Zand Irani Anis, Almuwais Ahmed, Gibbons Holly
Medicine, Gympie Hospital, Gympie, Queensland, Australia.
Medicine, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
BMJ Case Rep. 2020 Apr 8;13(4):e233306. doi: 10.1136/bcr-2019-233306.
An 85-year-old man with a background of transfusion-dependent chronic myelomonocytic leukaemia and chronic kidney disease stage III presented with symptomatic anaemia, acute kidney injury, sepsis and high anion gap metabolic acidosis (HAGMA). Initial treatment with intravenous antibiotics and blood transfusion was complicated by transfusion-associated circulatory overload, necessitating diuresis and non-invasive ventilation. Despite gradual clinical improvement, the patient's HAGMA persisted, and no cause was identified on urine testing or renal ultrasound. As the patient was on long-term dicloxacillin for infective endocarditis prophylaxis and regular paracetamol, pyroglutamic acidosis (PGA) (5-oxoproline acidosis) was considered. This was later confirmed with elevated serum levels, and the HAGMA resolved following cessation of these medications. Although considered an uncommon cause of HAGMA, PGA is likely also under-recognised, and to our knowledge, this may be the second reported case in the context of dicloxacillin.
一名85岁男性，有输血依赖型慢性粒单核细胞白血病和慢性肾脏病Ⅲ期病史，出现症状性贫血、急性肾损伤、脓毒症和高阴离子间隙代谢性酸中毒（HAGMA）。初始采用静脉抗生素和输血治疗，但出现了输血相关循环超负荷并发症，需要进行利尿和无创通气。尽管临床症状逐渐改善，但患者的HAGMA持续存在，尿液检查和肾脏超声未发现病因。由于患者长期服用双氯西林预防感染性心内膜炎且定期服用对乙酰氨基酚，考虑为焦谷氨酸酸中毒（PGA）（5-氧脯氨酸酸中毒）。后来血清水平升高证实了这一点，停用这些药物后HAGMA得到缓解。尽管PGA被认为是HAGMA的罕见病因，但可能也未得到充分认识，据我们所知，这可能是第二例与双氯西林相关的报道病例。
