Repeated intoxication presenting with azotemia, elevated serum osmolal gap, and metabolic acidosis with high anion gap: differential diagnosis, management, and prognosis

• Published in: International urology and nephrology Vol. 44; no. 1; pp. 309 - 314
• Main Authors: Prevost, Merideth, Sun, Yijuan, Servilla, Karen S., Massie, Larry, Glew, Robert H., Tzamaloukas, Antonios H.
• Format: Journal Article
• Language: English
• Published: Dordrecht Springer Netherlands 01.02.2012; Springer Nature B.V
• Subjects: 2-Propanol - blood; 3-Hydroxybutyric Acid - urine; Acetoacetates - urine; Acetone - blood; Acid-Base Equilibrium; Acidosis - complications; Aged; Alcoholic Intoxication - therapy; Azotemia - complications; Ethanol - blood; Ethanol - poisoning; Fatal Outcome; Fluid Therapy; Humans; Hyponatremia - complications; Ketosis - complications; Male; Medicine; Medicine & Public Health; Nephrology; Nephrology – Case Report; Octreotide - therapeutic use; Osmolar Concentration; Potassium Chloride - therapeutic use; Urology; 2-propanol; Anion gap; Osmolal gap; Alcoholic ketoacidosis; Azotemia; Metabolic acidosis; Acetone
• ISSN: 0301-1623; 1573-2584
• DOI: 10.1007/s11255-010-9796-6

A man with a history of alcoholism presented on two different occasions with mental changes, clinical signs of volume depletion, elevated serum osmolal gap, metabolic acidosis with high anion gap, metabolic alkalosis, hyponatremia, and azotemia after binge drinking of only ethanol. In both episodes, the serum contained ethanol, acetone, and 2-propanol (isopropanol), but no methanol or ethylene glycol. In the first episode, the rates of excretion of acetoacetate and 3-hydroxybutyrate in the urine were greatly increased. Volume repletion was the only treatment. In both episodes, azotemia and metabolic acidosis were rapidly reversed, while modest metabolic alkalosis was noted after treatment. The triad of azotemia, elevated osmolal gap, and high anion gap metabolic acidosis, which characterizes intoxication with methanol or ethylene glycol, can also develop in alcoholic ketoacidosis (AKA), an entity with substantially different management and outcome. Finding 2-propanol in the serum of patients with AKA indicates either concomitant 2-propanol ingestion or formation of 2-propanol from acetone.