Case presentation
The first case was a 49-year-old Saudi man who was found unconscious by his brother. He was brought to the emergency department (ED) by emergency medical services (EMS). On arrival, he showed decreased consciousness, hyperventilation, low-grade fever, and tachycardia. His family initially suspected that his condition was attributable to a drug overdose. He was intubated and mechanically ventilated because his Glasgow coma scale (GCS) score remained 9 despite efforts to stimulate and resuscitate him. His initial vital signs were as follows: blood pressure, 136/84 mmHg; heart rate, 145 beats/minute; respiratory rate, 56 breaths/minute; oxygen saturation, 98% in room air; and glucose level, 10 mmol/L. His physical examination was unremarkable apart from the presence of bilateral pinpoint pupils. After initial stabilization in the ED, he was admitted to the intensive care unit (ICU) because of low GCS and unstable vitals. He was maintained on mechanical ventilatory support and vasopressors because of hypotension. During the second day of his stay in the ICU, he started to show signs of worsening mental status and his computed tomography (CT) scan showed evidence of intracranial hemorrhage. His stay was complicated by ongoing evidence of sepsis and end organ damage represented by acute kidney impairment, worsening coagulopathy, rhabdomyolysis, and positive blood culture screen, with evidence of infective endocarditis on transesophageal echocardiography. This was managed by antibiotics and aggressive fluid and inotropic support. One week after admission, he showed no improvement in mental status and worsening neurological weakness. His repeated magnetic resonance imaging showed new middle cerebral artery infarction and the possibility of multiple infarcts. Attempts at weaning him from ventilatory support were unsuccessful and ended with placement of tracheostomy insertion. The patient was discharged on nasogastric and tracheostomy tubes in a stable condition but with poor functional state.
Our second patient was a 24-year-old man who was brought to our institution by EMS after a road traffic accident. Upon initial assessment, he was found to be intoxicated and agitated. His GCS score was 13. His initial vital signs were as follows: blood pressure, 114/61 mmHg; heart rate, 95 beats/minute; respiratory rate, 20 breaths/minute; oxygen saturation, 98% on room air; and glucose level, 5.7 mmol/L. His initial examination showed a red left eye but was otherwise unremarkable; furthermore, his extended focused assessment with sonography in trauma (eFAST) examination was negative. Apart from agitation, the findings of the patient’s physical examination were normal. The patient was hemodynamically stable upon assessment, with no signs of bleeding or other obvious injuries. He was acidotic with a pH of 7.25, and his HCO3 level was 10 mEq/L, as determined by analysis of the initial venous blood gas sample. Serum osmolality was 290 mOsm/kg. He received a fomepizole infusion; however, soon after sobering and admission, he discharged himself against medical advice.
The third patient was a 26-year-old man with no history of serious diseases, who presented to the ED complaining of blurry vision, vomiting, and hyperventilation that started the previous day after the consumption of an unknown amount of alcohol. He was alert and oriented to time, place, and person, with a GCS score of 15. His initial vital signs were as follows: blood pressure, 141/75 mmHg; heart rate, 92 beats/minute; respiratory rate, 20 breaths/minute; oxygen saturation, 100% in room air; and glucose level, 5.2 mmol/L. Analysis of his venous blood sample showed a pH of 6.9, and the HCO3 level was 5.7 mEq/L. The anion gap in his serum sample was 20 mEq/L, with a measured osmolality of 310 mOsm/kg (reference range, 275–295 mOsm/kg). His vision continued to diminish after admission. His management included fomepizole infusion, hemodialysis, thiamine infusion, and application of sodium bicarbonate boluses. Two days after admission, his laboratory markers normalized and he was discharged back to his normal condition, except for his vision derangement where he was referred to an ophthalmology specialized clinic where follow-up was lost.
Our fourth patient was a 25-year-old woman with a history of iron deficiency anemia who presented to the ED complaining of shortness of breath, dizziness, nausea, left flank pain, blurry vision, and palpitations. These symptoms had progressed over the last 3 days with alcohol consumption before she presented at our institution. The patient was conscious and oriented to time, place, and person. Her initial vital signs were as follows: blood pressure, 138/94 mmHg; heart rate, 104 beats/minute; respiratory rate, 22 breaths/minute; oxygen saturation, 98% in room air; and glucose level, 4.7 mmol/L. Her venous blood gas pH was 7.32 and HCO3 level was 15 mEq/L. The measured serum osmolality was 280 mOsm/kg and the anion gap was 15 mEq/L.
During admission, she received four doses of fomepizole infusion as per the institution poison control center protocol (0.9 g intravenous loading dose then 0.6 g q 12 hours). After completion of therapy, she was discharged home in her normal baseline condition.
The fifth patient was a 20-year-old woman who had been admitted and treated in another hospital for 1 week for acidosis and intoxication. She presented to our ED complaining of a 2-day history of bilateral complete vision loss. She had no other complaints. Her initial vital signs were as follows: blood pressure, 107/55 mmHg; heart rate, 54 beats/minute; respiratory rate, 20 breaths/minute; oxygen saturation, 99% in room air; and glucose level, 6 mmol/L. Her venous blood gas pH was 7.3 and HCO3 level was 14.9 mEq/L. The measured serum osmolality was 278 mOsm/kg, and the anion gap was 15 mEq/L. Upon admission, the patient received fomepizole infusion and was admitted for 3 days, during which time her condition improved, and she regained her vision. No hemodialysis was required. Patient was lost to follow-up after referral to ophthalmology.
Our sixth patient was a 27-year-old man who presented with complaints of vomiting and severe abdominal pain, restlessness, and blurry vision after alcohol consumption 2 days prior to his visit to our institution. His initial vital signs were as follows: blood pressure, 134/90 mmHg; heart rate, 84 beats/minute; respiratory rate, 20 breaths/minute; oxygen saturation, 98% in room air; and glucose level, 4.7 mmol/L. His venous blood gas showed a pH of 7.1, and the HCO3 level was 5 mEq/L. The measured serum osmolality was 296 mOsm/kg and the anion gap was 33 mEq/L. Methanol poisoning was strongly suspected, therefore, fomepizole, thiamine, folic acid, sodium bicarbonate infusion, and hemodialysis treatment were started. During his hospital stay, he received fomepizole as per the poison control center institution protocol (15 mg/kg intravenous loading dose of fomepizole followed by 10 mg/kg q 6 hours during his dialysis). He remained on continuous renal replacement therapy for 24 hours. He was discharged the next day after improvement and resolution of all his symptoms.
The seventh patient was a 36-year-old man who presented with complaints of fatigue, loss of appetite, and chest pain after consumption of alcohol 2 days prior to his visit to our institution. He had no visual symptoms and his GCS score was 15. The initial pH of his venous blood gas was 7.2, and the HCO3 level was 15 mEq/L. Serum osmolality was 277 mOsm/kg. He was administered fomepizole, folic acid, and sodium bicarbonate treatments and was soon discharged in good condition.
Our eighth patient was a 19-year-old woman with no history of serious diseases, who presented with acidosis, abdominal pain, vomiting, and blurred vision 2 days after the consumption of contaminated alcohol. The pH of her venous blood gas was 7.1, and the serum osmolality was 278 mOsm/kg. She was started on continuous renal replacement therapy upon admission, and given fomepizole, folinic acid, bicarbonate infusion until resolution of her symptoms was achieved. She was discharged back to her normal healthy baseline, with a referral to ophthalmology for follow-up.
The ninth patient was a 20-year-old woman who developed abdominal pain, nausea and vomiting, and blurred vision after attending a party. Analysis of her venous blood sample showed a pH of 7.34 and HCO3 level of 18 mEq/L. She was started on continuous renal replacement therapy upon admission and started on fomepizole infusion as per the poison control center institution protocol (15 mg/kg intravenous loading dose of fomepizole followed by 10 mg/kg q 6 hours during dialysis). She continued on treatment until resolution of her symptoms the next day. She was discharged back to her normal healthy baseline, with a referral to ophthalmology for follow-up.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.