Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis
The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at...
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| Format: | Article |
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Wiley
2015-01-01
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| Series: | Case Reports in Critical Care |
| Online Access: | http://dx.doi.org/10.1155/2015/272914 |
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| author | Eugene M. Tan Ejaaz Kalimullah M. Rizwan Sohail Kannan Ramar |
| author_facet | Eugene M. Tan Ejaaz Kalimullah M. Rizwan Sohail Kannan Ramar |
| author_sort | Eugene M. Tan |
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| description | The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient’s presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis. |
| format | Article |
| id | doaj-art-6459aa136dd04d60870691e4a8cdfa85 |
| institution | Kabale University |
| issn | 2090-6420 2090-6439 |
| language | English |
| publishDate | 2015-01-01 |
| publisher | Wiley |
| record_format | Article |
| series | Case Reports in Critical Care |
| spelling | doaj-art-6459aa136dd04d60870691e4a8cdfa852025-02-03T07:23:33ZengWileyCase Reports in Critical Care2090-64202090-64392015-01-01201510.1155/2015/272914272914Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic AcidosisEugene M. Tan0Ejaaz Kalimullah1M. Rizwan Sohail2Kannan Ramar3Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USADepartment of Emergency Medicine, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL 60153, USADivision of Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USADivision of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USAThe approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient’s presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis.http://dx.doi.org/10.1155/2015/272914 |
| spellingShingle | Eugene M. Tan Ejaaz Kalimullah M. Rizwan Sohail Kannan Ramar Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis Case Reports in Critical Care |
| title | Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis |
| title_full | Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis |
| title_fullStr | Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis |
| title_full_unstemmed | Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis |
| title_short | Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis |
| title_sort | diagnostic challenge in a patient with severe anion gap metabolic acidosis |
| url | http://dx.doi.org/10.1155/2015/272914 |
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