Salicylate Intoxication in an Infant: A Case Report

Abstract

In children, the most common cause of an ele-vated anion gap (AG) with ketonemia, ketonuria, hyper-glycemia, and glycosuria is diabetic ketoacidosis. However, when the clinical history is not clear, other causes must be considered. A 9-month-old girl was trans-ferred to our pediatric intensive care unit (PICU) because of severe metabolic acidosis. On admission, she presented with Kussmaul breathing, tachycardia, irritability, and fever. Blood gasses revealed metabolic acidosis with superimposed respiratory alkalosis and elevated AG. Fluid replacement and bicarbonate for urine alkalinization were started. Ketonemia, acidic urine with glycosuria, ketonuria, and high blood glucose prompted an insulin infusion. Measurement of plasma salicylate confirmed toxic levels. When confronted, the parents admitted to accidentally preparing the child's bottle with water containing salicylic acid 1000 mg. Although the incidence of salicylate intox-ication has declined, it remains an important cause of pediatric morbidity and mortality. Key Points As salicylate intoxication can manifest with hyperpnea, tachypnea, tachycardia, fever, coagulopathy, ketoacidosis, hyperglycemia, glycosuria, and ketonuria, it can be mistaken for other critical conditions that are more common in childhood, such as septicemia or diabetic ketoacidosis. When an infant or child presents with increased anion gap (AG) metabolic acidosis and respiratory alkalosis, salicylate intoxication must be suspected and considered, even if caregivers deny any possibility of accidental poisoning. Severe complications can appear when salicylate levels are decreasing or near therapeutic. If criteria for severe intoxication (altered mental status, non-cardiogenic pulmonary edema, or non-responsive AG acidosis) are present, extracorporeal removal of salicylate should be performed.