1
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Stewart GW. Pyroglutamate acidosis 2023. A review of 100 cases. Clin Med (Lond) 2024; 24:100030. [PMID: 38431210 DOI: 10.1016/j.clinme.2024.100030] [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] [Indexed: 03/05/2024]
Abstract
This review concerns the rare, acquired, usually iatrogenic, high-anion-gap metabolic acidosis, pyroglutamic acidosis. Pyroglutamate is a derivative of the amino acid glutamate, and is an intermediate in the 'glutathione cycle', by which glutathione is continuously synthesized and broken down. The vast majority of pyroglutamic acidosis cases occur in patients on regular, therapeutic doses of paracetamol. In about a third of cases, flucloxacillin is co-prescribed. In addition, the patients are almost always seriously unwell in other ways, typically with under-nourishment of some form. Paracetamol, with underlying disorders, conspires to divert the glutathione cycle, leading to the overproduction of pyroglutamate. Hypokalaemia is seen in about a third of cases. Once the diagnosis is suspected, it is simple to stop the paracetamol and change the antibiotic (if flucloxacillin is present), pending biochemistry. N-acetyl-cysteine can be given, but while the biochemical justification is compelling, the clinical evidence base is anecdotal.
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Affiliation(s)
- Gordon W Stewart
- Emeritus Professor of Experimental Medicine, UCL, Division of Medicine, University College London, London WC1E 6JJ, UK.
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2
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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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3
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Liu X, Liu M, Liu H, Yuan H, Wang Y, Chen X, Li J, Qin X. Comprehensive brain tissue metabolomics and biological network technology to decipher the mechanism of hydrogen-rich water on Radiation-induced cognitive impairment in rats. BMC Mol Cell Biol 2023; 24:30. [PMID: 37752412 PMCID: PMC10523633 DOI: 10.1186/s12860-023-00491-4] [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: 01/17/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Hydrogen-rich water (HRW) has been shown to prevent cognitive impairment caused by ionizing radiation. This study aimed to investigate the pharmacological effects and mechanisms of HRW on ionizing radiation by coupling the brain metabolomics and biological target network methods. METHODS AND RESULTS HRW significantly improves the cognitive impairment in rats exposed to ionizing radiation. Based on metabolomics and biological network results, we identified 54 differential metabolites and 93 target genes. The KEGG pathway indicates that glutathione metabolism, ascorbic acid and aldehyde acid metabolism, pentose and glucuronic acid interconversion, and glycerophospholipid metabolism play important roles in ionizing radiation therapy. CONCLUSION Our study has systematically elucidated the molecular mechanism of HRW against ionizing radiation, which can be mediated by modulating targets, pathways and metabolite levels. This provides a new perspective for identifying the underlying pharmacological mechanism of HRW.
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Affiliation(s)
- Xiaoming Liu
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China
| | - Mengya Liu
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China
| | - Huan Liu
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China
| | - Hui Yuan
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China
| | - Yong Wang
- School of forensic medicine, Shanxi Medical University, Taiyuan, 030001, P. R. China
| | - Xiaoman Chen
- School of forensic medicine, Shanxi Medical University, Taiyuan, 030001, P. R. China
| | - Jianguo Li
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China
| | - Xiujun Qin
- Department of Radiology and Environmental Medicine, China Institute for Radiation Protection, CAEA Center of Excellence on Nuclear Technology Applications for Non-Clinical Evaluation for Radiopharmaceutical, Shanxi Key Laboratory for Pharmaceutical Toxicology & Radiation Injury Pharmaceuticals, CNNC Key Laboratory for Radiotoxicology and Preclinical Assessment of Radiopharmaceuticals, Taiyuan, 030006, P. R. China.
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4
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Zhao S, Guo J, Xue H, Meng J, Xie D, Liu X, Yu Q, Zhong H, Jiang P. Systematic impacts of fluoride exposure on the metabolomics of rats. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2022; 242:113888. [PMID: 35872488 DOI: 10.1016/j.ecoenv.2022.113888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/09/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
Fluoride is widely present in the environment. Excessive fluoride exposure leads to fluorosis, which has become a global public health problem and will cause damage to various organs and tissues. Only a few studies focus on serum metabolomics, and there is still a lack of systematic metabolomics associated with fluorosis within the main organs. Therefore, in the current study, a non-targeted metabolomics method using gas chromatography-mass spectrometry (GC-MS) was used to research the effects of fluoride exposure on metabolites in different organs, to uncover potential biomarkers and study whether the affected metabolic pathways are related to the mechanism of fluorosis. Male Sprague-Dawley rats were randomly divided into two groups: a control group and a fluoride exposure group. GC-MS technology was used to identify metabolites. Multivariate statistical analysis identified 16, 24, 20, 20, 24, 13, 7, and 13 differential metabolites in the serum, liver, kidney, heart, hippocampus, cortex, kidney fat, and brown fat, respectively, in the two groups of rats. Fifteen metabolic pathways were affected, involving toxic mechanisms such as oxidative stress, mitochondrial damage, inflammation, and fatty acid, amino acid and energy metabolism disorders. This study provides a new perspective on the understanding of the mechanism of toxicity associated with sodium fluoride, contributing to the prevention and treatment of fluorosis.
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Affiliation(s)
- Shiyuan Zhao
- Translational pharmaceutical laboratory of Jining First People's Hospital, Jining Medical University, Jining 272000, China.
| | - Jinxiu Guo
- Translational pharmaceutical laboratory of Jining First People's Hospital, Jining Medical University, Jining 272000, China.
| | - Hongjia Xue
- Faculty of Science and Engineering, University of Nottingham Ningbo China, Ningbo 315100, China.
| | - Junjun Meng
- Translational pharmaceutical laboratory of Jining First People's Hospital, Jining Medical University, Jining 272000, China.
| | - Dadi Xie
- Department of Endocrinology, Tengzhou Central People's Hospital, Tengzhou 277500, China.
| | - Xi Liu
- Department of Pharmacy, Linfen People's Hospital, Linfen 041000, China.
| | - Qingqing Yu
- Department of Oncology, Jining First People's Hospital, Jining Medical University, Jining 272000, China; Laboratory of Biochemistry and Biomedical Materials, College of Marine Life Science, Ocean University of China, Qingdao 266003, China.
| | - Haitao Zhong
- Translational pharmaceutical laboratory of Jining First People's Hospital, Jining Medical University, Jining 272000, China.
| | - Pei Jiang
- Translational pharmaceutical laboratory of Jining First People's Hospital, Jining Medical University, Jining 272000, China.
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5
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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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6
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Zhang K, Yan H, Liu R, Xiang P, Zhang J, Deng K, Huang P, Wang Z. The Use of Gas Chromatography Coupled with High-Resolution Mass Spectrometry-Based Untargeted Metabolomics to Discover Metabolic Changes and Help in the Determination of Complex Causes of Death: A Preliminary Study. ACS OMEGA 2021; 6:2100-2109. [PMID: 33521449 PMCID: PMC7841927 DOI: 10.1021/acsomega.0c05178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/29/2020] [Indexed: 05/10/2023]
Abstract
The determination of cause of death (COD) is one of the most important tasks in forensic practice and is mainly based on macroscopical and microscopical morphological signatures. However, some CODs are hard to determine because the significant morphological signatures can be nonspecific, variable, subjective, or even absent in the real world. In this study, gas chromatography coupled with high-resolution mass spectrometry (GC-HRMS)-based untargeted metabolomics was employed to obtain plasma metabolic profiles of rats that died from anaphylactic shock (AS), mechanical asphyxia (MA), or sudden cardiac death (SCD). The metabolic alterations of each COD group compared to the control group were investigated using a principal component analysis, partial least-squares discriminant analysis, the Wilcoxon test, and fold change analysis. A range of differential features was screened, and 11, 8, and 7 differential metabolites were finally verified for the AS, MA, and SCD groups, respectively. We proposed some explanations that may account for these metabolic differences, including glucose metabolism, the tricarboxylic acid cycle, glycolysis, lipid metabolism, creatinine catabolism, and purine metabolism. Next, for each COD, we used its differential metabolites, which were obtained through comparisons of each COD group to the control group and represented the metabolic changes of the individual COD, to perform a receiver operating characteristic (ROC) analysis to preliminarily evaluate their ability to discriminate each COD group from the other COD groups. We found that creatinine in the AS group and malic acid and uric acid in the MA group might represent some specific metabolic changes for the relevant COD with high areas under the curve in the ROC curve analysis. Moreover, the combination panel for AS or MA also showed a good ability to discriminate it from the others. However, SCD had fewer metabolic signatures and was relatively harder to discriminate from the other CODs in our work. The preliminary study demonstrates the feasibility of GC-HRMS-based untargeted metabolomics as a promising tool to reveal metabolic changes in different death processes and to determine the complex CODs.
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Affiliation(s)
- Kai Zhang
- Department
of Forensic Pathology, College of Forensic Medicine, Xi’an Jiaotong University, Xi’an 710061, P. R. China
| | - Hui Yan
- Shanghai
Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai 200063, P. R. China
| | - Ruina Liu
- Department
of Forensic Pathology, College of Forensic Medicine, Xi’an Jiaotong University, Xi’an 710061, P. R. China
| | - Ping Xiang
- Shanghai
Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai 200063, P. R. China
| | - Ji Zhang
- Shanghai
Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai 200063, P. R. China
| | - Kaifei Deng
- Shanghai
Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai 200063, P. R. China
| | - Ping Huang
- Shanghai
Key Laboratory of Forensic Medicine, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai 200063, P. R. China
- . Tel.: +86-021-52367986
| | - Zhenyuan Wang
- Department
of Forensic Pathology, College of Forensic Medicine, Xi’an Jiaotong University, Xi’an 710061, P. R. China
- . Tel.: +86-029-82655472
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7
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Zand Irani A, Borchert G, Craven B, Gibbons H. Flucloxacillin and paracetamol induced pyroglutamic acidosis. BMJ Case Rep 2021; 14:14/1/e237536. [PMID: 33419747 PMCID: PMC7798777 DOI: 10.1136/bcr-2020-237536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 75-year-old woman was admitted to a regional hospital with an acute kidney injury (AKI) and nausea on a background of recent treatment for Staphylococcus aureus bacteraemia secondary to pneumonia. The treatment thereof resulted in a high anion gap metabolic acidosis (HAGMA). The pneumonia was initially treated with intravenous piperacillin and tazobactam and the patient transferred to a tertiary hospital. There, the diagnosis of S. aureus bacteraemia secondary to a pulmonary source was confirmed and treatment was changed to intravenous flucloxacillin and the patient was discharged to hospital in the home (HITH is a service that allows short-term healthcare at home to be provided to people who would otherwise need to be in hospital) to complete the antibiotic course. Five weeks after commencing flucloxacillin, the patient was referred back to hospital with nausea and worsening kidney function with an associated significant HAGMA. The patient has a background of chronic kidney disease and chronic back pain for which she was taking long-term paracetamol. The HAGMA was determined to be due to a pyroglutamic acidosis (PGA), deemed secondary to the combined use of paracetamol and flucloxacillin. This was subsequently confirmed with a plasma pyroglutamic acid concentration level of 7467 µmol/L (reference range 20-50 µmol/L) and a urinary level of 1700 mmol/mol creatinine (<110 mmol/mol creatinine). To our knowledge, this is the highest plasma and urinary levels published to date. Furthermore, considering the common use of paracetamol and penicillins, it is important to recognise HAGMA as a potential complication of co-administration of paracetamol and iso-oxylopenicillin. The HAGMA resolved after cessation of flucloxacillin despite the continuation of paracetamol and without administration of N-acetylcysteine. PGA-related HAGMA appears to be a unique potential side effect of iso-oxylopenicillin rather than other beta-lactams.
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Affiliation(s)
- Anis Zand Irani
- Gympie Hospital, Queensland Health, Gympie, Queensland, Australia
| | - Grace Borchert
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Craven
- Gympie Hospital, Queensland Health, Gympie, Queensland, Australia
| | - Holly Gibbons
- Gympie Hospital, Queensland Health, Gympie, Queensland, Australia
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8
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Pandey S, Adnan Siddiqui M, Azim A, Trigun SK, Sinha N. Serum metabolic profiles of septic shock patients based upon co-morbidities and other underlying conditions. Mol Omics 2021; 17:260-276. [PMID: 33399607 DOI: 10.1039/d0mo00177e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diagnosis and management of patients with septic shock is still a significant challenge for clinicians with its high mortality amongst hospitalized patients. Septic shock is a heterogeneous condition and is usually accompanied by various underlying disease conditions. Dissecting the specific metabolic changes induced by these underlying disease conditions through metabolomics has shown the potential to improve our understanding of the disease's relevant pathophysiological mechanisms, leading to improved treatment. This study has shown the metabolic alterations caused due to co-morbid conditions like diabetes, hypertension, CAD, and CKD in septic shock. It has also shown the distinct metabolic profiles of septic shock patients with underlying respiratory illnesses and encephalopathy. Metabolic profiling of sera obtained from 50 septic shock patients and 20 healthy controls was performed using high-resolution 1D 1H CPMG and diffusion-edited NMR spectra. Univariate and multivariate statistical analyses were performed to identify the potential molecular biomarkers. Noted dysregulations in amino acids, carbohydrates, and lipid metabolism were observed in septic shock patients. Further stratification within the septic shock patients based on co-morbid conditions and primary diagnosis has shown their role in causing metabolic alterations. Evaluation of these compounds during treatment will help design a personalized treatment protocol for the patients, improving therapeutics.
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Affiliation(s)
- Swarnima Pandey
- Centre of Biomedical Research, SGPGIMS Campus, Raebareli Road, Lucknow, 226014, India.
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9
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Zand Irani A, Almuwais A, Gibbons H. Acquired pyroglutamic acidosis due to long-term dicloxacillin and paracetamol use. BMJ Case Rep 2020; 13:13/4/e233306. [PMID: 32273269 PMCID: PMC7244275 DOI: 10.1136/bcr-2019-233306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
An 85-year-old man with a background of transfusion-dependent chronic myelomonocytic leukaemia and chronic kidney disease stage III presented with symptomatic anaemia, acute kidney injury, sepsis and high anion gap metabolic acidosis (HAGMA). Initial treatment with intravenous antibiotics and blood transfusion was complicated by transfusion-associated circulatory overload, necessitating diuresis and non-invasive ventilation. Despite gradual clinical improvement, the patient’s HAGMA persisted, and no cause was identified on urine testing or renal ultrasound. As the patient was on long-term dicloxacillin for infective endocarditis prophylaxis and regular paracetamol, pyroglutamic acidosis (PGA) (5-oxoproline acidosis) was considered. This was later confirmed with elevated serum levels, and the HAGMA resolved following cessation of these medications. Although considered an uncommon cause of HAGMA, PGA is likely also under-recognised, and to our knowledge, this may be the second reported case in the context of dicloxacillin.
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Affiliation(s)
| | - Ahmed Almuwais
- Medicine, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - Holly Gibbons
- Medicine, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
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10
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Song L, Zhuang P, Lin M, Kang M, Liu H, Zhang Y, Yang Z, Chen Y, Zhang Y. Urine Metabonomics Reveals Early Biomarkers in Diabetic Cognitive Dysfunction. J Proteome Res 2017; 16:3180-3189. [DOI: 10.1021/acs.jproteome.7b00168] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Lili Song
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Pengwei Zhuang
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Mengya Lin
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Mingqin Kang
- Jilin Entry-Exit Inspection and Quarantine Bureau, 1301 Puyang Street, Lvyuan District, Changchun City, Jilin Province, 130062, People’s Republic of China
| | - Hongyue Liu
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Yuping Zhang
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Zhen Yang
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Yunlong Chen
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
| | - Yanjun Zhang
- Chinese Materia Medica College, Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, People’s Republic of China
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11
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Berbee JK, Lammers LA, Krediet CTP, Fischer JC, Kemper EM. Metabolic acidosis caused by concomitant use of paracetamol (acetaminophen) and flucloxacillin? A case report and a retrospective study. Eur J Clin Pharmacol 2017; 73:1459-1465. [PMID: 28782093 PMCID: PMC5662679 DOI: 10.1007/s00228-017-2311-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE A patient was identified with severe metabolic acidosis, a high anion gap and 5-oxoproline accumulation, probably caused by the simultaneous use of paracetamol (acetaminophen) and flucloxacillin. We wanted to investigate the necessity to control the interaction between both drugs with an automatic alert system. METHODS To investigate the relevance of the interaction of paracetamol and flucloxacillin, a retrospective study was conducted. Data on paracetamol and flucloxacillin prescriptions and laboratory data (pH, Na+, HCO3-, Cl-, albumin and 5-oxoproline levels) were combined to assess the prevalence of acidosis, calculate the anion gap and analyse 5-oxoproline levels in clinically admitted patients using both drugs simultaneously. RESULTS In the 2-year study period, approximately 53,000 admissions took place in our hospital. One thousand and fifty-seven patients used paracetamol and flucloxacillin simultaneously, of which 51 patients (4.8%) had a serum pH ≤ 7.35. One patient, the same patient as presented in the case report, had a high anion gap and a toxic level of 5-oxoproline. CONCLUSION The prevalence of metabolic acidosis is very low and the only patient identified with the interaction was recognised during normal clinical care. We conclude that automatic alerts based on simultaneous use of paracetamol and flucloxacillin will generate too many signals. To recognise patients earlier and prevent severe outcomes, a warning system (clinical rule) based on paracetamol, flucloxacillin and pH measurement may be helpful. Early calculation of the anion gap can narrow the differential diagnosis of patients with metabolic acidosis and measurement of 5-oxoproline can explain acidosis due the interaction of paracetamol and flucloxacillin.
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Affiliation(s)
- J K Berbee
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - L A Lammers
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - C T P Krediet
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - J C Fischer
- Department of Clinical Chemistry, Academic Medical Centre, Amsterdam, the Netherlands
| | - E M Kemper
- Department of Hospital Pharmacy, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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12
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Mo L, Liang DL, Madden A, Aung AK. A case of delayed onset pyroglutamic acidosis in the sub-acute setting. Intern Med J 2016; 46:747-9. [DOI: 10.1111/imj.13104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- L. Mo
- Department of General Medicine; Alfred Health; Melbourne Victoria Australia
| | - D. L. Liang
- Department of Medicine; Melbourne Health; Melbourne Victoria Australia
| | - A. Madden
- Department of General Medicine; Alfred Health; Melbourne Victoria Australia
| | - A. K. Aung
- Department of General Medicine; Alfred Health; Melbourne Victoria Australia
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
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13
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Jullian-Desayes I, Borel JC, Guerber F, Borel AL, Tamisier R, Levy P, Schwebel C, Pepin JL, Joyeux-Faure M. Drugs influencing acid base balance and bicarbonate concentration readings. Expert Rev Endocrinol Metab 2016; 11:209-216. [PMID: 30058869 DOI: 10.1586/17446651.2016.1147951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Serum bicarbonate dosage is sensitive to pharmacological interferences. However, elevated bicarbonate concentration reflects chronic hypoventilation and has been proposed as a simple marker for screening patients with Obesity Hypoventilation Syndrome (OHS), a currently underdiagnosed multimorbid and high mortality disease. We provide a practical overview of the different drugs acting on the acid-base equilibrium to aid clinicians to interpret bicarbonate concentration readings. Little is known about the chronic impact of the usual doses of these drugs on serum bicarbonate concentration and further studies are needed. It is essential to take into account drugs that could interfere with this parameter to avoid misinterpretation of serum bicarbonate levels.
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Affiliation(s)
- Ingrid Jullian-Desayes
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
| | - Jean-Christian Borel
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- c Research and development department , AGIR à dom , Meylan , France
| | - Fabrice Guerber
- d Oriade Laboratory , Oriapole , Saint Martin d'Heres , France
| | - Anne-Laure Borel
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- e Endocrinology Department , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
| | - Renaud Tamisier
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- f Thorax and vessels, EFCR , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
| | - Patrick Levy
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- f Thorax and vessels, EFCR , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
| | - Carole Schwebel
- g Intensive Care Unit , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
| | - Jean-Louis Pepin
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- f Thorax and vessels, EFCR , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
| | - Marie Joyeux-Faure
- a Laboratory HP2, University of Grenoble Alpes , Grenoble , France
- b INSERM U1042, Laboratory HP2 , Grenoble , France
- f Thorax and vessels, EFCR , Grenoble University Hospital (CHU de Grenoble) , Grenoble , France
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Berger P, Ferlay C, Poiron L, Chillet P. Acidose métabolique à trou anionique élevé dans un contexte d’intoxication chronique au paracétamol (acétaminophène). TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2015. [DOI: 10.1016/j.toxac.2015.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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