Neurotoxic overdose in a young man: answer

D. Methanol intoxication The man’s initial serum methanol level was found to be 231 mmol/L. The methanol level quickly responded to treatment, and was undetectable after 36 hours. One week after extubation, he was severely rigid and bradykinetic with significant weakness in his upper and lower extremities. He had also suffered severe visual impairment from retinal toxicity. Two months later, with the benefit of aggressive physiotherapy, he was ambulating with minimal assistance and a two wheeled walker, and had 4/5 gross motor strength in both his upper and lower extremities. Methanol poisoning is relatively uncommon, but carries a high mortality rate [[1]Kraut J. Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management.Clin J Am Soc Nephrol. 2008; 3: 208-225Crossref PubMed Scopus (317) Google Scholar]. Ingested methanol is metabolized into formaldehyde and then formic acid by alcohol and formaldehyde dehydrogenases, respectively. The hallmarks of methanol poisoning are an anion gap metabolic acidosis and visual impairment. Formate causes demyelination and necrosis to the optic nerve and may cause permanent damage in 11–18% of patients [1Kraut J. Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management.Clin J Am Soc Nephrol. 2008; 3: 208-225Crossref PubMed Scopus (317) Google Scholar, 2Barceloux D.G. Bond G.R. Krenzelok E.P. et al.American academy of clinical toxicology practice guidelines on the treatment of methanol poisoning.J Toxicol Clin Toxicol. 2002; 40: 415-446Crossref PubMed Scopus (539) Google Scholar]. Although rare, putamen necrosis has been previously documented in methanol toxicity [3Blanco M. Casado R. Vazquez F. et al.CT and MR imaging findings in methanol intoxication.AJNR Am J Neuroradiol. 2006; 27: 452-454PubMed Google Scholar, 4Hsu H.H. Chen C.Y. Chen F.H. et al.Optic atrophy and cerebral infarcts caused by methanol intoxication: MRI.Neuroradiology. 1997; 39: 192-194Crossref PubMed Scopus (45) Google Scholar, 5Rubinstein D. Escott E. Kelly J.P. Methanol intoxication with putaminal and white matter necrosis: MR and CT findings.Am J Neuroradiol. 1995; 16: 1492-1494PubMed Google Scholar, 6Glazer M. Dross P. Necrosis of the putamen caused by methanol intoxication: MR findings.Am J Neuroradiol. 1993; 160: 1105-1106Google Scholar]. Affected patients may exhibit rigidity, bradykinesia, mask-like facies, speech abnormalities and tremor [1Kraut J. Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management.Clin J Am Soc Nephrol. 2008; 3: 208-225Crossref PubMed Scopus (317) Google Scholar, 2Barceloux D.G. Bond G.R. Krenzelok E.P. et al.American academy of clinical toxicology practice guidelines on the treatment of methanol poisoning.J Toxicol Clin Toxicol. 2002; 40: 415-446Crossref PubMed Scopus (539) Google Scholar, 3Blanco M. Casado R. Vazquez F. et al.CT and MR imaging findings in methanol intoxication.AJNR Am J Neuroradiol. 2006; 27: 452-454PubMed Google Scholar, 6Glazer M. Dross P. Necrosis of the putamen caused by methanol intoxication: MR findings.Am J Neuroradiol. 1993; 160: 1105-1106Google Scholar]. The putamen has relatively high oxygen and glucose consumption, and is thought to be particularly sensitive to the accumulation of formate, which causes local inhibition of cytochrome oxidase [[2]Barceloux D.G. Bond G.R. Krenzelok E.P. et al.American academy of clinical toxicology practice guidelines on the treatment of methanol poisoning.J Toxicol Clin Toxicol. 2002; 40: 415-446Crossref PubMed Scopus (539) Google Scholar]. Fomepizole is the preferred treatment, but ethanol is an acceptable alternative [[7]Megarbane B. Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole.Open Access Emerg Med. 2010; 2: 67-75Crossref PubMed Scopus (30) Google Scholar]. Both treatments inhibit alcohol dehydrogenase and prevent the accumulation of formate. Hemodialysis can also be used concurrently to remove methanol and formate while correcting the acidosis [2Barceloux D.G. Bond G.R. Krenzelok E.P. et al.American academy of clinical toxicology practice guidelines on the treatment of methanol poisoning.J Toxicol Clin Toxicol. 2002; 40: 415-446Crossref PubMed Scopus (539) Google Scholar, 7Megarbane B. Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole.Open Access Emerg Med. 2010; 2: 67-75Crossref PubMed Scopus (30) Google Scholar]. Neurotoxic overdose in a young man: questionJournal of Clinical NeuroscienceVol. 23PreviewA 33-year-old man was taken to the emergency department after his family observed a 5 day history of worsening depressive symptoms and new onset confusion. He had a history of a previous suicide attempt, but he had no other medical conditions and was not on any medications. The initial investigations found metabolic acidosis with an anion gap of 32. His serum osmolality was 558 mmol/kg, with an osmolar gap of 268 mmol/kg. The liver enzymes were mildly elevated with an aspartate aminotransferase level of 242 units/L and an alanine aminotransferase level of 247 units/L. Full-Text PDF

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