Multiogran failure in the course of metformin- associated lactic acidosis precipitated by acute hepatitis A infection: a case report

Multiogran failure in the course of metformin- associated lactic acidosis precipitated by acute hepatitis A infection: a case report

Metformin-associated lactic acidosis (MALA) is a rare but severe disorder, occurring primarily in patients with hepatic or renal impairment in the presence of additional triggers such as infection or toxaemia. A 69-year-old male with a history of type 2 diabetes mellitus, hypertension, and ischemic heart disease, without prior renal or hepatic impairment, presented to the Emergency Department with general malaise and progressive dyspnoea. Two weeks earlier, he had been treated with ciprofloxacin for otitis externa. His condition rapidly deteriorated, and he was admitted to the Intensive Care Unit with multiorgan failure. Laboratory evaluation revealed severe lactic acidosis with profound metabolic acidosis, acute kidney injury, and markedly elevated liver transaminases, consistent with metformin-associated lactic acidosis (MALA). Despite relatively low C-reactive protein levels, procalcitonin was markedly elevated. The patient required mechanical ventilation, vasopressor support, and continuous renal replacement therapy (CRRT). Extensive diagnostic work-up, including blood cultures, bronchoscopy with bronchoalveolar lavage, and viral testing for HBV and HCV, yielded negative results. Following intensive supportive therapy, the patient’s clinical condition gradually improved. Subsequent detailed history-taking and extended serological evaluation revealed acute hepatitis A, confirmed by positive anti-HAV IgM antibodies. The patient reported consumption of fermented shark meat (“hákarl”) during travel to Greenland approximately four weeks prior to admission, followed by transient gastrointestinal symptoms. Acute viral hepatitis was therefore considered a precipitating factor contributing to impaired metformin clearance and the development of severe lactic acidosis with multiorgan failure. MALA is a severe complication that can be potentially reversed with immediate intervention. In this case, the patient recovered without persistent renal or liver damage, underscoring the importance of a thorough medical history and rapid diagnosis.
(POL NEPHROL DIAL 2025; 29: 138-142)

J. Tambor, M. Nowicka, A. Zawiasa-Bryszewska, I. Kurnatowska