oa An unusual presentation of the chest and abdominal pain: toxic alcohol ingestion

Background: Methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol are common alcohols, whose consumption can lead to toxicity and significant morbidity and mortality^1,2. Clinicians must often rely on clinical features and laboratory values to determine the possible causative agent. Annually, almost 95,000 people die due to alcohol and it is the third leading cause of preventable deaths in the United States of America³. Case presentation: A 53-year-old male patient reported to the Emergency Department with vomiting, severe chest, and abdominal pain for one day. He looked unwell and was unstable. The blood gases showed metabolic acidosis with lactate of 10-mmol/L. Investigations on the line of Acute Mesenteric Ischemia, Pulmonary Embolism, and Aortic Dissection were negative. With time, the patient deteriorated with severe metabolic acidosis requiring rapid sequence intubation. Blood investigations showed multi-organ failure, high serum osmolarity, and high osmolar gap. Later, he was admitted to the intensive care unit and underwent hemodialysis. His laboratory test results improved, and he was extubated. Eventually, he revealed having taken homemade alcohol. Recommendations: High Anion Gap is a hallmark of toxic alcohol poisoning. A potential toxic alcohol ingestion surrogate marker is an elevated osmol gap. Abnormal presentation and a patient hiding key information can delay the diagnosis. The key to successful early diagnosis is good history taking, patient collaboration, complete examination, and interpretation of laboratory results. Isopropyl alcohol is associated with nausea, vomiting, and abdominal pain since it is a gastrointestinal irritant. Magnetic Resonance Imaging of the brain can play a role in diagnosing toxic alcohol ingestion especially methanol, due to its characteristics findings like hemorrhagic putamen necrosis (Figure 1), however, clinical suspicion should not delay a patient's treatment. Conclusion: Abnormal presentations are quite common, and one should always keep a wide differential diagnosis in mind. Uncommon causes of severe metabolic acidosis could be easily missed. The main success factor in the management of toxic alcohol ingestion is to recognize it, do the calculations, and provide treatment.