Profound metabolic acidosis and oxoprolinuria in an adult

Profound metabolic acidosis in critically ill adults sometimes remains unexplained despite extensive evaluation. A 58-year-old female presented in a confused state to the emergency department; she had been confused for several days. Laboratory evaluation revealed a high anion gap metabolic acidosis...

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Bibliographic Details
Published in:Journal of medical toxicology 2007-09, Vol.3 (3), p.119-124
Main Authors: Hodgman, Michael J, Horn, James F, Stork, Christine M, Marraffa, Jeanna M, Holland, Michael G, Cantor, Richard, Carmel, Patti M
Format: Article
Language:English
Subjects:
Acetaminophen
Acetaminophen - adverse effects
Acidosis
Acidosis - etiology
Acidosis - urine
Adults
Analgesics
Analgesics, Non-Narcotic - adverse effects
Antibiotics
Case studies
Creatinine
Critical Illness - therapy
Critically ill
Defects
Disturbance
Emergency medical services
Ethylene glycol
Female
Females
Glutathione
Health aspects
Humans
Illnesses
Intellectual disabilities
Laboratories
Lactic acid
Metabolic acidosis
Metabolic Diseases - chemically induced
Metabolic Diseases - diagnosis
Metabolic Diseases - etiology
Metabolic Diseases - urine
Metabolic disorders
Metabolism
Middle Aged
Patients
Pneumonia
Pyrrolidonecarboxylic Acid - urine
Risk factors
Salicylic acid
Sepsis
Toxicology Observations
Urine
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Summary:Profound metabolic acidosis in critically ill adults sometimes remains unexplained despite extensive evaluation. A 58-year-old female presented in a confused state to the emergency department; she had been confused for several days. Laboratory evaluation revealed a high anion gap metabolic acidosis and modestly elevated acetaminophen level. Lactic acid was only modestly elevated. There was no evidence of ketoacids, salicylate, methanol, or ethylene glycol. A urine sample submitted on day 1 of hospitalization revealed a markedly elevated level of 5-oxoproline. Originally described in children with an inherited defect of glutathione synthetase, 5-oxoproline is an unusual cause of metabolic acidosis. More recently this disturbance has been recognized in critically ill adults without a recognized inherited metabolic disorder. In most of these cases there has been the concomitant use of acetaminophen. Any causal relationship between acetaminophen and this disturbance is speculative. In critically ill adults with unexplained metabolic acidosis, 5-Oxoproline should be considered in the differential.
ISSN:1556-9039
1937-6995
DOI:10.1007/BF03160921