Letter to the Editor
Methanol poisoning caused by inhalation of solvent
Intoxicación por metanol por inhalación de disolvente
Servicio de Nefrología, Hospital Universitario de Álava, Vitoria, Álava, Spain
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It produces acidosis, visual and cognitive alterations.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are not many cases described as those that we present here, associated with methanol inhalation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 21-year-old woman with no medical history and in no medications who came to the emergency room complaining of blurred vision. She presents progressive decrease in vision during the last 24<span class="elsevierStyleHsp" style=""></span>h and respiratory distress. She refers a continued inhalation of universal solvent (methanol: 10–25% and toluene: 50–75%) during the last 5 days. She negates other toxics consumption.</p><p id="par0020" class="elsevierStylePara elsevierViewall">She reports inhalation of solvent since she was 13 years old that was stopped 5 years ago.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Physical exam: BP 123/87<span class="elsevierStyleHsp" style=""></span>mmHg; HR 88<span class="elsevierStyleHsp" style=""></span>bpm; O<span class="elsevierStyleInf">2</span> saturation 100% and breathing at 40<span class="elsevierStyleHsp" style=""></span>rpm; sleepy; reactive mydriatic pupils and normal oculomotor exploration. Finger-nose dysmetria (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0030" class="elsevierStylePara elsevierViewall">20-Year-old man, consumer of inhaled solvent since he was 8 years old. Intoxicated a year ago by glue (toluene) with optical atrophy and 10% visual acuity.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He came to the hospital complaining of general malaise, abdominal pain and vomiting during the last 24<span class="elsevierStyleHsp" style=""></span>h. The patient refers a continued inhalation of solvent for 3 days.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Physical examination: BP 115/82<span class="elsevierStyleHsp" style=""></span>mmHg; HR 110<span class="elsevierStyleHsp" style=""></span>bpm and respiratory rate of 38<span class="elsevierStyleHsp" style=""></span>rpm. Upon his arrival he was conscious and oriented, but with tendency to sleep in the following hours. Oculomotor exploration with mild reactive mydriasis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the clinical suspicion of intoxication by methanol and toluene whose levels are not available immediately, it was decided to administer bicarbonate and ethanol and perform a high flow hemodialysis session for 8<span class="elsevierStyleHsp" style=""></span>hours.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Case 1: At the end of the treatment, despite the correction of the electrolyte alterations, there was little improvement in the level of alertness and vision, with ophthalmological examination and MRI performed without finding. It was decided to repeat a new session of hemodialysis for 4<span class="elsevierStyleHsp" style=""></span>h, with discrete cognitive and discrete visual acuity improvement without total recovering at discharge.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Case 2: During the hemodialysis session the alert level progressively improved. He did not need a second session.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Toluene is in glues and solvents. It is metabolized to hippuric acid that is rapidly secreted by the kidney producing acidosis with normal or minimally elevated AG and hypokalemia due to volume contraction with RAA stimulation. It is lipophilic, so it acts rapidly in the CNS (euphoria, hallucinations, ataxia, confusion-coma, optic neuropathy, …). The treatment is limited to correct hydroelectrolytic alterations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Methanol is present in many industrial and domestic products. It is common to find cases of intoxication by ingestion and transdermal absorption, but there are few cases described of intoxication by inhalation.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Symptoms depend on the level of exposure: abdominal discomfort, CNS alterations, even coma and death, and visual disturbances (blurred vision, photophobia, scotomas, decreased acuity and even blindness). The presence of non-reactive mydriasis is a sign of poor prognosis and indicates the irreparable loss of vision.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is characterized by metabolic acidosis with high anion gap (accumulation of formic acid) and/or high osmolal gap (methanol accumulation).</p><p id="par0080" class="elsevierStylePara elsevierViewall">The value of osmolal and anionic gap depends on the time elapsed after intoxication. Initially, it has a high osmolal gap, subsequently it decreases when methanol is metabolized to its acid metabolites, increasing the anionic gap and decreasing the osmolal gap.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Therefore, in our cases that have been exposed to sustained slow poisoning, the anion gap is higher than osmolal.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The methanol level can be estimated by means of the osmolal gap: by subtracting the normal gap (10–12<span class="elsevierStyleHsp" style=""></span>mOsm/kg) and multiplying by the molecular weight of methanol (32<span class="elsevierStyleHsp" style=""></span>g/mol).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Methanol is metabolized via alcohol dehydrogenase (ADH) giving rise to formic acid, responsible for acidosis and visual damage by inhibiting mitochondrial function in the retina. Treatment includes the administration of ethanol, with 10–20 times greater affinity for ADH, with a complete inhibition at a concentration of 100<span class="elsevierStyleHsp" style=""></span>mg/dl.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The levels of formic acid are directly related to morbidity and mortality.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our cases, the high osmolal and anionic hiatus orientate to methanol as the main toxic, although hypokalemia and absence of acid urine indicate some effect of toluene.</p><p id="par0105" class="elsevierStylePara elsevierViewall">General indications of hemodialysis include a high methanol level (>50<span class="elsevierStyleHsp" style=""></span>mg/dL), metabolic acidosis, and visual or mental changes. It is well dialyzed because it is a small molecule (32<span class="elsevierStyleHsp" style=""></span>Da), not bound to proteins with a distribution volume of 0.6–0.7<span class="elsevierStyleHsp" style=""></span>l/kg.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7–9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Methanol poisoning is a serious condition whose initial treatment includes performing hemodialysis, rapidly reducing the levels of alcohol and its metabolites, decreasing morbidity and mortality. Since immediate determination of methanol is hard to obtain, the treatment must be extended until the improvement of the cognitive level and correction of the electrolyte alterations that are related to the toxic levels.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In cases of inhalation poisoning, the values of anionic gap are more important than the osmolal gap because they are usually slow intoxications, better tolerated, which delay the arrival of the patient in the emergency room. The attitude towards these patients has to be dictated by the clinic findings rather than the analytical data, since it is a serious situation that can lead to the permanent reduction of visual acuity and even death.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Robledo C, Saracho R. Intoxicación por metanol por inhalación de disolvente. Nefrologia. 2018;38:679–680.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The decreased potassium values and the high urinary pH for the level of acidosis indicates the presence of toluene.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sodium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">138<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">141<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Potassium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatine kinase \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46<span class="elsevierStyleHsp" style=""></span>U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">387<span class="elsevierStyleHsp" style=""></span>U/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloride \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osmolality (measured) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">305<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">315<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osmolality (calculated) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">289<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">293.8<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osmolal Gap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.2<span class="elsevierStyleHsp" style=""></span>mOsm/kg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bicarbonate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3<span class="elsevierStyleHsp" style=""></span>mmol/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.8<span class="elsevierStyleHsp" style=""></span>mmol/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lactate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1<span class="elsevierStyleHsp" style=""></span>mmol/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5<span class="elsevierStyleHsp" style=""></span>mmol/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anion gap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.3<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.2<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Methanol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.3<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.3<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urine pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1921434.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Complementary tests. Both patients show, metabolic acidosis with high anion gag (formic acid) and high osmolal gap (methanol).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxic alcohol ingestions: clinical features, diagnosis, and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Kraut" 1 => "I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 41 | 5 | 46 |
| 2024 October | 294 | 55 | 349 |
| 2024 September | 427 | 38 | 465 |
| 2024 August | 405 | 66 | 471 |
| 2024 July | 340 | 37 | 377 |
| 2024 June | 281 | 63 | 344 |
| 2024 May | 266 | 48 | 314 |
| 2024 April | 179 | 27 | 206 |
| 2024 March | 240 | 33 | 273 |
| 2024 February | 355 | 60 | 415 |
| 2024 January | 275 | 28 | 303 |
| 2023 December | 204 | 28 | 232 |
| 2023 November | 255 | 49 | 304 |
| 2023 October | 293 | 50 | 343 |
| 2023 September | 244 | 39 | 283 |
| 2023 August | 239 | 34 | 273 |
| 2023 July | 189 | 42 | 231 |
| 2023 June | 217 | 28 | 245 |
| 2023 May | 171 | 56 | 227 |
| 2023 April | 128 | 38 | 166 |
| 2023 March | 211 | 44 | 255 |
| 2023 February | 212 | 33 | 245 |
| 2023 January | 150 | 32 | 182 |
| 2022 December | 186 | 48 | 234 |
| 2022 November | 208 | 47 | 255 |
| 2022 October | 184 | 73 | 257 |
| 2022 September | 158 | 33 | 191 |
| 2022 August | 179 | 44 | 223 |
| 2022 July | 213 | 58 | 271 |
| 2022 June | 151 | 37 | 188 |
| 2022 May | 154 | 45 | 199 |
| 2022 April | 158 | 54 | 212 |
| 2022 March | 168 | 53 | 221 |
| 2022 February | 178 | 56 | 234 |
| 2022 January | 209 | 33 | 242 |
| 2021 December | 175 | 46 | 221 |
| 2021 November | 140 | 45 | 185 |
| 2021 October | 192 | 56 | 248 |
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| 2021 August | 191 | 37 | 228 |
| 2021 July | 188 | 47 | 235 |
| 2021 June | 174 | 37 | 211 |
| 2021 May | 174 | 62 | 236 |
| 2021 April | 413 | 96 | 509 |
| 2021 March | 270 | 37 | 307 |
| 2021 February | 199 | 35 | 234 |
| 2021 January | 256 | 27 | 283 |
| 2020 December | 217 | 18 | 235 |
| 2020 November | 177 | 19 | 196 |
| 2020 October | 133 | 20 | 153 |
| 2020 September | 179 | 19 | 198 |
| 2020 August | 188 | 19 | 207 |
| 2020 July | 253 | 17 | 270 |
| 2020 June | 169 | 20 | 189 |
| 2020 May | 173 | 14 | 187 |
| 2020 April | 215 | 17 | 232 |
| 2020 March | 237 | 27 | 264 |
| 2020 February | 194 | 23 | 217 |
| 2020 January | 269 | 28 | 297 |
| 2019 December | 200 | 24 | 224 |
| 2019 November | 278 | 25 | 303 |
| 2019 October | 321 | 22 | 343 |
| 2019 September | 441 | 26 | 467 |
| 2019 August | 326 | 21 | 347 |
| 2019 July | 298 | 34 | 332 |
| 2019 June | 161 | 26 | 187 |
| 2019 May | 151 | 13 | 164 |
| 2019 April | 128 | 43 | 171 |
| 2019 March | 89 | 27 | 116 |
| 2019 February | 38 | 20 | 58 |
| 2019 January | 36 | 42 | 78 |
| 2018 December | 48 | 49 | 97 |
| 2018 November | 2 | 1 | 3 |
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