Severe Anion Gap Metabolic Acidosis Resulting from Combined Chronic Acetaminophen Toxicity and Starvation Ketosis: A Case Report and Literature Review

Thomas Kalinoski

doi:10.12659/AJCR.934410

17 January 2022: Articles

Severe Anion Gap Metabolic Acidosis Resulting from Combined Chronic Acetaminophen Toxicity and Starvation Ketosis: A Case Report

Challenging differential diagnosis, Adverse events of drug therapy, Rare coexistence of disease or pathology

Thomas Kalinoski ^A*

DOI: 10.12659/AJCR.934410

Am J Case Rep 2022; 23:e934410

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Background Case Report Discussion Conclusions References:

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Table 3. Comparison of clinical characteristics of published cases.

	Acetaminophen dose (g/day)	Co-ingestions	Serum
	Acetaminophen dose (g/day)	Co-ingestions	pH (7.31-7.41)	pCO2 (mmHg, 41–51)	HCO3 (meq/L, 22–29)	Anion Gap (meq/L, 6–12)	Na+(meq/L, 135–145)	BUN (mg/dL, 6–24)	Cr (mg/dL, 0.74–1.35)	Glucose (mg/dL, 70–99)
Trevor-Jones []⁵	4.0	None	7.11	19	9.1	22	145	17.9	3.50	146
Hunter []⁶	–	Alcohol	7.19	14	11	19	140	–	3.49	–
	4.0	Alcohol	–	–	9.0	20	140	10.2	2.10	85
	–	Flucloxacillin	7.41	23	14	7	138	1.6	0.62	101
	1.0	None	7.51	16	15	27	139	9.6	1.66	91
	1.0	Flucloxacillin	–	–	14	16	145	5.3	0.86	–
Hodgman []⁷	–	Alcohol	7.02	10	3.0	33	148	17	1.7	128
Bersselaar []⁹	3.0	Flucloxacillin	7.16	53	18	18	143	–	1.79	–
Zand Irani [,]¹⁰	–	Flucloxacillin	7.26	20	9.0	17	137	6.2	2.33	–
	–	Dicloxacillin	7.31	27	14	21	–	28	3.67	256
Nordstrom O’Brian []¹¹	–	Alcohol	7.10		7	28	–	6.4	0.79	–
Duewall []¹²	–	None	7.09	28	10	22	140	59	3.6	–
Hundemer []¹³	1.3	None	7.29	27	12	28	–	–	0.9	–
Kortmann []¹⁵	4.0	Flucloxacillin	7.12	11	3.5	30	143	–	–	–
	–	Alcohol	7.20	27	10	28	141	–	1.75	–
	3.0	None	7.29	23	10	29	142	–	2.07	–
Howie []¹⁶	3.0	None	7.26	9.5	4.2	25	134	–	0.89	49
Fenves []¹⁷	–	None	–	–	8	47	145	123	5.9	85
	–	None	6.88	28	8	33	131	–	2.0	534
	–	Alcohol	7.16	14	5	24	143	–	–	166
	2.7	None	7.44	14	8	35	145	15	2.2	159
“–“ indicates that parameter was not indicated in cited article.
	Acetaminophen dose (g/day)	Co-ingestions	Serum				Urine
	Acetaminophen dose (g/day)	Co-ingestions	Lactate (mmol/L, 0.5–2.2)	Acetamino-phen level (mcg/ml, <2)	5-Oxo-proline (µmol/L, 20–50)	Ketones (mg/dL, negative)	Ethanol (mmol/L, negative)	5-Oxo-proline (mmol/mol Cr, <70)	Ketones (mg/dL, negative)
Trevor-Jones []⁵	4.0	None	1.2	–	–	21	–	700	–
Hunter []⁶	–	Alcohol	1.7	–	–	–	–	“+++”	Negative
	4.0	Alcohol	0.7	–	–	–	–	“+++”	“++”
	–	Flucloxacillin	–	–	–	–	–	“+++”	–
	1.0	None	1.5	–	–	–	–	“+++”	–
	1.0	Flucloxacillin	0.9	–	–	–	–	“+++”	Negative
Hodgman []⁷	–	Alcohol	3.1	49	–	Negative	Negative	2350	–
Bersselaar []⁹	3.0	Flucloxacillin	1.1	–	–	–	–	1721	–
Zand Irani [,]¹⁰	–	Flucloxacillin	–	–	7467	–	–	1700	–
	–	Dicloxacillin	1.3	–	62	–	–	–	–
Nordstrom O’Brian []¹¹	–	Alcohol	5.2	24	–	–	Negative	2000	–
Duewall []¹²	–	None	0.4	Negative	–	“1: 8”	Negative	8555	–
Hundemer []¹³	1.3	None	0.8	Negative	–	–	–	17455	Negative
Kortmann []¹⁵	4.0	Flucloxacillin	0.7	3.2	6573	–	–	16,623	Negative
	–	Alcohol	1.3	12	2292	–	–	4184	Negative
	3.0	None	1.6	–	1050	–	–	–	Negative
Howie []¹⁶	3.0	None	1.6	14	–	–	–	4970	“+”
Fenves []¹⁷	–	None	“Normal”	–	–	Negative	Negative	700	–
	–	None	15	6.8	6400	Negative	–	–	–
	–	Alcohol	2.5	–	2800	Negative	Negative	1000	–
	2.7	None	4.3	–	1050	Negative	–	2470	–
“–“ indicates that parameter was not indicated in cited article.

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Severe Anion Gap Metabolic Acidosis Resulting from Combined Chronic Acetaminophen Toxicity and Starvation Ketosis: A Case Report

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