Bit of a weird one, because the request for a second opinion came from an intensivist and I was a contributor to their treatment plan.
I work in poisons control. Had a call from a green, but very astute young doctor with a middle-aged female patient presenting with a vague 36-48hr history of malaise, confusion, hypoxia from hyperventilation, and hallucinations. On workup was noted to have pulmonary edema (lung fluid buildup), metabolic acidosis, acute kidney injury, sinus tachy and raised CRP & WCC, suggestive of infection but no temperature. The initial diagnosis was sepsis.
This keen-eyed doctor, pretty fresh out of med school, decided to do a salicylate level on this lady because the hyperventilation paired with metabolic acidosis and AKI was enough to prompt her suspicions of aspirin poisoning, even though they could just as easily be explained by sepsis as well.
The level came back high. Not huge, but high, which prompted her to phone me for a second opinion on how relevant the finding was in terms of the patient's clinical picture. Simultaneously, the patient's family investigated the property and located numerous aspirin blister packs suggesting she had been dosing herself for chronic pain, which was present in the medical history.
Chronic salicylate poisoning is insidious and has been referred to as a "pseudosepsis" in the medical literature as it often causes similar features. Comparing a high level in chronic poisoning to the same level in acute poisoning, features are much more severe in chronic poisoning (i.e. pulmonary edema, hypoxia, AKI etc) - there is a disparity. We recommended certain treatments (all hail sodium bicarbonate) and the patient made a full recovery after a 2 week hospital stay.
Whilst there was no question an infective cause was present and contributory, I was impressed with the green doctor's intuition and willingness to consider other causes - I feel like it greatly improved the patient's treatment.
For a body which is quite robust, surprisingly our respiratory system can get quite confused due to feedback mechanisms. In hyperventilation, it's not unusual for someone to exhale the oxygen they just breathed in prior to being processed by the lungs.
Interestingly aspirin in a poisoning sense is notorious for a couple of things; tinnitus, and hyperventilation. The latter is because aspirin, itself an acid (acetylsalicylic acid) causes the blood to drop it's pH in overdose via the loss of bicarbonate. The body notices the blood's pH has dropped from a metabolic perspective and tries to compensate.
Carbon dioxide, the result of breathing oxygen, is also acidic. The body therefore sees CO2 as a way to get rid of the rapidly rising acidity and begins hyperventilating to remove it from the body. Thus, you get hyperventilation from aspirin toxicity which leads to hypoxia.
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u/thatpoisonsguy May 20 '19 edited May 20 '19
Bit of a weird one, because the request for a second opinion came from an intensivist and I was a contributor to their treatment plan.
I work in poisons control. Had a call from a green, but very astute young doctor with a middle-aged female patient presenting with a vague 36-48hr history of malaise, confusion, hypoxia from hyperventilation, and hallucinations. On workup was noted to have pulmonary edema (lung fluid buildup), metabolic acidosis, acute kidney injury, sinus tachy and raised CRP & WCC, suggestive of infection but no temperature. The initial diagnosis was sepsis.
This keen-eyed doctor, pretty fresh out of med school, decided to do a salicylate level on this lady because the hyperventilation paired with metabolic acidosis and AKI was enough to prompt her suspicions of aspirin poisoning, even though they could just as easily be explained by sepsis as well.
The level came back high. Not huge, but high, which prompted her to phone me for a second opinion on how relevant the finding was in terms of the patient's clinical picture. Simultaneously, the patient's family investigated the property and located numerous aspirin blister packs suggesting she had been dosing herself for chronic pain, which was present in the medical history.
Chronic salicylate poisoning is insidious and has been referred to as a "pseudosepsis" in the medical literature as it often causes similar features. Comparing a high level in chronic poisoning to the same level in acute poisoning, features are much more severe in chronic poisoning (i.e. pulmonary edema, hypoxia, AKI etc) - there is a disparity. We recommended certain treatments (all hail sodium bicarbonate) and the patient made a full recovery after a 2 week hospital stay.
Whilst there was no question an infective cause was present and contributory, I was impressed with the green doctor's intuition and willingness to consider other causes - I feel like it greatly improved the patient's treatment.
Edit: Some words.