1,4-Butanediol Overdose: An Unrecognized Toxidrome

Résumé fourni par la source

Introduction: Butanediol (BD) is an industrial solvent, used for plastic manufacture. Illicit recreational use is associated with central nervous system (CNS) depressant effects (“date-rape drug”) and euphoria. Overdose can be lethal, but often unrecognized. We present a case of possible toxic alcohol exposure, turned out to be BD overdose. Case Description: 43yo man, found obtunded in a mechanical shop. Last seen normal 30 minutes prior, at same location. Field vitals unavailable. On admission: BP 146/97mmHg, HR 53, T33.9°C RR 20, obtunded, myotic pupils, no clonus. Unresponsive to naloxone and flumazenil, then intubated. Gastric aspirate showed a red sweet smelling liquid. Initial labs: Normal CBC Na 141 K 3.3 Cl 98 CO2 17 AG 26 BUN 13 Cr 0.98 Glu 115 Ca 9.0 Alk Phos 110 AST 207 ALT 319 TBili 0.46 Alb 4.3 Lactate 7.4 BHB (-). Vbg pH 7.35 pCO2 34. Acetaminophen, salicylate, EtOH and UDS(-). Labs 2h later were essentially unchanged & EtOH still (-). Measured serum Osm 312 with osmolal gap (OG) of 23. Nephrology consulted for ethylene glycol (EG) poisoning suspicion, fomepizole started. Labs 3h later had lower AG and OG (20 and 11, respectively), inconsistent with EG overdose. Patient extubated on the next day and endorsed ingesting 1,4-BD. EG and methanol levels were negative. Discussion: In vivo, BD is quickly metabolized to gamma-hydroxybutyric acid (GHB), an inhibitory neurotransmitter (GABA B receptor agonist) that causes euphoria and sedation. BD poisoning mimics other toxic alcohols toxidromes, but is not detected on traditional drug screening tests. An increased OG is typically present, and supportive care is the mainstay therapy. No antidote is available. Concomitant ingestion of ethanol increases its toxicity, and the use of EtOH as a competitive substrate for alcohol dehydrogenase is contraindicated. The majority of patients can be managed without dialysis, as GHB has a rapid clearance and short duration of clinical effects (between 2-5h). Take away lesson: BD overdose can be lethal. The presence of an increased OG with negative tests for other toxic alcohols may be a diagnostic clue. Management is supportive care.

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