title: Delayed recrudescence to toxic salicylate concentrations after salsalate overdose.
abstract: Salicylates are common exposures. We report an unusual case of salicylate ingestion, as salsalate, with resolution of symptoms and return of salicylate levels to non-toxic values, with a subsequent, unexpected recrudescence to toxic levels requiring reinstitution of therapy. A 31-year-old man ingested unknown amounts of salsalate, hydroxyzine, and a benzodiazepine. He was intubated and treated with IV sodium bicarbonate and two doses of oral activated charcoal. Eight hours after presentation, his serum salicylate concentration peaked at 55 mg/dL, and then decreased to a nadir of 5.6 mg/dL 38 h after presentation, coinciding with return of GI motility. Several hours later salicylate concentrations began to rise, peaking 67 h after presentation at 61.7 mg/dL. He was treated with sodium bicarbonate and charcoal, which resulted in decreased serum salicylate to therapeutic levels. Salicylate ingestions are known to exhibit unusual toxicokinetics and absorption in overdose; however, this is the first case we are aware of that shows a return to toxic concentrations after apparent resolution of toxicity. Recrudescence of salicylate concentrations to a degree that would dictate reinstitution of therapy for overdose is unusual and may warrant prolonged monitoring of serum salicylate concentrations in salsalate ingestions.
authors.affiliation: Department of Emergency Medicine, Oregon Health and Science University, Portland, OR 97239, USA. westp@ohsu.edu
authors.forename: Patrick L
authors.initials: PL
authors.lastname: West
authors.forename: B Zane
authors.initials: BZ
authors.lastname: Horowitz
mesh_terms: D000328:Adult; D000863:Antacids / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000506:poisoning*; D000931:Antidotes / Q000627:therapeutic use; D001569:Benzodiazepines / Q000506:poisoning; D002606:Charcoal / Q000627:therapeutic use; D003866:Depressive Disorder / Q000150:complications / Q000523:psychology; D062787:Drug Overdose; D006801:Humans; D006919:Hydroxyzine / Q000506:poisoning; D006993:Hypnotics and Sedatives / Q000506:poisoning; D008297:Male; D012008:Recurrence; D012459:Salicylates / Q000097:blood* / Q000506:poisoning*; D017693:Sodium Bicarbonate / Q000627:therapeutic use; D013313:Stress Disorders, Post-Traumatic / Q000150:complications / Q000523:psychology; D013406:Suicide, Attempted
chemical_list: D000863:Antacids; D000894:Anti-Inflammatory Agents, Non-Steroidal; D000931:Antidotes; D006993:Hypnotics and Sedatives; D012459:Salicylates; D001569:Benzodiazepines; D002606:Charcoal; D006919:Hydroxyzine; D017693:Sodium Bicarbonate; C014182:salicylsalicylic acid
references.citation: Am J Med. 1987 Oct;83(4):783-6
references.pmid: 2823600
references.citation: Lancet. 1981 Apr 4;1(8223):777
references.pmid: 6110974
references.citation: Ann Emerg Med. 1987 Apr;16(4):434-6
references.pmid: 3826813
references.citation: Clin Toxicol (Phila). 2007 Dec;45(8):815-917
references.pmid: 18163234
references.citation: Clin Pharmacol Ther. 1983 Oct;34(4):539-45
references.pmid: 6617077
references.citation: J Anal Toxicol. 1994 Jul-Aug;18(4):229-31
references.pmid: 7967546
references.citation: J Clin Pharmacol. 1981 Oct;21(10):401-4
references.pmid: 7309902
references.citation: Curr Med Res Opin. 1978;5(6):450-3
references.pmid: 350497
references.citation: Ann Intern Med. 1977 Dec;87(6):721-2
references.pmid: 22308
references.citation: Scand J Rheumatol. 1981;10(3):169-73
references.pmid: 7027430