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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 249-251
 

A rare presentation of methanol toxicity


Department of Medicine, UCMS and GTB Hospital, Delhi, India

Date of Submission17-Dec-2012
Date of Decision09-Jan-2013
Date of Acceptance20-Jan-2013
Date of Web Publication24-May-2013

Correspondence Address:
Nikhil Gupta
C158, Pushpanjali enclave, Pitampura, Delhi-110034
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.112484

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   Abstract 

Methanol is a highly toxic alcohol resembling ethanol in smell and taste. Methanol poisoning is a lethal form of poisoning that can cause severe metabolic acidosis, visual disturbances, and neurological deficit. Brain lesions typically described in methanol toxicity are in the form of hemorrhagic and non-hemorrhagic necrosis of the basal ganglia and sub-cortical white matter. To our knowledge, lesions in the parietal, temporal, or frontal areas of cerebrum and cerebellar hemispheres have been rarely reported so far. We herewith report this rare presentation.


Keywords: Basal ganglia, intoxication, methanol, necrosis, putamen


How to cite this article:
Gupta N, Sonambekar AA, Daksh SK, Tomar L. A rare presentation of methanol toxicity. Ann Indian Acad Neurol 2013;16:249-51

How to cite this URL:
Gupta N, Sonambekar AA, Daksh SK, Tomar L. A rare presentation of methanol toxicity. Ann Indian Acad Neurol [serial online] 2013 [cited 2019 Aug 19];16:249-51. Available from: http://www.annalsofian.org/text.asp?2013/16/2/249/112484



   Introduction Top


Methanol is a toxic alcohol readily available in household and industrial products. Methanol toxicity may be seen due to its unintentional or intentional abuse. It is associated with serious complications like metabolic acidosis, visual disturbances and neurological deficit. Diagnosis is based upon the typical clinical picture, metabolic acidosis, neuroimaging and high osmolar gap. Neuroimaging typically described in the literature involves the basal ganglia and sub-cortical white matter. However, brain lesions at other sites may occur as we describe in this case. This knowledge is necessary as prompt diagnosis and timely institution of treatment by administration of ethanol or fomepizole besides other adjuvant therapy can be life-saving.


   Case Report Top


A 51-year-old male presented with abdominal pain, nausea, and vomiting for 1 day with altered mentation, decreased urine output, and sudden onset blurring of vision since 12 h. The patient was a chronic alcoholic and smoker for last 10 years and there was history of consumption of unquantified amount of country liquor 1 day back. There was no history of fever, blood in urine, seizures, weakness, decreased sensations, or bowel disturbances. Other history was not significant. On examination, the patient was conscious but confused. His vitals were normal. General physical examination revealed mild pallor. On central nervous system examination, the Glasgow coma scale was E 4 M 5 V 3 ; there was diminished light perception in both the eyes; pupils were normal sized bilaterally but sluggishly reacting to light. Other cranial nerves were normal. There was no motor or sensory deficit. Cerebellar signs like finger nose test, dysdiadochokinesis, and heel-shin tests were abnormal on the right side. The patient had a wide based gait. Rest of his examination was normal. His complete blood count and liver function tests at the time of presentation were normal. Random blood sugar was 6.1 mmol/L. Kidney function tests showed blood urea nitrogen of 27 mmol/L, creatinine of 238 mmol/L, serum sodium 146 mmol/L, and potassium 4.2 mmol/L. Arterial blood gas revealed pH of 7.21, bicarbonate of 10 mmol/L, paCo 2 of 18 mm Hg. With clinical possibility of methanol toxicity, serum osmolar gap was calculated. It was found to be 74; serum methanol levels were sent which were high with value of 8.04 mmol/L. Magnetic resonance (MR) imaging of the brain revealed hemorrhagic conversion of infarct in bilateral parasagittal, parieto-occipital region. An acute infarct was seen in right cerebellum. There were punctate infarcts in bilateral frontal regions [Figure 1] and [Figure 2]. Visual-evoked response revealed prolonged bilateral (R > L) P100 and bilateral (R>>L) demylination of optic nerve. Serum levels of ammonia, vitamin B12, folate, amylase, and lipase were normal. The ultrasonography of the abdomen and the thyroid function tests were normal. In view of methanol poisoning, hemodialysis was done and ethanol was given through the naso-gastric tube since the patient could not afford fomepizole. The patient responded to treatment. Patient's visual acuity improved. Initially at presentation, it was finger-counting (FC+) at 1 m. Now the patient has visual acuity of 6/36 in both eyes without visual aids with minimal focal neurologic deficit and is on regular follow-up.
Figure 1: Infarct in rt. cerebellum and b/l parieto - occipital region

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Figure 2: Hemorrhagic infarct in b/l parieto - occipital region

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   Discussion Top


Methanol is a clear, colorless solvent used in anti-freeze solutions, varnishes, paint, and fuel. Methanol poisoning may occur due to accidental or suicidal ingestion of these, or it may occur due to consumption of adulterated alcoholic beverages. The lethal dose of methanol is around 1 g/kg. [1] Methanol by itself is largely non-toxic and toxicity results due to its metabolism into formaldehyde and formic acid in the liver. This also accounts for the time lag between substance ingestion and clinical manifestation which is considered to be around 6-24 h.

Patient may present with non-specific symptoms as nausea, vomiting, headache, dizziness, and weakness. Clinically, the patient may present with several complications like high anion gap metabolic acidosis, visual disturbances, and neurologic deficit. If not treated early, the patient may develop coma and succumb to the poisoning.

Cerebral infarction-ischemic as well as hemorrhagic, selectively affecting the putamen and sub-cortical white matter is known to occur in methanol poisoning. [2],[3] The reason for cerebral infarction in these selective regions is not known although many theories have been proposed.

According to some, this is attributed to the venous drainage pattern of the lenticular nucleus. Accumulation of methanol in high concentrations may occur in this region causing direct toxicity. [4] Relative ischemia due to the high metabolic rates of basal ganglia and optic nerves has also been proposed. [5] Anti-coagulation during hemodialysis may contribute to the hemorrhage in the infarcted areas of the brain. Apart from basal ganglionic involvement, lesions of the pontine tegmentum and peripheral white matter may also be seen. [6],[7],[8] However, apart from these, lesions in other parts of the cerebrum and cerebellum have rarely been reported so far. [9] In our case, the typical clinical features and laboratory parameters suggested methanol intoxication. MR imaging of brain revealed hemorrhagic infarcts in bilateral parasagittal, parieto-occipital region and an acute infarct was seen in right cerebellum. The possible mechanism could be methanol-induced cerebral vasospasm resultant of a large rise in intra-cytosolic calcium in cerebrovascular smooth muscle cells, as proposed by Li et al., [10] in his recent study. The patient improved clinically on administration after renal replacement therapy and ethanol. Recovery of vision is common with treatment in methanol poisoning and permanent visual impairment is only rarely seen. [11],[12],[13] Fomepizole, an alcohol dehydrogenase inhibitor, which is usually preferred in such cases over use of ethanol, could not be administered in our case due to patient's unaffordability.

This case report emphasizes the need to consider the possibility of methanol poisoning in patients presenting with altered mentation, visual disturbances, and brain lesions at atypical sites since timely institution of treatment can save the life.

 
   References Top

1.Buller F, Wood CA. Cases of death and blindness from Columbian spirits and other methylated preparations. JAMA 1904;43:972-7.  Back to cited text no. 1
    
2.Pelletier J, Habib MH, Khalil R, Salamon G, Bartoli D, Jean P. Putaminal necrosis after methanol intoxication. J Neurol Neurosurg Psychiatry 1992;55:234-5.  Back to cited text no. 2
    
3.Arora V, Nijjar IB, Multani AS, Singh JP, Abrol R, Chopra R, et al. MRI findings in methanol intoxication: A report of two cases. Br J Radiol 2007;80:e243-6.  Back to cited text no. 3
    
4.Koopmans RA, Li DK, Paty DW. Basal ganglia lesions in methanol poisoning: MR appearance. J Comput Assist Tomogr 1988;12:168-9.  Back to cited text no. 4
    
5.Sharpe JA, Hostovsky M, Bilbao JM, Rewcastle NB. Methanol optic neuropathy: A histopathological study. Neurology 1982;32:1093-100.  Back to cited text no. 5
    
6.Gaul HP, Wallace CJ, Auer RN, Fong TC. MR findings in methanol intoxication. AJNR Am J Neuroradiol 1995;16:1783-6.  Back to cited text no. 6
    
7.Blanco M, Casado R, Vázquez F, Pumar JM. CT and MR imaging findings in methanol intoxication. AJNR Am J Neuroradiol 2006;27:452-4.  Back to cited text no. 7
    
8.Anderson CA, Rubinstein D, Filley CM, Stears JC. MR enhancing brain lesions in methanol intoxication. J Comput Assist Tomogr 1997;21:834-6.  Back to cited text no. 8
    
9.Askar A, Al-Suwaida A. Methanol intoxication with brain hemorrhage: Catastrophic outcome of late presentation. Saudi J Kidney Dis Transpl 2007;18:117-22.  Back to cited text no. 9
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10.Li W, Zheng T, Wang J, Altura BT, Altura BM. Methanol elevates cytosolic calcium ions in cultured canine cerebral vascular smooth muscle cells: Possible relation to CNS toxicity. Alcohol 1999;18:221-4.  Back to cited text no. 10
    
11.Chew WB, Berger EH. Alkali treatment of methyl alcohol poisoning. J Am Med Assoc 1946;130:61-4.  Back to cited text no. 11
    
12.Hovda KE, Hunderi OH, Tafjord AB, Dunlop O, Rudberg N, Jacobsen D. Methanol outbreak in Norway 2002-2004: Epidemiology, clinical features and prognostic signs. J Intern Med 2005;258:181-90.  Back to cited text no. 12
    
13.Paasma R, Hovda KE, Tikkerberi A, Jacobsen D. Methanol mass poisoning in Estonia: Outbreak in 154 patients. Clin Toxicol (Phila) 2007;45:152-7.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]


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