High Anion Gap Research Articles

Diabetic Ketoacidosis and COVID-19: A Retrospective Observational Study.

Background Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM), mainly type 1 DM. DM is one of the comorbidities recognized as the predictor of the severity in COVID-19-positive patients. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness (COVID-19) has a bidirectional association with DM. DM is a state of chronic inflammatory condition and hyperglycemia that predisposes one to acquire an exaggerated form of COVID-19 infection. Moreover, in recent literature, it has been established that SARS-CoV-2 is capable of directly damaging beta cells of the pancreas, thereby inducing new-onset diabetes in previously non-diabetics. Hence, new-onset diabetes and severe metabolic consequences of pre-existing diabetes, such as DKA, are seen in COVID-19-positive patients. DKA in patients with COVID-19 may increase the risk of mortality and lead to poor prognosis. Methods This retrospective observational study includes 25 patients who presented to our hospital with DKA secondary to COVID-19 infection as a triggering factor. Demographic parameters, medical history, physical examination, laboratory tests including reverse transcriptase polymerase chain reaction test (RT-PCR), chest X-ray, treatment administered, clinical course, and outcomes were recorded. All data were computed and analyzed using SPSS Version 22.0 (IBM Corp., Armonk, NY, USA). Results Of the 25 cases, 14 were females, and a statistically significant difference was seen in the values of blood sugar (367 mg/dL), D-dimer, ferritin, blood urea nitrogen(BUN), and anion gap among males and females (p < 0.050). The males had higher mean values of blood sugar (367 mg/dL), BUN (60.63 mg/dL), D-dimer (1.09 mcg/mL), and ferritin (821.23 mcg/mL) than females, whereas females had a higher anion gap (20.85) than males. A negative correlation was seen between D-dimer and the following biochemical investigations in COVID-19 patients: serum bicarbonate, anion gap, chloride, BUN, creatinine, sodium, potassium, magnesium, and phosphorous. COVID-19 can present with atypical symptoms in patients with high blood sugar levels. Diabetics are more likely to experience effects on multiple organs compared to non-diabetic patients who mainly have lung involvement. Hence, a high degree of suspicion is essential to diagnose DKA early in COVID-19 patients. Conclusion These cases show that DKA can be precipitated by COVID-19 in a significant number of patients and that the presence of diabetes can also exaggerate the underlying COVID-19 infection, a bidirectional relationship. All cases were COVID-19-positive presenting with features characteristic of DKA. SARS-CoV-2 was precipitating factor of DKA. Patients with newly diagnosed diabetes or pre-existing diabetes were equally susceptible to DKA. Due to the high prevalence of both illnesses (DM and COVID-19) in our country, a high level of suspicion is required to detect DKA early and improve the outcome of COVID-19-related life-threatening hyperglycemic consequences.

Radiology Findings in a Case of Acute Methanol Intoxication Complicated with Intracranial Hemorrhage

Aim: Methanol intoxication is rare and it can be fatal. This case report aimed to describe the radiological findings in acute methanol intoxication complicated with intracranial hemorrhage in a young patient. Case Report: A 32 year-old man applied to emergency department with a major complaints of nausea, vomiting, double vision, and confusion. Glascow coma score (GCS) was 7 at the initial referral. Laboratory tests showed high anion gap metabolic acidosis. Acute methanol intoxication was diagnosed by aid of the patient anamnesis. Diffusion-weighted MRI (DW-MRI) showed similar diffusion restriction lesions in the putamen and cingulate gyrus of both cerebral hemispheres. The patient had a cardiac arrest during follow-up in the emergency department. He was converted to sinus rhythm with the interventions, intubated, and taken to the intensive care unit. GCS reduced to 3 during follow- up at the 4th day. Cerebral intraparanchimal hemorrhage at the level of left basal ganglia was observed in the brain computed tomography (CT). He was operated however remained comatose after the operation and died at the 8th day of admission. Conclusion: Possibility of methanol intoxication should be included in the differential diagnosis in patients with altered consciousness, vision disturbances and a high anion gap admitted to the emergency service. DW-MRI may be helpful in diagnosis by detecting symmetrical diffusion restrictions at the basal ganglia. Additionally radiologic methods like CT can be used to determine complications such as bleeding that may occur during the follow-up of the cases.

Acil Servise Başvuran Metil Alkol Zehirlenmelerinin Geriye Dönük Analizi

Objective: Methyl alcohol poisoning remains a significant cause of mortality and morbidity. This poisoning is still one of the important reasons for admission to emergency services. We aimed to examine the admission complaints, laboratory findings, treatment methods, clinical outcomes and examine the factors affecting the mortality of patients diagnosed with methyl alcohol poisoning in the emergency department.&#x0D; Methods: In this retrospective descriptive study, we analysed the patients who were considered to be diagnosed with methyl alcohol intoxication among those who came to our emergency department due to alcohol intoxication from June 1, 2018 to June 1, 2020.&#x0D; Results: The study included 20 (4.86%) individuals with methyl alcohol poisoning among 411 people who presented to the emergency department due to ethyl and methyl alcohol intake and resulting effects.The mean age of the patients was 47.35±14.2 years and 85% (n=17/20) were male. Upon reviewing the patients' admission symptoms, 70% were observed to have visual problems, 60% complaints of vomiting, 45% shortness of breath, and 40% changes in consciousness. In the study, it was revealed that 18.2%(n=2/11) females and 81.8%(n=9/11) males died, and the mortality rate was calculated as 55%(n=11/20).&#x0D; Conclusions: The presence of visual problems, hypotension, and coma in clinical findings, high anion gap metabolic acidosis, marked osmolar gap, an increase in lactate level, and hyperglycemia in laboratory findings may be the early signs of mortality in patients with methyl alcohol poisoning. Therefore, patients with these signs should be followed up more closely and treated.

S3621 Imaging Finding as a Clue for Accidental Salicylate Toxicity

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.

A CASE REPORT OF SYNCHRONOUS MULTIFOCAL NECROTIZING FASCIITIS DUE TO CLOSTRIDIUM SEPTICUM IN AN IMMUNOCOMPROMISED HOST

A CASE REPORT OF SYNCHRONOUS MULTIFOCAL NECROTIZING FASCIITIS DUE TO CLOSTRIDIUM SEPTICUM IN AN IMMUNOCOMPROMISED HOST

S1933 Acute Pancreatitis Attributed to COVID-19: An Unusual Infectious Etiology

Introduction: COVID-19 can affect multiple organs and has various presentations, including respiratory symptoms and fever being the most common. Gastrointestinal symptoms can be reported in up to 25% of patients, with diarrhea, nausea, and emesis the usual presentation. However, abdominal pain is less than 6.8% of cases, and of those, only 27% presented with Acute Pancreatitis (AP). Here we present a case of severe AP with multiorgan involvement as the initial presentation of COVID19. Case Description/Methods: Case of a 19 y/o Female with a medical history of Obesity class I arrived at the ED with recurrent emesis and altered mental status. Symptoms began around four days prior with 6-7 episodes of non-bloody, non-bilious emesis, fatigue, subjective fever, and decreased oral intake, followed by acute onset of diffuse abdominal pain. Upon arrival, the patient was found encephalopathic with dry oral mucosa, tachycardic and tachypneic. Laboratories were remarkable for lipase 2483, amylase 382, LDH 315, ALP 219 U/L, sodium 155 mEq/L, creatinine 1.33 mg/dL, bicarbonate < 9 mmol/L, pH 7.0, pO2Sat 96%, hematocrit 51.8%, WBC 14.9 cells/L, glucose 774 mg/dL, and COVID 19 PCR positive. Abdominal US and CT with no findings suggestive of gallstones or intraabdominal pathology. Aggressive intravenous fluid, insulin, broad-spectrum antibiotics, bicarbonate replacement, analgesia, and antiemetics were implemented. Hospitalization was complicated as the patient did not tolerate PO intake, and the high anion gap metabolic acidosis was difficult to close for several days. After almost two weeks in the ICU, the patient was discharged home without apparent pancreatitis or COVID-19 repercussions. Discussion: Our case did not have any risk factors for AP, and extensive investigations did not reveal a clear etiology. Viral, bacterial, fungal, and parasitic infections are less common causes of AP. There are limited data on COVID-19 and pancreatitis; however, recent studies suggest a higher mortality rate with a 20% increased chance of dying and worse clinical outcomes. The mechanism of pancreatic injury is not well understood, but there is a link between COVID-19 and the precipitation of autoimmune and systemic diseases. Our case is an example of severe pancreatic injury with multiorgan involvement in mild symptomatic COVID 19.

S2425 A Case Report of Volatile Ingestion-Induced Acute Esophageal Necrosis

Introduction: Acute esophageal necrosis (AEN), also known as black esophagus or acute necrotizing esophagitis, is a rare syndrome with diffuse circumferential black discoloration often of distal third esophageal mucosa due to relative hypovascularity and termination at the gastro-esophageal junction. It usually presents with upper GI hemorrhage. Despite controversial pathogenesis, there is strong consideration for a 2-hit hypothesis where an initial low-flow vascular state predisposes the mucosa to a severe topical injury. Chemical injury by gastric contents, toxin ingestion, severe infectious diseases, diabetic ketoacidosis and shock are associated with AEN. Advanced age, male gender and comorbidities like diabetes mellitus (DM), hypertension, cardiovascular disease, chronic kidney disease, malnutrition, chronic alcohol abuse, post-irradiation are predisposing risk factors for AEN. We present a patient with a favorable outcome of a generally rare, life-threatening condition due to early recognition and treatment. Case Description/Methods: A 74-year-old male presented to the hospital with shock and 3-day history of hematemesis. He had history of coronary artery disease, Type II Diabetes Mellitus, chronic obstructive pulmonary disease, esophageal adenocarcinoma post chemotherapy and radiation complicated by erosive esophagitis and alcoholism. Labs were significant for acute kidney injury (AKI), high anion gap metabolic acidosis (HAGMA), osmolar gap of 59 mOsm/kg and hemoglobin drop from 14 to 9 g/dL. Volatile panel not sent; drug-screen benign, infectious work-up negative. CT abdomen had distended stomach; thus, NG tube placed for decompression, yielding 700cc of coffee ground emesis. Upper endoscopy performed 2-days later showed Los Angeles Grade D esophagitis with entire esophagus with black appearance, gastric body erosions and superficial clean-based duodenal ulcers. Patient was continued on PPI twice daily for 8 weeks with planned repeat EGD (Figure). Discussion: This patient likely had volatile ingestion chemical injury given shock, hematemesis, AKI with HAGMA and osmolar gap. Despite AEN’s rarity with prevalence of 0.2 percent in autopsy states, given overall 32 percent mortality rate and 6 percent mortality rate directly attributed to complications of AEN, early recognition and prompt medical management is imperative for favorable outcomes. Treatment focuses on supportive therapy: namely resuscitation, PPIs, sucralfate, keeping the patient NPO and avoiding nasogastric tube to avoid esophageal perforation.Figure 1.: Proximal Acute Esophageal Necrosis.

S3259 A Case of Propofol-Induced Acute Liver Failure

Introduction: Propofol is a parenteral anesthetic routinely used for procedures given its beneficial pharmacokinetic profile of rapid onset of action and reversal. Propofol drug toxicity is rare but has been associated with idiosyncratic acute liver injury in a small number of cases. To the best of our knowledge, we present the second case of propofol-induced acute liver failure (ALF) reported in literature. Case Description/Methods: An 88-year-old male with concern for gastrointestinal bleed underwent an upper endoscopy with propofol used as the anesthetic agent. The patient tolerated the endoscopy well with no hemodynamic compromise during or afterwards. No source of bleeding was identified so the plan was to proceed with a colonoscopy the next day. Shortly after the procedure, he was noted to have altered mental status. Evaluation with routine laboratory testing revealed elevated AST of 3248 IU/L and ALT of 2411 IU/L, both increased from 35 IU/L and 24 IU/L, respectively. He was also found to have high anion gap metabolic acidosis and bicarbonate level less than 9 mEq/L. His altered mentation continued to worsen, and he became hemodynamically unstable requiring transfer to the intensive care unit. He had no history of liver disease or excessive alcohol use, no risk factors for viral hepatitis, and took no medications known to cause liver injury. Work-up was unremarkable for acute and chronic liver disease. Propofol was ultimately surmised as the cause of ALF. Unfortunately, the patient’s mental status progressively worsened despite hemodynamic stabilization and normalization of liver enzymes. His family ultimately chose to transition to comfort measures and the patient passed soon after. Discussion: The incidence of drug-induced liver injury is increasing in developed countries and is a major etiology of ALF, accounting for greater than 50% of cases. Drug toxicity secondary to an idiosyncratic reaction is unpredictable and occurs infrequently in certain individuals. While propofol is generally considered a safe agent widely used for sedation, propofol-induced acute liver injury is a rare outcome. To the best of our knowledge, it is reported to have caused five cases of acute hepatitis and one other case of ALF. We report the second case of ALF due to propofol with a lethal outcome. We recommend close monitoring of patients treated with propofol for signs of hepatitis and that ALF due to a drug insult should be considered after common causes have been excluded.

THE CLUE IS IN THE BLOOD GAS: A RARE MANIFESTATION OF LACTIC ACIDOSIS

THE CLUE IS IN THE BLOOD GAS: A RARE MANIFESTATION OF LACTIC ACIDOSIS

A Literature Review of the Therapeutic Perspectives of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis.

Euglycemic diabetic ketoacidosis (DKA), a side effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors, is a triad of high metabolic anion gap acidosis, raised serum and urine ketones, and serum glucose <250 mg/dl. SGLT2 inhibitors cause a carbohydrate deficit by glucosuria, which leads to an increased glucagon/insulin ratio, the metabolic shift from glucose to lipid utilization causing ketogenesis, and hence euglycemic DKA. Additional factors like the ketogenic diet, illness, surgery, and pregnancy contribute to precipitating these episodes. Keywords searchincluded "Euglycemic DKA and SGLT2 inhibitors" in PubMedand Google Scholar, to compile data from existing articles that provide information on the withholding and restarting period of the drug after a euglycemic DKA episode. SGLT2 inhibitors, used in the treatment of type 2 DM, have an average half-life of 11-13 hours, so most articles suggested withholding the drug three days before any elective surgery but some articles suggested a longer withholding period based on other precipitating factors contributing to euglycemic DKA. Hence, we came up with patient inclusion criteria and concomitant therapies review that we need to consider in making this decision. In addition, a multidisciplinary approach is required when laying out guidelines for restarting the drug to have a unanimous approach. After reviewing the existing literature, it is clear that concrete guidelines are required to decide on drug withholding and restarting periods after a euglycemic DKA episode, as they vary among different institutions and different specialties. We believe it is crucial to consider patient inclusion criteria and concomitant therapies in forming those guidelines.

A rare case report of combined metformin-associated lactic acidosis and diabetic ketoacidosis

BackgroundTriad of diabetic ketoacidosis (DKA) comprises of hyperglycemia with serum glucose > 11 mmol/L, high anion gap metabolic acidosis and ketonemia. Hyperlactemia is often noted in patients with DKA. Metformin use is one of the risk factors of hyperlactemia, resulting in high anion gap metabolic acidosis, known as metformin associated lactic acidosis (MALA). This report is of a 60-year-old woman with type 2 diabetes mellitus who presented with combined metformin-associated lactic acidosis MALA and DKA.Case presentationA 60-year-old diabetic female presented to the emergency department with complaints of abdominal pain, vomiting and diarrhea. She was on metformin for the last 10 years, but despite compliance to medications, her HbA1c was 14.1. With an aim to improve her glycemic control, linagliptin 5 mg once a day was added 1 month ago. Initial investigations in ED including arterial blood gas analysis revealed metabolic acidosis, ketosis, hyperlactemia, and acute kidney injury. In view of metabolic acidosis and ketosis with elevated blood glucose level, she was diagnosed to have DKA. Compared to isolated DKA, patients with combined MALA and DKA have severe metabolic acidosis, a greater degree of hyperlactatemia but less extensive ketoacidosis. Hence, she was diagnosed to have combined MALA and DKA. She was admitted to intensive care unit and treated with intravenous fluids, insulin infusion, and continuous renal replacement therapy. Her metabolic acidosis, hyperlactemia, and kidney injury resolved and she was discharged well.ConclusionThis report has shown the importance of rapid diagnosis and management of the rare and challenging diagnosis of combined MALA and DKA. The main goal of therapy is preventing hyperglycemia and ketosis, resolution of metabolic acidosis, and removal of accumulated metformin using intensive therapies like aggressive fluid resuscitation and early initiation of renal replacement therapy. Adjustment of dose of medications is needed to avoid this complication.

Analysis of the variables involved in the time to resolution of metabolic parameters in adults with diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening complication characterized by hyperglycemia, metabolic acidosis, and ketonemia. Although the time to resolution of DKA has been estimated at 12 to 18 hours, the factors that could prolong it have not been fully studied. Retrospective study of medical records of adult patients admitted to the general ward with a diagnosis of DKA. They were classified according to severity as mild, moderate and severe. The time to resolution of crisis (TRC) was defined as that necessary until normalization of metabolic parameters. A logistic regression analysis was performed to evaluate the association between TRC>12 hours and continuous variables. ROC analysis and survival analysis were performed using a Cox regression model. 85 patients were studied. 48.23% presented severe DKA. The TRC was 14 hours, being higher in severe DKA. Patients with TRC>12 hours had a lower pH and HCO3-, and a higher anion gap, white blood cells, and volume of crystalloids used. Logistic regression analysis showed that pH and crystalloid volume correlated with TRC>12 hours. ROC analysis determined a pH cutoff value of 7.13 for TRC>12 hours (sensitivity 77%, specificity 88%). The Cox regression showed that a pH<7.13 on admission is associated with a higher TRC (HR 3.30). A pH lower than 7.13 at the time of hospital admission identifies patients with DKA who will need a longer time to resolve their metabolic parameters.

Serum Anion Gap Level Predicts All-Cause Mortality in Septic Patients: A Retrospective Study Based on the MIMIC III Database.

Sepsis is a significant threat in the intensive care unit (ICU) worldwide because it has high morbidity and mortality rates. Early recognition and diagnosis of sepsis are essential for the prevention of adverse outcomes. The present study aimed to quantitatively assess the association between serum anion gap (AG) levels and 30- and 90-day all-cause mortality among sepsis patients. Clinical data of patients diagnosed with sepsis were extracted from the Medical Information Mart for Intensive Care III (MIMIC III) database. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate the association between serum AG levels and all-cause mortality. A receiver operating characteristic (ROC) curve was drawn to quantify the efficacy of using the serum AG level to predict all-cause mortality. A total of 3811 patients were included in the study. The Kaplan-Meier curves showed that patients with higher serum AG levels had a shorter survival time than those with lower levels. Serum AG levels were found to be highly effective in predicting all-cause mortality secondary to sepsis (30-day: AUROC = 0.703; 90-day: AUROC = 0.696). The Cox regression model further indicated that the serum AG level was an independent risk factor for 30- and 90-day mortality in sepsis (HR 3.44, 95% CI 2.97-3.99 for 30-day; HR 3.17, 95% CI 2.76-3.65 for 90-day, P < 0.001 for both). High serum AG may be considered as an alternative parameter for predicting the death risk in sepsis when other variables are not immediately available. Prospective large-scale studies are needed to support its predictive value in the clinic.

Methanol induced intracranial hemorrhage: A rare case report

Intracranial hemorrhage is a rare but fatal complication in methanol poisoning. We report a case of large bilateral basal ganglia hematoma in a 29-years old man with methanol poisoning. He drank alcohol, and was admitted to a tertiary level hospital 6 hours post-ingestion for depressed mental status, lower blood pressure, and high anion gap metabolic acidosis. After fourteen days of methanol exposure, he suddenly developed left sided weakness with one episode of seizure attack. MRI of brain was carried out and showed large intracerebral bleed basal ganglia, specially putaminal and brain edema with midline shift. The uncommon presentation of methanol poisoning is highlighted in this case report. Bangladesh J Medicine 2022; 33: 300-303

Pseudohypobicarbonatemia in a patient with amyloidosis.

We report a case of a patient who had critically low serum bicarbonate (HCO3 -) levels ranging from 8 to 11mmol/L on repeated venous measurements using an enzymatic/photometric assay. This prompted hospitalization and treatment with intravenous sodium bicarbonate (NaHCO3) followed by oral NaHCO3. He was evaluated for potential causes of high anion gap metabolic acidosis without any etiology found. He continued to have low serum HCO3 - levels despite maintenance oral NaHCO3 therapy and was referred for a second opinion where further laboratory work was pursued. An arterial blood gas was obtained, which revealed normal whole blood pH and HCO3 - levels. A different enzymatic/photometric assay revealed a normal serum HCO3 - level at 21mmol/L. Additional workup revealed paraproteinemia, which was thought to interfere with the enzymatic process by which his serum HCO3 - was measured, resulting in erroneous values.

A False-Positive Gamma-Hydroxy Butyric Acid Urine Screening in a Patient with High Anion Gap Metabolic Acidosis Due to Ethylene Glycol Poisoning.

A young woman with a history of several suicide attempts was admitted to the hospital after suspicion of a new intoxication without definite identification of the causing agent. The patient had a high anion gap metabolic acidosis (HAGMA) with respiratory compensation, a lactate gap and an osmolar gap at admission. Initial toxicological screening showed no abnormalities except for a weak positive gamma-hydroxy butyric acid (GHB) enzymatic screen in urine. This finding could not be confirmed using chromatographic analysis nor be explained by the presence of known cross-reacting substances like ethanol. In this case, falsely elevated urinary GHB screening was caused by the ingestion of ethylene glycol. To confirm that the interference was due to ethylene glycol or its metabolites, we performed a spiking experiment. Cross reactivity was linked to ethylene glycol and was low in our experiments (0.1-0.2%). Substantial amounts of ethylene glycol are required to slightly elevated GHB results, depending on the endogenous cutoff used. We can conclude that ethylene glycol can give rise to falsely elevated urinary GHB levels at ethylene glycol concentrations that are typically found in intoxications.

Chronic methanol toxicity through topical and inhalational routes presenting as vision loss: Case report

Present a rare case of loss of vision because of chronic dermal application of methanol. Methanol intoxication can cause irreversible neurologic sequelae if unrecognized and untreated. Ingestion is the most common form of toxicity; however, dermal and inhalational exposures likewise occur but are documented rarely. While acute intoxication is commonly encountered, chronic exposure to methanol should also be highlighted. We report a case of a 57-year-old female presenting in the emergency room with progressive dyspnea, metabolic acidosis with high anion gap, and metabolic encephalopathy. After emergency hemodialysis, the patient complained of vision loss on both eyes. Initial non-contrast cranial magnetic resonance imaging (MRI) revealed restricted diffusion of the intraorbital segment of both optic nerves. A thorough history revealed that she was applying a clear colorless liquid bought online all over her body for alleged pruritus for more than a year. The syndrome of metabolic acidosis with high anion gap, metabolic encephalopathy, vision loss, and laboratory findings led us to suspect a diagnosis of chronic methanol poisoning with an acute component. The liquid in question was sent for chemical analysis and result showed that it consisted of 95.5% Methanol. N/A. The toxicity in the absence of oral consumption, the complications of chronic form of methanol intoxication, and the uncommon radiologic finding seen in diffusion-weighted imaging (DWI).

Elevated Anion Gap Metabolic Acidosis With High Osmolar Gap and Increased Serum Acetone Level: A Case Report

Acetone poisoning, although not very common, can present with varied signs and symptoms. High acetone levels in serum can be due to exogenous exposure or endogenous production of acetone. Unlike certain alcohol toxicities, acetone does not cause high anion gap metabolic acidosis.A 69-year-old male presented to our service with shock and acute encephalopathy and required intensive care support. Initial laboratory investigation showed high anion gap metabolic acidosis with high osmolar gap. Serum acetone level was elevated. Clinicians need to be aware of how to elucidate such metabolic disturbances and associated toxicities.

Association Between High Serum Anion Gap and All-Cause Mortality in Non-Traumatic Subarachnoid Hemorrhage: A Retrospective Analysis of the MIMIC-IV Database.

Background:High serum anion gap (AG) on admission is often correlated with poor outcomes in critically ill patients; however, data in patients with non-traumatic subarachnoid hemorrhage (SAH) are lacking. Herein, we aimed to identify the association between serum AG and all-cause mortality in patients with non-traumatic SAH.MethodsA retrospective analysis of data from the Medical Information Mart for Intensive Care (MIMIC-IV) database was performed on critically ill patients with non-traumatic SAH. Serum AG was collected on Intensive Care Unit (ICU) admission, and ICU and hospital all-cause mortality were analyzed. The multivariate Cox proportional hazard regression model and Kaplan-Meier survival curve analysis were used to analyze the correlation of serum AG with ICU and hospital all-cause mortality. Furthermore, interaction and subgroup analyses were evaluated for the consistency of these correlations.ResultsA total of 893 patients with non-traumatic SAH were included in this study. The all-cause mortality in ICU and hospital were 14.8% (132/893), and 18.9% (169/893), respectively. Multivariate analysis after adjusting for potential confounders indicated that high serum AG levels (≥16 mmol/L) were associated with increased risk of ICU and hospital all-cause mortality as compared to that with low serum AG levels (<16mmol/L), (hazards ratio (HR): 2.31 [95% CI: 1.58–3.38]) and HR: 1.91 [95% CI: 1.36–2.67)], respectively). Similarly, the Kaplan–Meier (K–M) survival curve also showed that patients with high serum AG levels presented with a lower survival rate. Stratified analyses further showed that depending on the variable testes, an association between higher serum AG levels and hospital all-cause mortality in different subgroups was observed.ConclusionAmong patients with non-traumatic SAH, high serum AG level at ICU admission was associated with increased ICU and hospital all-cause mortality.

Diabetic ketoacidosis as a complication of methanol poisoning; a case report

IntroductionDiabetic ketoacidosis (DKA) is a complication of diabetes presenting with high anion gap metabolic acidosis. Methanol poisoning, on the other hand, is a toxicology emergency which presents with the same feature. We present a case of methanol poisoning who presented with DKA.Case presentationA 28-year-old male was referred to us with blurred vision and loss of consciousness three days after ingestion of 1.5 L of an unknown mixture of bootleg alcoholic beverage. He had history of insulin-dependent diabetes and had neglected his insulin shots on the day prior to hospital admission due to progressive loss of consciousness. Vital signs were normal and venous blood gas analysis showed severe metabolic acidosis and a methanol level of 10.2 mg/dL. After eight hours of hemodialysis, he remained unresponsive. Diabetic ketoacidosis was suspected due to positive urine ketone and blood sugar of 411 mg/dL. Insulin infusion was initiated which was followed by full awakening and extubation. He was discharged completely symptom-free after 4 weeks.ConclusionsDiabetic ketoacidosis and methanol poisoning can happen simultaneously in a diabetic patient. Given the analogous high anion gap metabolic acidosis, physicians should pay particular attention to examination of the diabetic patients. Meticulous evaluation for both conditions is highly recommended.