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See AYS, Lau AZ, Thiruvengadam S. Pyroglutamic acidosis in the setting of Staphylococcus aureus bacteremia treated with flucloxacillin-An uncommon cause of high anion gap metabolic acidosis. Clin Case Rep 2024; 12:e9243. [PMID: 39114848 PMCID: PMC11305870 DOI: 10.1002/ccr3.9243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 08/10/2024] Open
Abstract
Pyroglutamic acidosis (PGA) or 5-Oxoprolinuria is an uncommon and often overlooked cause of high anion gap metabolic acidosis (HAGMA). This case highlights the importance of systematically approaching HAGMA, and to consider PGA as a differential diagnosis when medications that disrupt the γ-glutamyl cycle such as flucloxacillin and paracetamol are present.
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Affiliation(s)
- Aaron Yee Shuen See
- Medical SchoolUniversity of Western AustraliaPerthWestern AustraliaAustralia
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Gaur D, Michalopulos MG, Drake KA, Gattineni J. Acetaminophen induced high anion gap metabolic acidosis: a potentially under-recognized consequence from a common medication. Pediatr Nephrol 2024:10.1007/s00467-024-06396-4. [PMID: 38954037 DOI: 10.1007/s00467-024-06396-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 07/04/2024]
Abstract
While metabolic acidosis is one of the most common complications in patients with chronic kidney disease (CKD), there are several uncommon etiologies that are challenging to diagnose. Here, we describe a patient on peritoneal dialysis who developed high anion gap metabolic acidosis secondary to acquired 5-oxoprolinemia from acetaminophen use. While CKD is a known risk factor for developing this potentially serious complication, this case further highlights how 5-oxoproline accumulation can occur, even with therapeutic dosing of acetaminophen.
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Affiliation(s)
- Dhruv Gaur
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, 75390, USA
| | - Michael G Michalopulos
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, 75390, USA
| | - Keri A Drake
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, 75390, USA
| | - Jyothsna Gattineni
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, 75390, USA.
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Abedian Kalkhoran H, Zwaveling J, van Hunsel F, Kant A. An innovative method to strengthen evidence for potential drug safety signals using Electronic Health Records. J Med Syst 2024; 48:51. [PMID: 38753223 PMCID: PMC11098892 DOI: 10.1007/s10916-024-02070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 04/25/2024] [Indexed: 05/19/2024]
Abstract
Reports from spontaneous reporting systems (SRS) are hypothesis generating. Additional evidence such as more reports is required to determine whether the generated drug-event associations are in fact safety signals. However, underreporting of adverse drug reactions (ADRs) delays signal detection. Through the use of natural language processing, different sources of real-world data can be used to proactively collect additional evidence for potential safety signals. This study aims to explore the feasibility of using Electronic Health Records (EHRs) to identify additional cases based on initial indications from spontaneous ADR reports, with the goal of strengthening the evidence base for potential safety signals. For two confirmed and two potential signals generated by the SRS of the Netherlands Pharmacovigilance Centre Lareb, targeted searches in the EHR of the Leiden University Medical Centre were performed using a text-mining based tool, CTcue. The search for additional cases was done by constructing and running queries in the structured and free-text fields of the EHRs. We identified at least five additional cases for the confirmed signals and one additional case for each potential safety signal. The majority of the identified cases for the confirmed signals were documented in the EHRs before signal detection by the Dutch Medicines Evaluation Board. The identified cases for the potential signals were reported to Lareb as further evidence for signal detection. Our findings highlight the feasibility of performing targeted searches in the EHR based on an underlying hypothesis to provide further evidence for signal generation.
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Affiliation(s)
- H Abedian Kalkhoran
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands.
- Department of Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands.
| | - J Zwaveling
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
| | - F van Hunsel
- The Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands
| | - A Kant
- Department of Clinical Pharmacology and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
- The Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands
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Billet S, Vanbiervliet P, Remery M, Dekoninck J, Janssens W. The concomitant use of paracetamol and flucloxacillin. A rare cause of high anion gap metabolic acidosis in the frail oldest old. Acta Clin Belg 2023; 78:509-515. [PMID: 37573520 DOI: 10.1080/17843286.2023.2246226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES This article describes the occurrence of a high anion gap metabolic acidosis (HAGMA) in two older, female patients with a methicillin sensitive staphylococcus aureus (MSSA) infection. Both patients received flucloxacillin and paracetamol. Both of them initially improved but declined rapidly after two to three weeks of treatment. They developed a severe HAGMA resulting in their death. The objective of this article is to determine whether old age is a major risk factor for developing HAGMA when combining paracetamol with flucloxacillin. METHODS A literature study was conducted using the MEDLINE database, PubMed. The used MeSH terms were 'flucloxacillin, acetaminophen, glutathione synthetase deficiency and acidosis'. Furthermore, we used two cases to illustrate our findings. RESULTS The origin of the high anion gap metabolic acidosis is the accumulation of 5-oxoproline which is known to occur when combining flucloxacillin with paracetamol due to their interaction with different enzymes of the gamma glutamyl cycle. This leads to the depletion of glutathione and the formation of 5-oxoproline. This phenomenon has a higher risk of occurring in frail older adults as most of them have several predisposing risk factors which result in lower baseline glutathione reserve. These risk factors include old age, malnutrition, assigned female at birth, pre-existing kidney and/or liver dysfunction, uncontrolled diabetes and sepsis. CONCLUSION The purpose of this article is to raise awareness of this phenomenon and its higher occurrence in frail older adults, which hopefully will lead to an earlier diagnosis with a better outcome for the patient.
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Affiliation(s)
- Sarah Billet
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Mark Remery
- Department of Internal Medicine, AZ Oudenaarde, Oudenaarde, Belgium
| | - Julien Dekoninck
- Department of Geriatric Medicine, Tielt Sint-Andries Hospital, Tielt, Belgium
| | - Wim Janssens
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Al-Shalan HAM, Zhou L, Dong Z, Wang P, Nicholls PK, Boughton B, Stumbles PA, Greene WK, Ma B. Systemic perturbations in amino acids/amino acid derivatives and tryptophan pathway metabolites associated with murine influenza A virus infection. Virol J 2023; 20:270. [PMID: 37990229 PMCID: PMC10664681 DOI: 10.1186/s12985-023-02239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Influenza A virus (IAV) is the only influenza virus causing flu pandemics (i.e., global epidemics of flu disease). Influenza (the flu) is a highly contagious disease that can be deadly, especially in high-risk groups. Worldwide, these annual epidemics are estimated to result in about 3 to 5 million cases of severe illness and in about 290,000 to 650,000 respiratory deaths. We intend to reveal the effect of IAV infection on the host's metabolism, immune response, and neurotoxicity by using a mouse IAV infection model. METHODS 51 metabolites of murine blood plasma (33 amino acids/amino acid derivatives (AADs) and 18 metabolites of the tryptophan pathway) were analyzed by using Ultra-High-Performance Liquid Chromatography-Mass Spectrometry with Electrospray Ionization at the acute (7 days post-infection (dpi)), resolution (14 dpi), and recovery (21 dpi) stages of the virus infection in comparison with controls. RESULTS Among the 33 biogenic amino acids/AADs, the levels of five amino acids/AADs (1-methylhistidine, 5-oxoproline, α-aminobutyric acid, glutamine, and taurine) increased by 7 dpi, whereas the levels of ten amino acids/AADs (4-hydroxyproline, alanine, arginine, asparagine, cysteine, citrulline, glycine, methionine, proline, and tyrosine) decreased. By 14 dpi, the levels of one AAD (3-methylhistidine) increased, whereas the levels of five amino acids/AADs (α-aminobutyric acid, aminoadipic acid, methionine, threonine, valine) decreased. Among the 18 metabolites from the tryptophan pathway, the levels of kynurenine, quinolinic acid, hydroxykynurenine increased by 7 dpi, whereas the levels of indole-3-acetic acid and nicotinamide riboside decreased. CONCLUSIONS Our data may facilitate understanding the molecular mechanisms of host responses to IAV infection and provide a basis for discovering potential new mechanistic, diagnostic, and prognostic biomarkers and therapeutic targets for IAV infection.
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Affiliation(s)
- Huda A M Al-Shalan
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia
- Department of Microbiology/Virology, College of Veterinary Medicine, Baghdad University, Baghdad, Iraq
| | - Lu Zhou
- Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhifan Dong
- Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Penghao Wang
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia
| | - Philip K Nicholls
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia
| | - Berin Boughton
- Australian National Phenome Centre, Computational and Systems Medicine, Health Futures Institute, Murdoch University, Murdoch, WA, Australia
| | - Philip A Stumbles
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia
- Telethon Kids Institute, Perth Children's Hospital, Nedlands, WA, Australia
| | - Wayne K Greene
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia
| | - Bin Ma
- School of Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, WA, Australia.
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Lenz J, Alt V, Dienemann T. Severe acidosis due to 5-oxoprolinase inhibition by flucloxacillin in a patient with shoulder prosthesis joint infection. J Bone Jt Infect 2022; 7:71-74. [PMID: 35464148 PMCID: PMC9022110 DOI: 10.5194/jbji-7-71-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/14/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract. We report a case of a 64-year-old female patient with severe metabolic
acidosis. Inhibition of 5-oxoprolinase by flucloxacillin was found to be
the cause of the metabolic derailment.
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Affiliation(s)
- Julia Elisabeth Lenz
- Department of Trauma Surgery, University Medical Center Regensburg,
Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg,
Regensburg, Germany
| | - Thomas Dienemann
- Department of Surgery, Surgical Intensive Care Unit, University
Medical Center Regensburg, Regensburg, Germany
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Connolly L, Briggs E. Acquired pyroglutamic acidaemia in a critically ill patient with chronic paracetamol use: A case report. SAGE Open Med Case Rep 2022; 10:2050313X211068561. [PMID: 35035973 PMCID: PMC8753234 DOI: 10.1177/2050313x211068561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/02/2021] [Indexed: 11/21/2022] Open
Abstract
Pyroglutamic acid is an endogenous organic acid and a metabolite in the γ-glutamyl cycle, involved in glutathione metabolism. Accumulation of pyroglutamic acid is a rare cause of high anion gap metabolic acidosis. There are multiple risk factors for pyroglutamic acid accumulation, such as chronic paracetamol use and sepsis. In this case report, we discuss how we came to this diagnosis, how it was subsequently managed and why it is an important consideration for critically ill patients with risk factors who are likely to end up in an intensive care setting. Pyroglutamic acid recognition and treatment could benefit patients in the critically ill population as pyroglutamic acid is a rare cause of high anion gap metabolic acidosis, which is likely under-recognised and easily treated. Inappropriate management of metabolic disorders can contribute to patient morbidity and mortality. Therefore, the recognition and appropriate management of pyroglutamic acidaemia could benefit patients with risk factors for its development in a critical care setting.
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Affiliation(s)
- Lee Connolly
- Department of Intensive Care, Joondalup Health Campus, Joondalup, WA, Australia
| | - Ed Briggs
- Department of Intensive Care, Joondalup Health Campus, Joondalup, WA, Australia
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Kalinoski T. Severe Anion Gap Metabolic Acidosis Resulting from Combined Chronic Acetaminophen Toxicity and Starvation Ketosis: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2022; 23:e934410. [PMID: 35034948 PMCID: PMC8787572 DOI: 10.12659/ajcr.934410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 68-year-old
Final Diagnosis: 5-oxoproline toxicity • anion gap metabolic acidosis • starvation ketoacidosis
Symptoms: Confusion • weakness
Medication: —
Clinical Procedure: —
Specialty: General and Internal Medicine • Nephrology
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Affiliation(s)
- Thomas Kalinoski
- Department of Internal Medicine, Olive View - UCLA Medical Center, Sylmar, CA, USA
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Pandolfi S, Chirumbolo S, Ricevuti G, Valdenassi L, Bjørklund G, Lysiuk R, Doşa MD, Lenchyk L, Fazio S. Home pharmacological therapy in early COVID-19 to prevent hospitalization and reduce mortality: Time for a suitable proposal. Basic Clin Pharmacol Toxicol 2021; 130:225-239. [PMID: 34811895 PMCID: PMC9011697 DOI: 10.1111/bcpt.13690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 01/08/2023]
Abstract
The COVID‐19 pandemic is a highly dramatic concern for mankind. In Italy, the pandemic exerted its major impact throughout the period of February to June 2020. To date, the awkward amount of more than 134,000 deaths has been reported. Yet, post‐mortem autopsy was performed on a very modest number of patients who died from COVID‐19 infection, leading to a first confirmation of an immune‐thrombosis of the lungs as the major COVID‐19 pathogenesis, likewise for SARS. Since then (June–August 2020), no targeted early therapy considering this pathogenetic issue was approached. The patients treated with early anti‐inflammatory, anti‐platelet, anticoagulant and antibiotic therapy confirmed that COVID‐19 was an endothelial inflammation with immuno‐thrombosis. Patients not treated or scarcely treated with the most proper and appropriate therapy and in the earliest, increased the hospitalization rate in the intensive care units and also mortality, due to immune‐thrombosis from the pulmonary capillary district and alveoli. The disease causes widespread endothelial inflammation, which can induce damage to various organs and systems. Therapy must be targeted in this consideration, and in this review, we demonstrate how early anti‐inflammatory therapy may treat endothelia inflammation and immune‐thrombosis caused by COVID‐19, by using drugs we are going to recommend in this paper.
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Affiliation(s)
- Sergio Pandolfi
- High School of Oxygen Ozone Therapy, University of Pavia, Pavia, Italy.,Unit of Neurosurgery, Villa Mafalda Health Clinics, Rome, Italy
| | - Salvatore Chirumbolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | | | - Luigi Valdenassi
- High School of Oxygen Ozone Therapy, University of Pavia, Pavia, Italy
| | - Geir Bjørklund
- Department of Direction Board, Council for Nutritional an Environmental Medicine (CONEM), Mo i Rana, Norway
| | - Roman Lysiuk
- CONEM Ukraine Life Science Research Group, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Monica Daniela Doşa
- Department of Pharmacology, Faculty of Medicine, Ovidius University, Constanta, Romania
| | - Larysa Lenchyk
- CONEM Ukraine Pharmacognosy and Natural Product Chemistry Research Group, National University of Pharmacy, Kharkiv, Ukraine
| | - Serafino Fazio
- Department of Internal Medicine, University of Naples Federico II, Naples, Italy
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