S3621 Imaging Finding as a Clue for Accidental Salicylate Toxicity

Abstract

Introduction: The rise of acetaminophen use as an antipyretic in children dramatically decreased the incidence of salicylate toxicity in children. However, it is still relatively common in adults and usually overlooked by physicians especially in elderly patients due to non-specific presentation and unawareness of salicylate-containing medications. We present a case of salicylate toxicity secondary to Pepto-Bismol abuse. Suspicion was raised after a radiopaque density was found in a non-contrast CT abdomen. Case Description/Methods: A 62-years-old female with a history of compensated heart failure, COPD, and hypertension presented with lethargy, diaphoresis, and epigastric pain. The pain was associated with nausea and occasional vomiting. Vital signs showed HR 105, BP 110/60, RR 18, and oxygen saturation of 94 % on ambient air. Physical exam was remarkable for scattered mild expiratory wheezes. Lab results were significant for high anion gap metabolic acidosis with HCO3 16 mmol/L, Creatinine 1.4 mg/dL, and BUN 30 mg/dL. Non-contrast CT abdomen showed a contrast material in the stomach (Figure). Further history was then taken from the patient who reported ingestion of around 60 tablets of Pepto-Bismol over the last 48 hours trying to relieve her stomach pain. Salicylate toxicity was then suspected, and the salicylate level was checked and it was 26 mg/dl. The patient was then treated with activated charcoal and supportive IV fluids. The patient’s symptoms were resolved and she was discharged home. Discussion: Diagnosis of salicylate toxicity is challenging, specifically in the elderly with the non-specific presentation. In addition, salicylate is an ingredient of many over-the-counter (OTC) medications, that many physicians are not aware of, such as Alka-seltzer, Bufferin, Vanquish, Pepto-Bismol, etc. Our patient had salicylate toxicity after ingestion of around 60 tablets of Pepto-Bismol. Suspicion was raised after finding a picture of oral contrast in the patient’s stomach in a non-contrast study. Pepto-Bismol (bismuth subsalicylate) can appear as a contrast on imaging due to the hyperdense property of the bismuth ingredient. The property of this medicine should be taken into consideration. Otherwise, such incidental findings can be missed as a clue for a certain condition (as in our patient) or lead to unnecessary workup, patient anxiety, and waste of resources in other situations. Our case also demonstrates the importance of taking a thorough history including OTC medications.Figure 1.: Non-contrast CT abdomen shows a picture similar to contrast material secondary to Pepto Bismol ingestion.