Case #10

(EXOTIC AND BIZARRE TOXICOLOGY AT ITS FINEST)

HISTORY

The patient is a 65 year old WWII veteran who presents to a V.A hospital with acute mental status change. His past medical history is significant for alcohol abuse and a seizure disorder.

PHYSICAL

• General: The patient is confused, but in no apparent distress
• Vitals: BP=170/95 P=100 RR=20 T=96
• HEENT: NC/AT, PERRL, EOMI
• Lungs: CTA
• HT: Irreg RR, no murmurs
• Abd: Distended, mild epigastric tenderness, no masses
• Rectal: (-)Heme
• Ext: Pitting edema of feet, good pulses
• Nicotine stained finger tips
• Neuro: No focal deficits

DIAGNOSTIC STUDIES

• Lytes: Na=131 K=4.0 Cl=104 HCO3=12
• BUN/Cr: 17/5.7
• Tox Screen: Negative
• Toxic alcohols Negative
• Ethanol: Zero
• CPK: WNL
• Phenytoin: 49mcg/ml
• Urine: (+) ketones

CLINICAL COURSE

The patient was admitted with a preliminary diagnosis of:

1. Phenytoin toxicity
2. Alcoholic/starvation ketosis

After 3 days of declining mental status and worsening renal function, the patient is hemodialyzed.

At this time, family members revealed that the day prior to admission, the patient had ingested......

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