Aventura Hospital and Medical Center, Aventura, FL, USA.
SUNY Upstate Medical University, Syracuse, NY, USA.
CEN Case Rep. 2020 Feb;9(1):11-14. doi: 10.1007/s13730-019-00417-0. Epub 2019 Oct 1.
Ingestion of toxic alcohols (TA) typically presents with a high anion gap (AG) metabolic acidosis, and elevated osmolar gap (OG). Hemodialysis (HD) has not been recommended in early phases of intoxication with high OG and normal AG metabolic acidosis. We describe the case of a 40-year-old male who was brought to our emergency department for reported paint thinner ingestion. He was unable to protect his airway and required intubation. Blood gas showed respiratory acidosis, an initial AG, corrected by albumin of 12.75, lactic acid 5.26 mmol/L, and an OG of 170. Patient was treated with bicarbonate drip, fomepizole and emergent HD, which improved his neurologic status. Days after his admission, alcohol levels came positive for a co-ingestion of ethylene glycol, diethylene glycol, and methanol. Most of the TA are metabolized into their toxic byproducts by the enzyme alcohol dehydrogenase (ADH). The kinetics of these alcohols will be altered when there is co-ingestion of multiple substances. Moreover, early ingestions will translate in a high OG without a high AG. False elevation of lactate can occur with the ingestion of ethylene glycol due to a cross-reaction with L-lactate oxidase in the analyzer. In our case, the administration of fomepizole followed by an early HD given the poor clinical improvement, was followed by a fast recovery of the neurological status and potentially prevented renal failure. A high index of suspicion for TA ingestion should be raised when encountering an individual with lactic acidosis, high OG, and normal AG.
摄入有毒醇（TA）通常会导致高阴离子间隙（AG）代谢性酸中毒和升高的渗透压间隙（OG）。在 OG 高和 AG 正常代谢性酸中毒的早期阶段，不建议进行血液透析（HD）。我们描述了一位 40 岁男性的病例，他因报告摄入油漆稀释剂而被带到我们的急诊部。他无法保护自己的气道，需要插管。血气显示呼吸性酸中毒，AG 初始值为 12.75，经白蛋白纠正，乳酸 5.26mmol/L，OG 为 170。患者接受碳酸氢钠滴注、甲吡唑和紧急 HD 治疗，改善了神经状态。入院数天后，检测到患者同时摄入了乙二醇、二甘醇和甲醇，其酒精水平呈阳性。大多数 TA 被酶醇脱氢酶（ADH）代谢为其有毒副产物。当同时摄入多种物质时，这些醇的动力学将发生改变。此外，早期摄入会导致高 OG 而不是高 AG。由于分析仪中 L-乳酸氧化酶的交叉反应，摄入乙二醇会导致假性乳酸升高。在我们的病例中，由于临床改善不佳，给予甲吡唑治疗后早期进行 HD，随后神经状态迅速恢复，可能预防了肾衰竭。当遇到患有乳酸酸中毒、高 OG 和正常 AG 的个体时，应高度怀疑 TA 摄入。
