Abstract: SA-PO391
Unexplained Bromide Toxicity Presenting as Hyperchloremia and Negative Anion Gap
Session Information
- Genetic and Diagnostic Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 902 Fluid and Electrolytes: Clinical
Authors
- Iftikhar, Hasan, George Washington University Hospital, Washington, District of Columbia, United States
- Sharma, Shailendra, George Washington University Hospital, Washington, District of Columbia, United States
Introduction
Brominev. is a deep red colored liquid primarily used in manufacture of chemical agents. Serum bromide concentration is difficult to quantify due to interference with other halogens, though when measured by x-ray fluorescence spectrometry is between 3.2 to 5.6 mg/L. Significant environmental exposure is mostly limited to industrial setting. Bromide toxicity was well recognized in early twentieth century when use of bromide containing drugs was widespread. Toxic effects of bromide include neuropsychiatric disturbances, tremors, gait imbalance, rash, and dermatitis.
Case Description
An 82-year-old male was seen in the emergency room with sudden cognitive decline, visual hallucinations, gait disturbance and multiple falls. His medical history was significant for squamous cell cancer of head and neck and Myasthenia Gravis. His medication list included scheduled infusion of IVIG every four weeks and ipratropium bromide 20 mcg inhaler two to three times daily. Notably, he was not on Pyridostigmine bromide. Physical examination was significant for blood pressure of 93/55 mm Hg, and fluctuating mental status. Serum chloride was found to be 163 mmol/L with anion gap of negative 65. Remaining serum chemistries, complete blood count, liver function tests, urinalysis, blood gas, TSH, Salicylate and Tylenol levels, B12 and cortisol levels were unremarkable. Multiple repeat labs continued to show high chloride concentration.. Simultaneous chloride measurements were obtained employing indirect ion-selective and colorimetric method; serum values thus obtained were 135 mmol/L and 103 mmol/L respectively.. Colorimetric method is less susceptible to interference from other halides. Concurrent serum bromide level was reported as 1100mg/L. Patient refused both saline diuresis and hemodialysis for bromide clearance, and expired at his home six weeks following discharge.
Discussion
Because of interference by other halogens in routine measurements, a high bromide level can masquerade as hyperchloremia with large negative anion gap. Thus when encountered, bromism should be kept in mind