A 50‐year‐old male painter with a history of depression presented to the emergency room with altered mental status. His wife stated he had been acting strangely the night prior to admission and was found in bed that morning unresponsive and diaphoretic. He had been depressed because of recently losing his job. Initial vital signs revealed hypothermia (35°C), tachycardia (121 beats per minute), and hypoxia (oxygen saturation of 85% on a 100% nonrebreather). Exam was notable for a middle‐aged, well‐developed diaphoretic man in severe respiratory distress. His Glasgow coma score was 3 (E1M1V1), and his pupils were fixed and dilated. A stat arterial blood gas revealed a pH of 6.76, pCO2 of 25.8 mm Hg, and bicarbonate of 3.5 mEq/L. Laboratory results included a sodium of 137, potassium 7.4, bicarbonate 5, chloride 101, blood urea nitrogen 9, creatinine 2.0, glucose 368, lactic acid 11.8 mmol/L, and serum osmolality 378 mOsm/kg. His anion gap was 31, calculated osmolar gap 78, and serum alcohol level < 5 mg/dL. He was intubated and started on a bicarbonate infusion for metabolic acidosis and hyperkalemia. Shortly after intubation, he developed generalized tonic‐clonic seizures, requiring intravenous lorazepam and phenobarbital administration. On further questioning, his wife noted that he complained of blurry vision the night prior to admission and had been alone in the garage all day. Given his severe anion‐gap metabolic acidosis and high calculated osmolar gap, toxic alcohol ingestion was suspected. Methanol toxicity was suspected because of the blurred vision, and his wife confirmed his access to paint thinner. Fomepizole therapy was initiated, followed by emergent hemodialysis. Despite initiating treatment within hours of admission, his neurological status did not improve and subsequent computed tomography of the head revealed diffuse edema and bilateral uncal herniation. Brain death was confirmed with an apnea test. Toxicology screen later confirmed methanol toxicity.
Methanol poisoning in the United States is rare, with only 2059 cases resulting in 11 fatalities in 2007. Methanol, or wood alcohol, is a common solvent used in antifreeze and paint thinner and as an alternative to ethanol for ingestion (moonshine). Initially nontoxic, digestion and oxidization by alcohol dehydrogenase lead to formaldehyde and formic acid, causing end‐organ damage and potentially death if not rapidly recognized and treated. Concomitant ingestion of ethanol can competitively inhibit alcohol dehydrogenase, thus delaying clinical presentation.
This case illustrates morbidity and mortality is related to delays in presentation and treatment. Empiric fomepizole is warranted with an anion‐gap metabolic acidosis and high calculated osmolar gap without awaiting toxicology screen, with the differential including methanol, ethylene glycol, and isopropyl alcohol poisoning. Poor outcomes are associated with a pH < 7.0 and neurological dysfunction on presentation.
J. Cohen ‐ none; V. Boggala ‐ none; D. Feinstein ‐ none
To cite this abstract:Cohen J, Boggala V, Feinstein D. A Mortal Case of Moonshine. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 255. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-mortal-case-of-moonshine/. Accessed April 8, 2020.