An Unusual Case of Refractory Metabolic Acidosis
A 25-year-old young male was brought to emergency department with history of headache, pain in abdomen, vomiting, difficulty in breathing, and multiple episodes of generalized tonic-clonic seizures, followed by loss of consciousness since last 10 h. There was no history of fever or head injury. He was chronic alcoholic and non-smoker. On examination, his general condition was low (E1M3 V1), he was tachypneic, his skin was cold and clammy, peripheral pulses were not palpable, and blood pressure was not recordable. Pupils were normal in size, not reacting to light and bilateral planter response was non-elicitable. Auscultation of chest revealed bilateral coarse crepitations. Rest of the examination was within normal limits. Arterial blood gas (ABG) analysis showed pH – 6.8, pCO2 – 23 mmHg, pO2 – 61 mmHg, plasma bicarbonate – 5 mmol/l, chloride – 96 mmol/l, serum lactate – 2.7 mmol/l, serum osmolality – 360 mmol/l, serum Na+ – 151meq/L, serum K+ – 4.6 meq/L and random blood sugar – 87 mg/dl. The patient was intubated and put on ventilatory support with 100% oxygen, intravenous fluids, dopamine, and noradrenaline infusion. Intravenous phenytoin loading was done for seizures.\nInvestigations revealed hemoglobin-12.9 gm%, total leukocyte count-14800/cumm, differential leukocyte count-P62 L38, platelet count-2.34 lacs/cumm, blood urea-86 mg/dL, and serum creatinine-2.6 mg/dL. Urine examination was normal. Liver function test showed SGOT-675IU/L, SGPT-437IU/L, and normal serum bilirubin. Calculated osmolality was 336 mmol/L suggestive of high anion gap metabolic acidosis with high osmolar gap. X-ray chest showed bilateral infiltrates in basal lung fields. Computed tomography (CT) of head showed necrosis in bilateral basal ganglia suggestive of alcoholic intoxication. In view of CT findings, history of alcohol intake was reviewed in detail. Patient attendees denied any usage of alcohol in last 10 days because of family restrictions that he was imposed. They also gave a history of consumption of some homeopathic preparation for the cough for last 5 days and he was taking it in excess to normal prescription. No other medicine was being given to the patient. Attendants were asked to bring the homeopathic medicine and it was Causticum Hah having 90% alcohol by vol/vol []. Patient had taken three bottles (1350 mL) of homeopathic medicine in last 5 days out of which about 450 mL (one bottle) was consumed in 2-3 h. The patient was managed on the lines of alcohol intoxication with dextrose containing fluids, intravenous thiamine, bicarbonate infusion, and intravenous broad spectrum antibiotics. Blood ethanol level of the patient was not done because this facility is currently not available in our institution and patient's attendant refused to get it done from outside laboratory due to financial constraints. The repeated ABG analysis showed persistent acidosis with low serum bicarbonate. There was no improvement in blood pressure and general condition of the patient. The patient died on 3rd day of the admission.