Methanol, Paracetamol Toxicities and Acute Blindness

Methanol toxicity remains a common problem in developing countries including Saudi Arabia. However, it is much less available than other toxins; thus, clinical suspicion and correlation play pivotal roles in diagnosis. On the other hand, paracetamol is widely available and overdose/toxicity is highly suspected especially in young females. Diagnosis of methanol toxicity can be difficult in cases where history is not readily available and it requires a high degree of suspicion, especially when ingestion of another substance is revealed first as should not preclude the possibility of co-ingestion. We report a case of a medically free 26 year old woman who was brought to the Emergency Department (ED) of our hospital with a history of ingestion of a massive amount of paracetamol tablets and a concurrent abdominal pain with vomiting. After arrival, she became unresponsive with Glasgow Coma score (GCS) of 8/15 and was mechanically ventilated. Initial laboratory investigations identify the paracetamol level of 1200 ug/ml and a significantly high anion gap metabolic acidosis. Owing to the suspicious circumstances and the depth of acidosis, a co-ingestion of methanol and ethylene glycol was suspected. Upon further evaluation, osmolal gap was found to be significantly high as well. Since neither volatile compound screening nor Fomepizole were available in our hospital, an urgent N-acetylcysteine and sodium bicarbonate (NaHCO(3)) were started alongside hemodialysis. Subsequent brain computed tomography (CT) and magnetic reasoning imaging (MRI) revealed changes in putamen and basal ganglia most consistent with methanol toxicity. She was successively extubated on day four of hospitalization with residual visual deficits that had resolved eventually after several follow-ups.