Abstract: TH-PO397
Mind the Gap: Pyroglutamic Acidosis as a Not-so-Rare Cause of High Anion Gap Metabolic Acidosis (HAGMA)
Session Information
- Fluid, Electrolyte, Acid-Base Disorders: Clinical - I
November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid, Electrolytes, and Acid-Base Disorders
- 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical
Authors
- Beavin, Sam, University of Kentucky Medical Center, Lexington, Kentucky, United States
- Ahmed, Sadiq, University of Kentucky Medical Center, Lexington, Kentucky, United States
Introduction
In addition to the common causes of high-anion gap metabolic acdiosis (such as lactic acidosis, ketoacidosis, and toxic alcohol ingestion), pyroglutamic acidosis can also result in HAGMA. This case report illustrates a patient in which otherwise unexplained metabolic acidosis was attributed to 5-oxoproline accumulation in the setting of chronic acetaminophen exposure and malnutrition.
Case Description
A 39-year-old man with a history of paraplegia, malnutrition, and prior PEG tube placement was admitted for management of a gastro-cutaneous fistula involving abdominal wall takedown and partial omentectomy. His post-operative course was complicated by pneumonia, septic shock, and AKI-D requiring two sessions of iHD on hospital days 8 and 10. Following HD treatments, he recovered renal function with appropriate urine output and stable electrolytes. During this period, he was started on scheduled acetaminophen 4 g daily for pain control.
Over the course of subsequent hospital days 11–13, he developed worsening AGMA with a peak anion gap of 26. After initial respiratory compensation, he ultimately required intubation for tachypnea and worsening hypercarbia. The workup for common causes of AGMA was non-revealing with normal lactate, D-lactate, alcohol, and beta-hydroxybuterate levels. Organic acid analysis of urine showed significantly elevated levels of 5-oxoproline excretion (6797 mmol/mol Cr., reference range: <62). Acetaminophen was discontinued, with subsequent resolution of metabolic acidosis over the next 3 days.
Discussion
This case demonstrates the development of HAGMA in a malnourished patient after several days of acetaminophen ingestion where the workup for common causes of HAGMA was non-revealing. In these situations, the accumulation of 5-oxoproline (pyroglutamic acid) is an important consideration. This rare condition can occur due to chronic acetaminophen exposure and subsequent glutathione depletion, particularly in the setting of poor nutritional status and a malfunctioning intestine.
Acidosis Trend
| Hospital Day | HCO3- | Anion Gap |
| Day 10 (last iHD) | 21 | 18 |
| Day 11 | 18 | 22 |
| Day 12 | 15 | 23 |
| Day 13 (Acetaminophen stopped) | 10 | 26 |
| Day 14 | 15 | 21 |
| Day 15 | 21 | 14 |