An unusual cause of severe metabolic acidosis

A 50-year-old man was transferred to the intensive care unit with high anion gap metabolic acidosis. Investigations suggested a diagnosis of pyroglutamic acidaemia. Factors contributing to the acidosis were medications (paracetamol and flucloxacillin), sepsis and renal failure. The acidosis resolved with supportive therapy and withdrawal of the drugs. It is important to recognise this treatable aetiology of metabolic acidosis.

A 50-year-old man with cerebral palsy, intellectual impairment and epilepsy was referred to hospital with a 1-week history of fever, chills, rigors, haematuria and loin pain. His usual medications included phenytoin 300 mg/day, phenobarbitone 30 mg/day and carbamazepine 1200 mg/day. There was no history of prior renal disease.