HoPingKong-isms

(hyperthermia can cause rhabdomyolysis)

1. "....What are you lying on? This is a giant question...a maximus question....are you crushed by this?"..... this was in the context of patients found either unconscious or unable to get up for prolonged periods of time. He is referring to rhabdomyolysis. The 'maximus' comment must refer to the gluteus maximus, and the 'are you crushed?'....for sure that is for crush injuries. We discussed rhabdomyolysis here.

2. "...Let's think about cardiac causes of syncope...hey....Adam is here today...". Yep, this is a Stokes-Adams Attack, named after William Stokes and Robert Adams - two Irish physicians.

3. "...Sometimes you have overt alcoholics, then there are social drinkers...I'm thinking of the smallest room in the house..." So what's the smallest room in the house? The closet. He was referring to "closet alcoholics". We discussed alcohol related issues here, seizure disorders here, and toxic alcohol ingestions here.

4. "....Think about Captain Morgan!...". This was said in the context of him shaking his arms and head - convulsing. "Yes...this is a 'Rum Fit'". Also known as an alcohol withdrawal seizure. Remember your CAGE questionnaire to screen for alcohol-related problems:

• do you feel the need to Cut back your drinking?
• do you ever feel Annoyed at people critiquing your drinking?
• do you ever feel Guilty about your alcohol consumption?
• do you ever have an Eye opener? (Alcohol first thing in the morning)

• 1 point is given every time your patient answers "yes" to a question. ....then you just add up the points.
  

• Most patients with alcohol dependence will have a score of 2 or greater. About 80% of patients without alcoholism will score 0 points.
  

Here is a paper from JAMA written by local talent on the utility of alcohol screening tools.

Methanol and Ethylene Glycol

Today we discussed a patient who presented in a Hyperosmolar Non-Ketotic state secondary to hyperglycemia. You can read more about the precipitants and management of DKA and HONK here.

We also discussed poisoning with methanol and ethylene glycol - either by intentional or unintentional ingestion.

These get metabolized in the liver first by Alcohol Dehydrogenase, then Aldehyde Dehydrogenase. They have toxic byproducts - Formic Acid in methanol poisoning, and Calcium Oxalate in ethylene glycol. Formic acid causes renital edema and destruction and can also lead to ischemia in the basal ganglia. Calcium oxalate can cause irreparable renal damage.

What to do? Firstly, "intoxications" have to be on your differential diagnosis - if you don't think about it, you will never diagnose it. Also consider other co-ingestions with prescribed or non-prescribed drugs/toxins.

Clinical Hints: Patients may have a decreased level of consciousness and those with methanol intoxication may complain of blurry vision. Look for evidence of renal failure, a raised anion gap, and an elevated osmolar gap. Note that it is possible to have methanol/ethylene glycol poisoning with a normal osmolar gap. Also note that if patients co-ingest alcohol, this will delay the presentation of methanol/ethylene poisoning. Send off blood levels for these alcohols.

Plan: Basically we want to get rid of the methanol or ethylene glycol - and dialysis is the fastest and most effective mechanism to do this. We also want to prevent the formation of our toxic byproducts (formic acid and/or calcium oxalate). How do we do this?

• Ethanol: best given intravenously. The alcohol dehydrogenase will work on ethanol rather than methanol/ethylene glycol - preventing the formation of toxic byproducts. It is cheap, but difficult to dose.
  
• Fomepizole: this will directly inhibit alcohol dehydrogenase. Easy to use, very effective, very expensive.
  

Links:

• A great paper assessing the utility of Fomepizole in methanol intoxication.
• Pictures of calcium oxalate stones in the urine of a patient with ethylene glycol poisoning.
  

Dion Phaneuf of the Calgary Flames (smoking the Ottawa Senators) pictured left.

Wernicke-Korsakoff syndrome

Wernicke's and Korsakoff's syndromes are the result of Thiamine deficiency - usually related to chronic alcohol consumption, but can be seen in other disorders of malnutrition (eg. anorexia nervosa, gastrointestinal surgery).

Wernike's Encephalopathy presents as a classic triad of

1. Oculomotor dysfunction: in particular lateral rectus palsies - uni or bilateral, but nystagmus and oculomotor nerve deficits are also seen.
2. Gait ataxia
3. Encephalopathy

MRI may show lesions around the cerebral aqueduct. Mamillary body atrophy is quite a specific sign from Werneke's encephalopathy.

Korsakoff's Syndrome represents permanent neurological damage from thiamine deficiency. Patients have anterograde and retrograde amnesia, but a preserved sensorium and often have preservation of long term memory and other cognitive skills. Confabulation is classic feature in this disorder.

When patients present to hospital and chronic alcoholism is suspected, we always give Thiamine upfront - before glucose - to prevent Wernicke's and Korsakoff's syndromes.

You can read more about alcohol withdrawal here.
Here is a good review article from NEJM about Alcohol and Drug withdrawal.

Seizure-Related Topics

• Check out the treatment of Status Epilepticus here.

• We also talked about TB meningitis, and you can read a bit more about the diagnosis and treatment of that over here.

• Check out Alcohol Withdrawal syndromes over here.