Methanol Overdose

This is an interesting yet very sad case.

The patient in his early 40s presented to ER with decreased level of consciousness. The patient remained comatose and had to be intubated for airway protection.

His laboratory studies revealed a profound anion gap metabolic acidosis and a significantly elevated serum osmolarity and osmolal gap.

Methanol overdose was suspected and the patient was immediately given Fomepizole IV and started on Bicarbonate drip.

The patient had a long history of alcohol abuse. His initial CT head revealed a diffuse brain atrophy unusual for his young age. Note a diffuse volume loss and enlarged ventricles on the upper image above. Prolonged and severe alcohol abuse is known to cause brain atrophy.

Despite aggressive medical management the patient remained acidotic so hemodialysis treatment was initiated.

Several hours after the admission the patient “blew his pupils” - his pupils became large and unresponsive to light.

Repeat CT head revealed diffuse cerebral edema due to Methanol overdose. Note almost complete collapse of the ventricles and absence of gyri and sulci(bottom image above). This appearance of the brain is very similar to a brain of the patient suffering from a severe anoxic encephalopathy.

Subsequently, the patient was pronounced brain dead based on clinical criteria and confirmatory test (nuclear brain perfusion scan).