2011.12.162011.12.16指導醫師：許景瑋醫師指導醫師：許景瑋醫師報告者：報告者： fellow 1 fellow 1 潘恆之潘恆之

Name: 趙 o 林 Sex: male Age: 39 years old Chart number: 8767453 He visited our emergent room on 2011/11/04

Patient Profile

Acute onset of blurred vision lasts for one day.

Chief Complaint

This 39 y/o gentleman denied hypertension, diabetes mellitus or other systemic diseases.

He had experienced intermittent nausea, vomiting , and progressive anorexia since 11/01. Acute onset of blurred vision , dizziness, headache were noted since 11/04 morning. Besides, he suffered from intermittent bloody stool for 1 years.

No dyspnea, orthopnea, urine output decrease, abdominal pain, chest pain, fever, chillness or

cough.

He almost drinks every day. He often fogets to eat due to drunk. He drank 公賣局米酒 on 11/03 night.

Present Illness

He denied significant systemic diseases, such

as diabetes mellutis , hypertension, heart, kidney, or lung diseases.

Current medicine: nil

Past History

Allergy: no known allergy Alcohol: he drinks 米酒 at least 1 bottle per

day; betel-nut: denied; cigarette: 1 ppd/day since young age

Over-the-counter medication or chinese herb: denied

Personal History

Family History

No family history of diabetes mellutis, malignancy, heart, liver, kidney, or hereditary diseases.

Vital signs: T:36’C , P:116 bpm, R:17/min , BP:137/92

mmhg General apperance: chronic ill looking Consciousness: clear, GCS: E4V5M6 HEENT: conjunctive: not pale, sclera: anicteric pupil: 3mm/3mm , light reflex: +/+, EOM: full/full Chest: symmetric expansion , clear breathing sound Heart: regular heart beat without murmur Abdomen: soft and flat, normoactive bowel, no tenderness liver/spleen: impalpable, no palpable bladder Extremity: free movement, no pitting edema Digital rectal exam: yellowishy stool

Physical Examination

11/04 Laboratory Data

WBC 5800/ul

Hgb 13.5 g/dl

Hct 41.1 fl

MCV 89.2 pg/cell

RDW 15.1 %

PLT 189000/uL

PT 10.7 sec

INR 1.0

11/04 Laboratory data

ABG

PH 7.24

PCO2 16.3 mmHG

PO2 50.8 mmHG

HCO3 6.8 mm/L

SaO2 81.0 %

Osmo gap: Serum Osm – calculated Osm ( 2 [Na] + [BUN]/2.8 + [glucose]/18

+ [EtOH]/4.6) = 21.86 mOsm/kg

BUN 14.7 mg/dl

Creatinine 0.99 mg/dl

ALT 58 IU/L

NA 134 mEq/L

K 3.8 mEq/L

Sugar 124 mg/dL

Osm 302 mosm/KgH2O

Alcohol < 5 mg/dL

=> Anion gap: ?

11/04 Brain CT

Impression: subtle low attenuation in cerebellum and prominent cerebellar sulci. DDX: cerebral cortical atrophy or infarct, pleased clinical correlation.

Metabolic acidosis with high osmolar gap,

etiology? favor methanol intoxication related

Bloody stool, favor hemorrhoid related

Impression

Closely monitor vital signs, mental status and

consult ophthalmologist for thorough visual exam Complete metabolic acidosis survey, please check

anion gap, ketone, lactate, ethyl alcohol and urine AG

Suggest the patient take ethanol as antidote Arrange hemodialysis for increasing methanol

elimination Follow up methanol level, blood Osm, and ABG Give thiamine and watch out for alcohol withdrawal

Plans

11/05 Ocular Examination

OD OS

IOP soft soft

VA CF/50cm CF/50cm

Lid NP NP

CONJ NP NP

EOM full full

P Ortho Ortho

K clear clear

AC Deep/clear Deep/clear

IRIS NP NP

Pupil 3mm 3mm

L/R +/+ sluggish +/+

RAPD + -

Lens clear clear

F’d disc pinkish, hyperemia change, margin clear

disc pinkish, margin clear

Laboratory data

ABG 11/05 11/06

PH 7.319 7.445

PCO2 23.1 38.1 mmHG

PO2 47.5 90.1 mmHG

HCO3 11.6 25.5 mm/L

SBE -20.6 1.5 mm/L

SaO2 81.1 97.2 %

11/05 11/06

Cr 0.76 mg/d

AST 49 IU/L

ALT 38 IU/L

Osm 273 mosm/KgH2O

Methanol 45.6 < 0.1 mg/dL

Blood ketone

Negative

Lactate 12.3 mg/dL

HD HD

Other examination

11/07 Sigmoidoscopy :Impression: No active bleeder. Colon polyp, R-S colon Mixed hemorrhoid.

11/09 Brain MRI :

Impression:

Normal brain MR study.

11/09 Follow-up Ocular Examination

s/s : still blurred vision (ou) VA: ou CF/50cm RAPD: + (od) clear corea, AC and lens (ou) fundus: decreased hyperemia of the r’t

disc, but disc margin is sl. blurred

=> Discharge and OPD follow-up !!

Methanol are frequently found in high concentration

in automotive antifreeze and de-icing solutions, windshield wiper fluid, solvent cleaners, fuels, other industrial products, and adulterant in homemade distillates.

Most serious poisonings occur following ingestion; inhalation and dermal exposures rarely cause toxicity.

Lethal dose – 1 g/kg Toxicity dose – 0.25ml/kg of 100% methanol

(>8g)

Threshold of treatment – 20~25mg/dL

Summary of exposure

Methanol metabolism

1

33

6

Toxicity

( Liver )

( Liver )

Kidney ： 3~5%Lung ： 12%

Half life

8 hr

20 hr

Elimination

Adult: 8.5 mg/dl/hrChild: 0.88 mg/dl/hr

51hr

@

Clinical features

Early toxicity (acute intoxication) CNS ： sedation, disinhibition, ataxia,

headache GI ： abdominal pain, nausea, vomiting

Late toxicity (severe metabolic acidosis develops 6-12 hours after exposure )

HEENT ： Ocular toxicity CV: tachycardia, arrythmia, bradycardia (fatal poisoning), cardiac arrest, severe hypotension Respiratroy: tachypnea, sudden respiratory failure Neurologic: coma, seizure, basal ganglia necrosis with parkinsonian features, polyneuropathy, optic atrophy GI: abdominal pain, anorexia, nausea, vomiting, necortizing pancreatitis (severe poisoning)

Clinical features

GU: acute renal failure, hamaturia Acid-base: metabolic acidosis (concurrent ethanol ingestion may delay acidosis > 1 hr ) Electrolyte: hypomagnesemia, hypokalemia, hypophophatemia Musculoskeletal: rhabdomyolysis (severe poisoning) Reproductive: birth defects of CNS (ingested together with other solvents)

Keypoints of PE: Vital sign, mental status, pupuils, thorough visual exam

Clinical features

Relative afferent

pupillary defect

@

Normal

Diagnostic testing

Finger sugar (rule out hypoglycemia, DKA, HHNK)

Arterial or venous blood gas , renal function,

electrolytes, serum osmolality, methanol, ethanol ,

ethylene glycol, isopropanol concentration, lactate,

acetaminophen and salicylate levels (to help

determine diagnosis) high anion gap? HCO3 <8 ? Osm gap

> 10 ? mild elevated lactate levels? ECG Pregnancy test in women of childbearing age

Keep airway, breathing, circulation ： * Endotracheal intubation if mental status

change or respiratory failure hyperventilated with large minute ventilations to prevent profound

acidemia * IV crystalloid + vasopressors if hypotension

Treatment

Decontamination : * GI – not very useful ( methanol is rapidly absorbed and binds poorly to activated charcoal). Gastric aspiration by NG tube within 60 mins of ingestion maybe useful. * Eye – irrigate with water for > 15 mins * Dermal – remove contaminated clothing and wash exposed area with soap and

water

Treatment

Medication : a. If PH < 7.3, give Sodium bicarbonate 1-2meq/kg bolus + 132 meq in 1L D5W run 150-250cc/hr b. Antidote – ADH inhibition (give as soon as possible) * Fomepizole – 15mg/kg iv loading + 10mg/kg q12h x 4 doses Followed by 15mg/kg q12h if necessary * Ethanol – 8ml/kg of a 10% ethanol solution ivf loading + 1ml/kg/hr of 10% ethanol solution. Titrate serum EtOH to 100 mg/dL

Treatment

or

Hemodialysis -- rapidly remove both methanol and its toxic

acid metabolites (methanol half life 8 hrs 2.5 hrs) * Indication : a. Known methanol intoxication -- High anion gap metabolic acidosis -- End organ damage (visual changes) b. Suspected methanol intoxication -- Unexplained high anion gap metabolic acidosis + high plasma osmolar gap ( PH < 7.3 if strongly suspected, PH < 7.1 if weakly susected)

Treatment

Cofactor therapy – combine with ADH

inhibition Folinic acid (leucovorin) 50mg iv q4-6hor Folic acid 50mg IV q4-6h increases clearance of formate

Admission criteria: acidosis, visual symptoms, or methanol >

25mg/dL

Treatment