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Case Report

2008/07/25
General Data
• 51y/o male patient
• Mainland China fisherman
• Presented to ER on 2008/06/12 18:27pm
• Smoking: (+)
• Drinking: (+)
• Denied Hx of major systemic diseases
• Denied allergy Hx
Chief complaint
• Severe abdominal pain since 12pm,
nausea sensation and vomiting several
times
• Vital Signs: (97/06/12)
– BP : 140/80mmHg
– PR : 88/min
– RR : 24/min
– BT : 36.40C
Present Illness
• Abdominal pain complained since
afternoon. The pain was colicky and
intermittent. He was initially brought to
LMD and was referred to our ER.
Physical Examination
• Cons: E4V5M6, Clear
• Pupils: (2+/2+)
• HEENT: Not pale or icteric
• Neck: Supple
• Chest: Bilateral clear BS
• Heart: Regular HB, No murmur
• Abdomen: Diffuse tenderness, Voluntary
muscle guarding
• Ext: Freely and movable
Laboratory Findings
• Hb – 15.9 g/dL
• WBC – 19500/uL N/L 83.6%/11.6%
• Glucose – 255 mg/dL
• Cr – 1.8 mg/dL
• AST – 425 U/L
• NA – 121.3 mmol/L
• K – 6.1 mmol/L
• Lipase – 123 U/L
• EKG – NSR (90/min)
Further examination
• T Bil – 2.8 g/dL
• ALK-P – 118 U/L
• ALT – 91 U/L
• Blood osmolality – 324mOSM/L
• BUN – 25 mg/dL
• Alc – 16 mg/dL
• Cl – 83 mmol/L
• Amylase – 282 U/L
ABG and other Data
• pH – 6.753
• pCO2 – 15.2
• pO2 – 129.1
• HCO3 – 2.1
• Anion Gap = Na - (Cl + HCO3-)
• Anion Gap – 36
• Osmolar Gap = Measured Posm – Calculated
Posm (Posm = 2(Na) + glucose/18 + BUN/2.8 )
• Osmolality Gap – 67
DISCUSSION
Toxins and disease states associated with
an elevated AG metabolic acidosis
Drugs and medical conditions not
listed in MUDPILES
Toxins with elevated Osmol gap
• Mannitol
• Alcohols: ethanol, ethylene glycol,
isopropanol, methanol, propylene glycol
• Diatrizoate
• Glycerol
• Acetone
• Sorbitol
Methanol
Intoxication
Methanol
• Commonly found in automobile windshield
washer solvent, gas line antifreeze, copy
machine fluid, fuel for small stoves, paint
strippers, and as an industrial solvent.
• Can be absorbed rapidly from the gut, skin
and lung.
• Slowly metabolized first to formaldehyde
(by ADH) ,and then to formic acid
Metabolic pathway of methanol
Metabolism and Half life
• Methanol is oxidized 10 times more slowly
than ethanol.
• Ethanol has a 10 to 20 times greater
affinity for alcohol dehydrogenase than
methanol
• The serum half-life of methanol after mild
toxicity is 14 to 20 hours, and, after severe
toxicity, 24 to 30 hours
• 1mL/kg is considered lethal
Elimination
• Hepatic: 75%~85%
• Renal: 2%~5%
• Pulmonary: 10%~20%
• Alcohol dehydrogenase oxidizes methanol
to formaldehyde, which is converted
rapidly to formic acid by formaldehyde
dehydrogenase
• The folate-dependent pathway oxidizes
formic acid to carbon dioxide
Time course
• Initial symptoms generally occur 12-24 hours
after ingestion.
• The interval between ingestion and the
appearance of symptoms is correlated with the
volume of methanol ingested and the amount of
ethanol concomitantly ingested; competitive
inhibition exists between the two.
• Methanol blood levels peak at 30-90 minutes
following ingestion and are often not correlated
with time to symptom appearance
Neurologic effects
• Headache
• Vertigo
• Lethargy
• Confusion
• Hemorrhagic and nonhemorrhagic damage
of the putamen
• Coma and seizures may occur in severe
cases, probably as a result of cerebral
edema
GI effects
• Nausea
• Vomiting
• Abdominal pain
• Pancreatitis
Opthalmologic effects
• Blurred vision, snow field
• Decreased visual acuity
• Photophobia
• Constricted visual fields
• Fixed and dilated pupils
• Retinal edema
• Visual defects may present in 25% of
severe cases
Specific effects due to Formic acid
• High anion gap metabolic acidosis
• Inhibit cytochrome oxidase chain, leading
to lactate formation
• Visual impairment, papilledema
• Pancreatitis
• High osmol gap
Treatment
• ABC’s
• GI decontamination( gastric lavage ) +
Ativated charcoal
• Fluid supply and Thiamine 100mg iv q6h
• Correction of metabolic acidosis with
bicarbonate
• Alcohol dehydrogenase (ADH) blockade
• Arrange hemodialysis if necessary.
• Adjuvant therapy – folic acid
Indications for Dialysis
• Signs of visual or CNS dysfunction
• Peak methanol level > 20mg/dl
• pH < 7.15
• History of ingestion > 30ml
ADH competitive inhibitor
• Ethanol
– Loading dose : 0.8g/kg
– Maintain dose : 66-130mg/kg/hr
• Alcoholism : 100-154mg/kg/hr
• Hemodialysis : 250-350mg/kg/hr
• IV with 10% solution
• Oral with 20%-30% solution
Indications and Treatment
Take Home message
ABG – High anion gap metabolic acidosis:
• C: CO, CN
• A: aspirin, alcohol
• T: toluene, theophylline
• M: methanol, metformin
• D: DKA, AKA, SKA.
• U: uremic toxin
• P: paraldehyde, phenformin
• I : Iron, INH
• L: lactic acidosis
• E: ethylene glycol
References
• Emergency medicine; A comprehensive
study guide 6th edition (Oct 2003): Judith
E Tintinalli
• Differentiating the Causes of Metabolic
Acidosis in Poisoned patient : Clin Lab
Med 26(2006) 31-48 Bryan S. Judge
• 甲醇中毒的診斷與治療 台中榮總 急診毒物
科 洪東榮主任
• Emedicine: methanol intoxication