Gap Metabolic Acidosis Research Articles

A multidisciplinary approach to managing unusual complications following corrosive ingestion in a young adult: A case report

This case report presents the clinical management of a 24-year-old female patient who was presented to the emergency room with a history of corrosive ingestion. The patient experienced a complex clinical course involving cardiogenic shock, myocarditis, high anion -gap metabolic acidosis, esophagitis, and pulmonary complications. The issue at hand could not have been caused by only corrosive ingestion; it looked like a distinct matter involved. This case highlights the challenges in diagnosing and managing such cases and the importance of a multidisciplinary approach to optimize patient outcomes.

Mckittrick–Wheelock syndrome: an often, overlooked complication of rectal adenomas

One [1] rare but serious complication of rectal adenomas that is often overlooked is McKittrick–Wheelock syndrome (MKWS). The syndrome typically incorporates the signs and symptoms secondary to the accentuated secretion of fluids from a rectal villous adenoma. For instance, Barendse et al. [2] recently reported two cases, both of whom presented with renal failure and were later found to have giant rectal adenomas. The rectal adenomas usually measure greater than 4 cm in size. The typical triad of MKWS includes renal failure and electrolytic imbalance in the setting of chronic diarrhea due to an underlying villous adenoma [3]. The larger and more distal the adenoma, the more severe the syndrome. The hypersecretion may be so severe that severe azotemia may result [4]. The syndrome is a secondary to accentuated secretion of PG-E2 by the rectal adenoma. Hypokalemia and hyponatremia are frequently seen. Altered mental status may occur in severe cases of MKWS [5]. Oliguria is usually present. Profuse mucous diarrhea is typical. Severe rhabdomyolysis may also occur. Severe cases may progress to hypokalemic and hypochloremic ‘high anion’ gap metabolic acidosis. Rarely, colonic-pseudo obstruction may occur as recently reported by Wakeman [6]. Immediate and aggressive replacement of fluids and electrolytes is deemed necessary once the diagnosis of MKWS is made [7]. The renal failure usually improves following endoscopic mucosal resection of the rectal adenoma [8]. Choi et al. [9] recently reported the successful use of laparoscopic low anterior surgical resection. The cyclooxygenase inhibitor indomethacin is also of some value in the management of MKWS. MKWS needs to be treated as soon as diagnosis is made, as cardiac arrhythmias may result, which may result in significant mortality. There is a need to increase awareness about MKWS amongst physicians, especially surgeons.

Metabolic Acidosis with a Raised Anion Gap Associated with High 5-Oxoproline Levels; An Under-Recognized Cause for Metabolic Acidosis in Intensive Care

Metabolic acidosis is a common problem in ICU patients. Frequent causes of metabolic acidosis with a raised anion gap include lactic acidosis and ketoacidosis. In recent years high anion gap acidosis due to acquired 5- oxoprolinuria has been reported in association with chronic paracetamol use 1. There have been occasional reports of acidosis due to 5-oxoproline in an ICU setting 2 but to date there does not seem to be a general awareness of this phenomonen. 5-oxoproline is an amino acid derivative within the γ-glutamyl cycle within the liver, When gluathione stores are depleted γ-glutamycycteine synthase activity increases in an attempt to replenish the glutathione stores. However in the process excess glutamylcycteine is produced which is then converted into 5-oxoproline which can accumulate and cause a metabolic acidosis. We present a case series of unexplained high anion gap metabolic acidoses in ICU associated with an acculumation of 5-oxoproline. These patients had a background history of alcohol abuse and/or malnutrition and had received paracetamol 4 g/day over periods of 2-3 weeks in ICU. Urinary 5-oxoproline levels were tested and were found to be abnormally high. In all these cases cessation of the paracetamol resulted in correction of the acidosis. It is likely that a combination of predisposing factors and prolonged paracetamol treatment resulted in depletion of glutathione stores in these patients. ICU patients may have risk factors for depletion of glutathione stores. Prolonged use of paracetamol in these patients can further deplete gluathione and introduce the risk of developing metabolic acidosis due to 5-oxoproline.

Congenital Annular Erythema in Two Newborns: Similar Morphology, Divergent Etiologies

The inconsistent use of the term “erythema annulare centrifugum” has created confusion, in that it has been applied to a group of distinct diseases as if they were a single condition. The literature becomes more ambiguous when different names are given to annular eruptions that have a similar pathogenesis. We present two neonates who presented at birth with similar diffuse erythematous annular eruptions, but differed in their serologic and histopathologic findings. The first child was otherwise healthy and had normal laboratories findings that excluded both infectious and autoimmune diseases. His biopsy showed a perivascular and interstitial infiltrate throughout the entire dermis that was composed of lymphocytes, histiocytes and numerous eosinophils. The second neonate had elevated anti‐Ro and anti‐La antibodies, thrombocytopenia and a non‐anion gap metabolic acidosis. His biopsy showed focal vacuolar degeneration of the basal layer. There was a perivascular and interstitial infiltrate that extended throughout the dermis which consisted primarily of nuclear debris. Within the cytoplasm of the few intact histiocytes and neutrophils, were hematoxylin bodies, giving these cells the appearance of LE cells. We discuss the clinical and histopathological findings in these two neonates and attempt to clarify the nomenclature pertaining to the annular erythemas.