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

  • Nephrology – Case Report
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Abstract

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.

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Acknowledgments

We thank Lucy Hunsaker for drafting the figure in this report.

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Authors and Affiliations

  1. Department of Medicine, University of New Mexico (UNM) School of Medicine, Albuquerque, USA

    Merideth Prevost

  2. Renal Section (111C), Raymond G. Murphy VA Medical Center and UNM School of Medicine, 1501 San Pedro, SE, Albuquerque, NM, 87108, USA

    Yijuan Sun, Karen S. Servilla & Antonios H. Tzamaloukas

  3. Pathology Service, Raymond G. Murphy VA Medical Center, Albuquerque, USA

    Larry Massie

  4. Department of Biochemistry and Molecular Biology, University of New Mexico School of Medicine, Albuquerque, NM, USA

    Robert H. Glew

Authors
  1. Merideth Prevost
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  2. Yijuan Sun
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  3. Karen S. Servilla
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  4. Larry Massie
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  5. Robert H. Glew
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  6. Antonios H. Tzamaloukas
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Correspondence to Antonios H. Tzamaloukas.

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Prevost, M., Sun, Y., Servilla, K.S. et al. Repeated intoxication presenting with azotemia, elevated serum osmolal gap, and metabolic acidosis with high anion gap: differential diagnosis, management, and prognosis. Int Urol Nephrol 44, 309–314 (2012). https://doi.org/10.1007/s11255-010-9796-6

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  • DOI: https://doi.org/10.1007/s11255-010-9796-6

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