title: Pyroglutamic acidosis in association with therapeutic paracetamol use.
abstract: Long-term use of paracetamol (at therapeutic doses) can cause the accumulation of endogenous organic pyroglutamate, resulting in metabolic acidosis with an elevated anion gap. This occurs in the presence of malnutrition, infection, antibiotic use, renal failure and pregnancy. Given the prevalence of these risk factors, this condition is thought to be relatively common in a hospitalised population but is probably significantly underdiagnosed. Prompt recognition is essential because the condition is entirely reversible if the causative agents are withdrawn.Here we describe five cases of pyroglutamic acidosis that we have encountered in a tertiary referral hospital. Together they illustrate the common clinical risk factors and the excellent prognosis, once a diagnosis is made. We describe how a rudimentary acid-base analysis (calculation of the anion gap) usually leads to the diagnosis but how a more nuanced approach may be required in the presence of mixed acid-base disorders.
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK and University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hunter
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Cate
authors.initials: C
authors.lastname: Lawson
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Evangelia
authors.initials: E
authors.lastname: Galitsiou
authors.affiliation: Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Fiona
authors.initials: F
authors.lastname: Gifford
authors.affiliation: Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: John J
authors.initials: JJ
authors.lastname: Neary
mesh_terms: D000082:Acetaminophen / Q000009:adverse effects* / Q000378:metabolism / Q000627:therapeutic use; D000138:Acidosis / Q000139:chemically induced*; D000328:Adult; D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000009:adverse effects* / Q000378:metabolism / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011761:Pyrrolidonecarboxylic Acid / Q000097:blood* / Q000378:metabolism
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen; D011761:Pyrrolidonecarboxylic Acid
keywords: 5-oxoproline; acidosis; anion gap; paracetamol; pyroglutamate