Unidentified anion gap metabolic acidosis.

A 35-month-old female with nonketotic hyperglycinemia (NKH) presented to the Emergency department with severe hypoglycemia, fever, and several episodes of seizures. Due to worsening respiratory status, additional seizures and anion gap worsening metabolic acidosis the patient was transferred to the pediatric intensive care unit. The useful mnemonics for causes of high anion gap metabolic acidosis are the classic MUDPILES (representing Methanol, Uraemia, Diabetes, Paraldehyde, Iron (and Isoniazid), Lactate, Ethylene glycol, and Salicylate) and the more recently proposed GOLD MARK (Glycols [ethylene and propylene], Oxoproline, l-lactate, d-lactate, Methanol, Aspirin, Renal failure, and Ketoacidosis) as causes of the anion gap metabolic acidosis were all ruled out. Relatively stable concentrations of salicylate (approximately 10 mg/dL, 0.7 mmol/L) were noted, despite no evidence the patient received aspirin Therefore further laboratory testing was performed. A Basic-Acid-Neutral (BAN) gas chromatography mass-spectroscopy (GC-MS) Drug screen of urine was undertaken. A large benzoic acid peak was identified by spectral match, which supported the clinical history that the patient was taking sodium benzoate powder 1175 mg as a dietary supplement three times a day. However, salicylate was not identified. This patient had benzoic acid concentration in excess of 2000 µg/mL. Given that benzoic acid is a weak acid, with a pK of approximately 4 it is almost completely ionized at pH 7. Therefore, the large amount of benzoic acid was not only thought to be contributing to the patient's anion gap metabolic acidosis, but the source of the interference in the salicylate assay.

Detection of synthetic cannabinoids in herbal incense products.

OBJECTIVE: We investigated the ability of clinical drug of abuse tests to detect synthetic cannabinoids. RESULTS: A broad class GC/MS drug screening method detected JWH-018 and JWH-073 in methanolic extracts and teas steeped from herbal incense products in three of four products tested. CONCLUSIONS: Synthetic cannabinoids are present in herbal incense purchased over the internet.

Effects of folic acid fortification and multivitamin therapy on homocysteine and vitamin B(12) status in cardiac transplant recipients.

BACKGROUND: Hyperhomocysteinemia is a frequent finding after cardiac transplantation, but increased folate intake induces a decrease in total homocysteine concentrations. In 1998, food in Canada was fortified nationwide with folic acid. We assessed the impact of routine folate fortification on homocysteine concentrations in our cardiac transplant population. METHODS: In 18 subjects, we measured total homocysteine (tHcy), serum folate, and cobalamin concentrations in 1997 (before folate fortification) and in 1998 (after fortification). We repeated the analysis after specific multivitamin supplementation for 10 weeks. RESULTS: We found a significant decrease in baseline tHcy concentrations and in folate concentrations between 1997 and 1998. However, we also found a decrease in serum cobalamin concentrations. We found a correlation between decreased cobalamin concentrations and the methionine synthase A2756G genotype, but not with other common polymorphisms associated with homocysteine metabolism. After multivitamin supplementation, we observed a trend toward further decrease in tHcy concentrations and a significant increase in serum folate and cobalamin concentrations. Finally, we measured serum methylmalonic acid concentrations, an index of tissue cobalamin status. We did not find a correlation between increased methylmalonic acid concentrations and decreased serum cobalamin, perhaps related to the confounding effect of altered renal status on methylmalonic acid excretion. CONCLUSIONS: National folate fortification was associated with decreased tHcy and increased folate concentrations in our cardiac transplant population. Additional administration of vitamin supplements induced a further decrease in tHcy and an increase in folate. Finally, folate fortification unveiled cobalamin deficiency in some patients, associated with the methionine synthase A2756G mutation.