and blood glucose, 85 mg/dL. Aspartate aminotransferase level is 32 U/L; alanine aminotransferase, 19 U/L. The anion gap is 21 mEq/L. To evaluate the anion gap elevation, the venous lactate level is measured; the result is 79.1 mg/dL (8.78 mmol/L) (normal, 3 to 12 mg/dL [0.33 to 1.33 mmol/L]). Which of the following is the most likely cause of this patient's metabolic acidosis?
A. Type B lactic acidosis secondary to nucleoside reverse transcriptase inhibitor (NRTI) therapy.
B. Infection caused by P jiroveci or other organisms.
C. Metabolic abnormalities related to hepatic dysfunction.
D. Renal insufficiency.

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