Case report: Salicylate intoxication can present with a normal anion gap metabolic acidosis depending on method used for measuring chloride

Severe salicylate intoxication usually presents with a high anion gap metabolic acidosis. We describe a patient with severe salicylate intoxication that presented with a surprisingly normal anion gap metabolic acidosis. Initial salicylate level was 594 mg/L (therapeutic range 50-300 mg/L). In this case, the anion gap was normal due to a falsely elevated chloride concentration measured using a direct ion-selective electrode (ISE) (ABL90-flex). Since earlier case reports have shown that salicylate ions can interfere with chloride measurement using different ISEs, available samples were re-analyzed using an indirect ISE (Roche Cobas 8000), in which salicylate levels up to 1000 mg/L were found to cause no significant interference. With this method, chloride concentration was found to be 115 instead of 122 mmol/L, leading to the expected elevated anion gap. We performed a spike experiment to investigate the impact of different salicylate levels and bicarbonate concentrations on the measured chloride concentration for both methods. This experiment showed that the difference between chloride concentrations was mainly explained by interference with bicarbonate. It is important for clinicians to be aware of this possible interference, since a high anion gap metabolic acidosis can be a clue to suspect salicylate poisoning and early recognition and appropriate treatment is important. The patient was successfully treated with hemodialysis and no rebound toxicity was observed.

Seasonal Xylem Sap Acidification Is Governed by Tree Phenology, Temperature and Elevation of Growing Site

pH of xylem sap (pHx) was determined in three trees (Malus domestica (apple tree), Picea abies and Pinus cembra) in response to seasonal changes. Conifer trees from lowland (600 m) were compared to trees growing at the alpine timberline (1950 m a.s.l.). Xylem sap was extracted with a Scholander pressure bomb and pHx was measured with a pH microsensor. In all species, pHx changed markedly with season. In spring, pHx was acidic; during winter, the pHx was more alkaline. In apple trees, the pHx did not show a significant correlation with temperature but was rather affected by developmental stage. During flushing in spring, xylem sap acidification took place concomitant to the developmental stage “tight cluster”, when foliar development enables a significant transpiration and a consequent movement of water in the xylem. The xylem sap of the two studied conifers showed a significantly larger seasonal alkalinisation (+2.1) than found in apple trees (+1.2) and was significantly more pronounced at the timberline. Xylem sap acidification took place before bud break. pHx had a significant negative correlation with soil temperatures and corresponded to already reported pHx of angiosperms. Overall, pHx appears to be a sensitive stress marker and indicator of activity status in tree xylem.

Optimising alkalinisation and its effect on QRS narrowing in tricyclic antidepressant poisoning

AIMS

The objectives were to determine the effect of NaHCO₃ and/or mechanical ventilation on the biochemical profile and serum alkalinisation in tricyclic antidepressant (TCA) poisoning and investigate the impact of effective alkalinisation therapy on the QRS interval in TCA poisoning.

METHODS

This was a retrospective review of TCA poisonings from three Australian toxicology units and a poisons information centre (Jan 2013 to Jan 2019). We included patients with TCA toxicity who ingested>10 mg/kg or had clinically significant toxicities consistent with TCA poisoning, and analysed patients' clinical, electrocardiogram and biochemical data.

RESULTS

Of 210 patients, 84 received NaHCO₃ and ventilation (dual therapy), 12 NaHCO₃ , 46 ventilation and 68 supportive care treatment. When compared with single/supportive groups, patients who received dual therapy had taken a significantly higher median dose of TCA (1.5 g vs1.3 g, P < .001), a longer median maximum QRS interval (124 ms, interquartile ranges [IQR] 108-138 vs106 ms, IQR 98-115, P < .001) and were more likely to have seizures (14% vs3%, P = .006) and arrhythmias (17% vs1%, P < .001). The dual therapy group demonstrated greater increases in serum pH (median 0.11, IQR 0.04-0.17) compared to the single/supportive therapy group (median 0.03, IQR -0.01-0.09, p < .001). A greater proportion of patients reached the target pH 7.45-7.55 in the dual therapy group (59%) compared to the single/supportive therapy group (10%) (P < .001). For each 100 mmol bolus of NaHCO₃ given, the median increase in serum sodium was 2.5 mmol/L (IQR 1.5-4.0). QRS narrowing occurred twice as quickly in the dual therapy vs single/supportive therapy group.

CONCLUSIONS

A combination of NaHCO₃ and mechanical ventilation was most effective in achieving serum alkalinisation and was associated with a more rapid narrowing of the QRS interval. We advise that the maximal dose of NaHCO₃ should be <400 mmol (6 mmol/kg).

Is a pre-analytical process for urinalysis required?

For the reliable urinary measurement of calcium, phosphate and uric acid, a pre-analytical process by adding acid or base to urine samples at laboratory is recommended in order to dissolve precipitated solutes. Several studies on different kind of samples and analysers have previously shown that a such pre-analytical treatment is useless. The objective was to study the necessity of pre-analytical treatment of urine on samples collected using the V-Monovette^® (Sarstedt) system and measured on the analyser Architect C16000 (Abbott Diagnostics). Sixty urinary samples of hospitalized patients were selected (n=30 for calcium and phosphate, and n=30 for uric acid). After acidification of urine samples for measurement of calcium and phosphate, and alkalinisation for measurement of uric acid respectively, differences between results before and after the pre-analytical treatment were compared to acceptable limits recommended by the French society of clinical biology (SFBC). No difference in concentration between before and after pre-analytical treatment of urine samples exceeded acceptable limits from SFBC for measurement of calcium and uric acid. For phosphate, only one sample exceeded these acceptable limits, showing a result paradoxically lower after acidification. In conclusion, in agreement with previous study, our results show that acidification or alkalinisation of urine samples from 24 h urines or from urination is not a pre-analytical necessity for measurement of calcium, phosphate and uric acid.

Milk-alkali syndrome (MAS) as a complication of the treatment of hypoparathyroidism - a case study

Milk-alkali syndrome (MAS), characterized by renal failure, metabolic alkalosis and hypercalcemia, is a severe and life-threatening complication of the treatment of hypoparathyroidism. The clinical course is often sudden and is not preceded by any prodromal symptoms. Occurrence does not depend on the duration of hypoparathyroidism treatment, although it is closely related to the applied therapy, especially the dose of calcium carbonate and active vitamin D preparations. Drugs influencing the glomerular filtration rate (angiotensin receptor blockers, sartans, aldosterone receptor antagonists, thiazide diuretics), lack of adequate routine control, changing the calcium carbonate supplementation, dehydration, a diet rich in pH-basic foods (i.e. vegetarian diet), pregnancy and other associated conditions are listed among the factors triggering MAS. A higher calcium carbonate dose is directly associated with an increased risk of milk-alkali syndrome. In case of a high calcium demand it is necessary to control renal function and monitor the level of calcium in the serum more frequently, aiming for the lower end of the reference range. If MAS has been confirmed or if there are alarming neurological symptoms suggestive of hypercalcemia, the patient must be sent to the hospital immediately. Treatment of MAS involves: discontinuation of calcium and vitamin D supplementation, and intravenous infusion of normal saline solution to eliminate volume deficiencies and to achieve forced diuresis while maintaining proper fluid balance. As soon as there is improvement in the patient's clinical condition, it is necessary to begin the treatment of comorbidities increasing the risk of renal failure or alkalosis (i.e. vomiting, diarrhea).

Understanding the RALF family: a tale of many species

Small secreted peptides are gaining importance as signalling molecules in plants. Among the 1000 open reading frames (ORFs) in the Arabidopsis (Arabidopsis thaliana) genome potentially encoding small secreted peptides, the members of the RAPID ALKALINIZATION FACTOR (RALF) family of peptides have been linked to several physiological and developmental processes. Here, we provide a comprehensive overview of current knowledge on the RALF family. Discovered in tobacco (Nicotiana tabacum), the role of RALF peptides has been investigated in numerous plant species. Together, these observations suggest that RALF peptides impact on acidification and cell expansion during growth and development. Although few components of the signalling pathway have been revealed, the recent identification of FERONIA (FER) as a RALF receptor and plasma membrane H(+)-ATPase 2 as a downstream target provide a major step forward.