Acute Ethanol Intoxication: Αn Overlooked Cause of High Anion Gap Metabolic Acidosis With a Marked Increase in Serum Osmolal Gap

Measurement of serum osmolal gap is a useful tool in suspected toxic alcohol ingestion. Normal levels of osmolal gap are typically <10 mOsm/kg). Osmolal gap >20 mOsm/kg is usually caused by ingestion of methanol, ethylene glycol, isopropanol, propylene glycol, diethylene glycol, or organic solvents such as acetone but rarely of ethanol alone. Herein, we describe the case of a severe ethanol intoxication presenting with a marked increase in the osmolal gap. An 18-year-old male was referred to the emergency department of our hospital, in a comatose state, following binge drinking. blood gas analysis revealed a high anion gap metabolic acidosis. In addition, it was found an extremely elevated osmolal gap of 91 mOsm/kg. The increment of the osmolal gap and the high anion gap acidosis could not be attributed to methanol/ethylene glycol intoxication, alcoholic ketoacidosis, or other cause of acidosis. The calculated osmolal concentration of ethanol was 91 mOsm/kg (osmolal concentration of ethanol is equal to the serum ethanol levels (mg/dL) divided by 3.7). Thus, the increase in the osmolal gap was a result of ethanol intoxication solely. Acute, isolated, ethanol intoxication may be a rare cause of a marked increase of osmolal gap with high anion gap metabolic acidosis. Clinicians should be alerted to the possibility of acute ethanol intoxication in a patient presenting with high anion gap metabolic acidosis and an extremely elevated osmolal gap. Toxicologic screen tests should be performed to identify the aetiology of the gap rise and proper therapy should be administered.

AB0161 THE IMPACT OF BIOLOGICAL AGENTS ON CARDIOVASCULAR RISK FACTORS OF PATIENTS DIAGNOSED WITH RHEUMATOID ARTHRITIS

Background:

The risk of cardiovascular disease in patients with rheumatoid arthritis (RA) is 1.5-2 fold higher than in people of the same age and sex of the general population.1,2,3 This marked risk is attributed to the systemic chronic inflammation which is characteristic of the disease.

Objectives:

The aim of this study is to evaluate cardiovascular risk factors and early atherosclerosis in rheumatoid arthritis patients, treated with biological agents.

Methods:

This is a prospective, observational study. Thirty-five patients treated with synthetic DMARDs with no previous history of a cardiovascular event included. We compared total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), triglycerides (TGs), Apolipoprotein A1 (ApoA1), Apolipoprotein B (ApoB) and Lipoprotein A (LpA), the titer of autoantibodies against oxidised LDL(anti-oxLDL), systolic blood pressure, inflammatory markes as C-reactive protein (CRP) and erythrocytes sedimentation rate (ESR) between baseline and after 6 months of biological agents initiation. An ultrasonographic measurement of intima-media thickness (IMT) of carotids was also performed by an experienced sonographer at baseline and after one-year follow-up.

Results:

As regards the demographic characteristics of patients, the mean (SD) age was 54(14) years, disease duration 4,3(1.4) years, 22.9% were smokers and 68,6% were women. Anti-TNF was administered in 71,4% of patients while the rest non anti-TNF was given as treatment. Six months after treatment initiation, patients presented with a significant increase in mean (SD) HDL[69(19)vs58(15)] and ApoA1[177(34)vs162(31)] levels (p value <0,001) with a simultaneous significant reduction of mean (SD) systolic blood pressure [128(12)vs136(14)] and the titer of anti-oxLDL[0,132(0,042)vs0,190(0,056)]. ΙΜΤ was also reduced after one-year reassessment [0,8(0,3) mm vs 0,9(0,3)mm, (p value <0,001 for all comparisons)].

Conclusion:

Biological agents administration was accompanied by an improved lipid profile in a six-month period and a significant reduction of IMT, confirming that RA patients are prone to early atherosclerosis and probably biological agents initiation correlates strongly with cardiovascular risk reduction.

References:

[1]Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis and rheumatism. 2008 Dec 15;59(12):1690–1697.

[2]Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Annals of the rheumatic diseases. 2012 Sep;71(9):1524–1529.

[3]Solomon DH, Karlson EW, Rimm EB, Cannuscio CC, Mandl LA, Manson JE, et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation. 2003 Mar 11;107(9):1303–1307.

Disclosure of Interests:

None declared

Pleural effusion in chronic myelomonocytic leukemia

Pleural effusion in 4 patients with chronic myelomonocytic leukemia (CMML) is described in this report. According to the literature, pleural effusion in CMML is a poorly understood and rare occurrence. Two of our patients presented with pleural effusion as an initial symptom while the other 2 developed it during the course of the disease. In only 1 patient was the pleural effusion due to leukemic infiltration while in the other 3 it was a reactive phenomenon. Peripheral lymphadenopathy was observed only in the former patient who died of acute leukemia. After prednisolone therapy the pleural effusions resolved in the other 3 patients.