scholarly journals A Case Report of Massive Acetaminophen Poisoning Treated with a Novel “Triple Therapy”: N-Acetylcysteine, 4-Methylpyrazole, and Hemodialysis

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Emily A. Kiernan ◽  
Julie A. Fritzges ◽  
Kathryn A. Henry ◽  
Kenneth D. Katz
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Triple Therapy ◽  
Complete Resolution ◽  
Altered Mental Status ◽  
Rapid Onset ◽  
Anion Gap ◽  
High Dose ◽  
Emergency Physicians ◽  
Transplant Center

Massive acetaminophen (N-acetyl-p-aminophenol; APAP) ingestion is characterized by a rapid onset of mitochondrial dysfunction, including metabolic acidosis, lactemia, and altered mental status without hepatotoxicity which may not respond to the standard doses of N-acetylcysteine (NAC). A 64-year-old woman without medical history presented comatose after an ingestion of 208 tablets of Tylenol PM™ (APAP 500 mg and diphenhydramine 25 mg). The initial APAP concentration measured 1,017 µg/mL (therapeutic range 10-30 µg/mL), and elevated anion gap metabolic acidosis, lactemia, and 5-oxoprolinemia were detected. High-dose intravenous (IV) NAC, 4-methylpyrazole (4-MP), and hemodialysis (HD) were initiated. She was transferred to a liver transplant center and continued both NAC and HD therapies until complete resolution of metabolic acidosis and coma without developing hepatitis. She was discharged without sequelae. This is the fourth highest APAP concentration recorded in a surviving patient. Moreover, this is the first report of a novel “triple therapy” using NAC, 4-MP, and HD in the setting of massive APAP ingestion that presents with coma, elevated anion gap metabolic acidosis, and lactemia. Emergency physicians should recognize these critically ill patients and consider high-dose NAC, 4-MP, and HD to be initiated in the emergency department (ED).

scholarly journals Accidental transdermal methanol poisoning presenting to a regional emergency department

CJEM ◽  
2019 ◽  
Vol 21 (3) ◽  
pp. 435-437
Author(s):  
Chelsea R. Beaton ◽  
Clinton Meyer
Keyword(s):  
Emergency Department ◽  
Differential Diagnosis ◽  
Metabolic Acidosis ◽  
Laboratory Testing ◽  
Clinical Findings ◽  
Anion Gap ◽  
List Type ◽  
Emergency Physicians ◽  
Clinical Presentations ◽  
Learning Points

Learning Points:•Know and identify clinical presentations of toxic alcohols.•Understand the differential diagnosis of high anion gap metabolic acidosis.•Appreciate the importance of history and clinical findings in establishing methanol toxicity diagnoses, especially in centres where laboratory testing is unavailable.•Recognize the value of provincial poison centres in supporting emergency physicians in the diagnosis and management of poisonings and overdoses.

scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

scholarly journals Profound metabolic acidosis from pyroglutamic acidemia: an underappreciated cause of high anion gap metabolic acidosis

CJEM ◽  
2010 ◽  
Vol 12 (05) ◽  
pp. 449-452 ◽  
Author(s):  
Thomas J. Green ◽  
Jan Jaap Bijlsma ◽  
David D. Sweet
Keyword(s):  
Emergency Department ◽  
Lactic Acid ◽  
Metabolic Acidosis ◽  
Ethylene Glycol ◽  
Inborn Errors Of Metabolism ◽  
Pyroglutamic Acid ◽  
Anion Gap ◽  
Emergency Patient ◽  
Inborn Errors ◽  
Chronic Ingestion

ABSTRACTThe workup of the emergency patient with a raised anion gap metabolic acidosis includes assessment of the components of “MUDPILES” (methanol; uremia; diabetic ketoacidosis; paraldehyde; isoniazid, iron or inborn errors of metabolism; lactic acid; ethylene glycol; salicylates). This approach is usually sufficient for the majority of cases in the emergency department; however, there are many other etiologies not addressed in this mnemonic. Organic acids including 5-oxoproline (pyroglutamic acid) are rare but important causes of anion gap metabolic acidosis. We present the case of a patient with profound metabolic acidosis with raised anion gap, due to pyroglutamic acid in the setting of malnutrition and chronic ingestion of acetaminophen.

The Protean Neuropsychiatric and Vestibuloauditory Manifestations of Neurosarcoidosis

2017 ◽  
Vol 22 (4-5) ◽  
pp. 205-217 ◽  
Author(s):  
Jacqueline J. Greene ◽  
Ilka C. Naumann ◽  
Janet M. Poulik ◽  
Kevin T. Nella ◽  
Lindsay Weberling ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Cochlear Implantation ◽  
Psychiatric Symptoms ◽  
Altered Mental Status ◽  
Rapid Onset ◽  
Normal Serum ◽  
High Dose ◽  
Leptomeningeal Enhancement ◽  
History Of

Background: A rare subset of sarcoidosis, neurosarcoidosis, is reported to occur in 5-7% of sarcoid patients and can manifest in a variety of ways. The most common are facial paralysis and optic neuritis, less commonly causing cochleovestibulopathy, blindness, anosmia, and other cranial nerve (CN) palsies. The sensory deficit may be severe and psychiatric symptoms may result from the effects of the disease or steroid treatment. Although MRI-compatible cochlear implants are now available, concerns about the feasibility of recoverable hearing with cochlear implantation in these patients as well as the practical difficulty of disease monitoring due to implant artifact must be considered. Results: We present 3 recent cases from different institutions. The first is a 39-year-old man with a history of progressively worsening hearing loss, followed by visual loss, delusions, agitation, ataxia, and musical auditory hallucinations, diffuse leptomeningeal enhancement on MRI with a normal serum angiotensin-converting enzyme (ACE) level but elevated cerebrospinal fluid (CSF) ACE levels, suggesting neurosarcoidosis, was treated with corticosteroids, and underwent successful cochlear implantation. The second is a 36-year-old woman with rapid-onset horizontal diplopia, left mixed severe sensorineural hearing loss (SNHL) and tinnitus, diffuse leptomeningeal enhancement on MRI, and progressive palsy of the left CNs IV, VI, VII, IX, X and XI, with altered mental status requiring admission following high-dose intravenous corticosteroids. The third is a 15-year-old boy who presented with sudden, bilateral, profound SNHL, recurrent headaches, and left facial weakness refractory to antivirals, ultimately diagnosed with neurosarcoidosis following an aborted cochlear implantation where diffuse inflammation was found, and histopathology revealed Schaumann bodies; he was treated with methotrexate and later underwent successful cochlear implantation. Conclusions: Neurosarcoidosis is an elusive diagnosis and can cause hearing loss and psychiatric symptoms. Cochlear implantation for patients with severe hearing loss should be considered once the diagnosis is confirmed, as it is possible to achieve a successful level of hearing. Psychiatric symptoms can manifest with the onset of neurosarcoidosis, result from CN deficits, or develop as a side effect from long-term, high-dose corticosteroids, and should be monitored carefully in patients with neurosarcoidosis.

scholarly journals Acidosis and coma after hemodialysis.

1997 ◽  
Vol 8 (5) ◽  
pp. 853-856
Author(s):  
R Taylor ◽  
J Bower ◽  
M M Salem
Keyword(s):  
Metabolic Acidosis ◽  
Ethylene Glycol ◽  
Suicide Attempts ◽  
Altered Mental Status ◽  
Anion Gap ◽  
Toxic Metabolites ◽  
Ethylene Glycol Poisoning ◽  
Rapid Clearance ◽  
Dialysate Solution ◽  
Osmolal Gap

Ethylene glycol poisoning is a rare yet potentially fatal illness seen most commonly in association with ingestion by alcoholics or in suicide attempts. It is characterized by an elevated anion gap metabolic acidosis, osmolal gap, calcium oxalate crystals in the urine, and a well-defined clinical picture. Prompt treatment is crucial because effective intervention can prevent the neurologic, cardiac, pulmonary, and renal sequelae associated with ethylene glycol poisoning. Hemodialysis offers rapid clearance of ethylene glycol and its toxic metabolites. In this article, the case of a hemodialysis patient who suffered contamination of the dialysate solution with ethylene glycol, leading to altered mental status, coma, and severe anion gap metabolic acidosis, is reported. Despite prolonged dialysis and correction of the acidosis, the patient remained comatose and subsequently died.

scholarly journals A Case of Methotrexate Neurotoxicity Presented as Status Epilepticus, Encephalopathy, and High Fever

2019 ◽  
Vol 7 ◽  
pp. 232470961986231 ◽  
Author(s):  
Itay Ayalon ◽  
Shirley Friedman ◽  
Yoav Binenbaum ◽  
Noga Oppenheimer ◽  
Shelly Shiran ◽  
...  
Keyword(s):  
Emergency Department ◽  
Status Epilepticus ◽  
Altered Mental Status ◽  
High Fever ◽  
High Dose ◽  
High Dose Methotrexate ◽  
Care Providers ◽  
Dose Methotrexate ◽  
Imaging Sequence ◽  
Recent Diagnosis

High-dose methotrexate is used to treat a range of adult and childhood cancers including osteosarcoma. Significant neurotoxicity is reported in 1% to 4.5% of patients treated with high-dose methotrexate and can present in a wide variety of symptoms. We present a case of a 14-year-old boy with a recent diagnosis of osteosarcoma who presented to the emergency department with status epilepticus, altered mental status, and very high fever secondary to methotrexate neurotoxicity. We review current literature and discuss some controversies related to this state. We also describe high fever as one of the possible symptoms associated with this condition and suggest using specific magnetic resonance imaging sequence to uncover abnormal findings related to this state. Since high-dose methotrexate is not a rare treatment in this era, we believe that in addition to oncologists, emergency department and intensive care providers should be aware of the potential role of methotrexate in causing significant neurotoxicity and include it in the differential diagnosis when treating a patient presenting with new neurological symptoms in the setting of recent high-dose methotrexate treatment.

scholarly journals Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis presenting to the emergency department with status epilepticus

CJEM ◽  
2014 ◽  
Vol 16 (05) ◽  
pp. 425-428 ◽  
Author(s):  
Brodie Nolan ◽  
Katharina Plenk ◽  
David Carr
Keyword(s):  
Emergency Department ◽  
Status Epilepticus ◽  
Mental Status ◽  
Young Patients ◽  
Complete Recovery ◽  
Altered Mental Status ◽  
Emergency Physicians ◽  
Varicella Zoster ◽  
Aspartate Receptor ◽  
Nmdar Encephalitis

ABSTRACT Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a recently described and underdiagnosed entity that typically affects young, previously healthy individuals. Patients usually present in phases, which may include refractory seizures, psychosis, unresponsiveness, and autonomic instability. The diagnosis of anti-NMDAR encephalitis is challenging; however, prompt diagnosis and early treatment can lead to complete recovery. The incidence of anti-NMDAR encephalitis may be as high as four times that of encephalitis from herpes simplex, varicella-zoster, and West Nile viruses; however, it remains an underrecognized disorder. Early initiation of immunotherapy in anti-NMDAR encephalitis has been found to improve patient outcomes. Because of this, emergency physicians must be vigilant and consider this diagnosis in patients with altered mental status in whom a toxicologic or other etiology is not suspected. Early consideration of this diagnosis can facilitate urgent neurology consultation and prevent diagnostic delays arising from psychiatric referrals. It is essential to consider this diagnosis in suspicious emergency department presentations, particularly young patients who present with altered mental status, psychosis, or new-onset seizure activity when other obvious causes are ruled out. Emergency physicians should discuss the possibility of empirical intravenous immunoglobulin administration with neurology consultants if anti-NMDAR encephalitis is suspected. We describe the case of a 20-year-old man with anti-NMDAR encephalitis who presented to the emergency department with status epilepticus.

scholarly journals Lactation Ketoacidosis: A case series

2019 ◽  
Vol 19 (4) ◽  
pp. 359 ◽  
Author(s):  
Abdullah M. Al Alawi ◽  
Usama Al Amri ◽  
Henrik Falhammar
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Metabolic Diseases ◽  
Ketone Bodies ◽  
Epigastric Pain ◽  
Case Series ◽  
Anion Gap ◽  
University Hospital ◽  
Rare Type ◽  
Balanced Diet

Lactation ketoacidosis is an extremely rare type of high anion gap metabolic acidosis. We report two lactating women who were diagnosed with lactation ketoacidosis. The first patient presented to the Emergency Department at Royal Darwin Hospital, Darwin, Australia, in 2018 with lethargy, nausea and abdominal pain after she commenced a new diet regimen based on three meals of protein per day and free of glucose, gluten and dairy products. The second patient presented to the Emergency Department at Sultan Qaboos University Hospital, Muscat, Oman, in 2018 with headache, severe malaise, epigastric pain and worsening of gastroesophageal symptoms. Blood investigation results showed that both patients had high anion gap metabolic acidosis, ketosis and hypoglycaemia. The patients responded well to intravenous dextrose and resumption of a balanced diet. Both patients were able to continue breastfeeding and remained well on follow-up.Keywords: Breastfeeding; Starvation; Hypoglycemia; Ketosis; Acid-Base Imbalance; Metabolic Diseases; Ketone Bodies; Fasting; Case Series; Australia; Oman.

scholarly journals Ethylene Glycol Poisoning: An Unusual Cause of Altered Mental Status and the Lessons Learned from Management of the Disease in the Acute Setting

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
R. Singh ◽  
E. Arain ◽  
A. Buth ◽  
J. Kado ◽  
A. Soubani ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Ethylene Glycol ◽  
Mental Status ◽  
Kidney Injury ◽  
Altered Mental Status ◽  
Lessons Learned ◽  
Anion Gap ◽  
Tubular Damage ◽  
Elderly Male ◽  
Laboratory Findings

Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps.

scholarly journals Hemodynamically significant atrial fibrillation in a previously healthy man with ethylene glycol toxicity

2014 ◽  
Vol 1 (1) ◽  
pp. 21
Author(s):  
Ryan Thompson ◽  
Allan R. Mottram
Keyword(s):  
Atrial Fibrillation ◽  
Renal Failure ◽  
Metabolic Acidosis ◽  
Ethylene Glycol ◽  
Mental Status ◽  
Altered Mental Status ◽  
Late Presentation ◽  
Electrical Cardioversion ◽  
Anion Gap ◽  
Healthy Man

Ethylene glycol ingestion is a well-described phenomenon that results in altered mental status, anion gap metabolic acidosis, and renal failure. Cardiac sequelae of ethylene glycol ingestion have not been well described in the literature. We report a case of a young, previously healthy man who developed atrial fibrillation successfully treated with electrical cardioversion in the setting of a large ethylene glycol ingestion with a late presentation.

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