A 35-year-old man presents to the emergency room with nausea, tremors, and altered mental status. He recently stopped drinking alcohol cold-turkey. Could his issues be withdrawal or a lava lamp he drank? Watch an engaging analysis of this case above to find out what happened.
Read the transcript below:
AW is a 35-year-old man, presenting to the emergency room with nausea, tremors, and altered mental status.
His wife, Sheila, is in a panic because her husband had at least four seizures in the last 15 minutes.
AW was a dad who had a problem.
For several years, he just couldn't get enough from the bottle, until one day, he hurt his family in a haze and vowed to never drink ever again.
Days after his last drink, AW began shaking.
A tingling pricked into his fingertips. Little bugs were crawling underneath his skin. He was sweating, but was shivering cold. He was tired, but couldn't sleep. He had intense cravings, and no access to drink.
In bed now, delirious, AW saw the glowing lava lamp on his nightstand.
There must be some nice drink inside, he thought.
A little sip of it would cure all his problems, he thought.
Immediately after one-shotting the entire lava lamp, AW started rolling on the floor. He clenched parts of his bed frame, as his stomach curled in his body.
This feels better already, he thought.
As the night continued, AW became more delirious as he found himself huddled over the toilet. It's morning now, and Sheila finds her husband on the bathroom floor, seizing non-stop. She calls for 911. In the ambulance, paramedics see him suffer yet another seizure as he's brought to the emergency room where we are now.
Given this history of present illness, there's several clues as to what's happening.
Sheila tells the admitting nurse that her husband stopped drinking cold turkey, but doesn't tell the nurse that he mistakenly drank a lava lamp the night before. As his seizures recur, each successive one becomes longer and more intense.
This makes sense because alcohol, or more formally ethanol, depresses the central nervous system. Years of overconsumption cause the brain to adapt to its presence in blood, so suddenly taking it away can cause brain problems, which brings us to the first clue.
The seizures. The shaking. The bugs underneath his skin. This is clearly a case of severe alcohol withdrawal.
As the medical team continues its assessment, AW's convulsions develop into status epilepticus, a life-threatening electrical discharge of brain lasting longer than five minutes. He no longer regains consciousness in-between his seizures.
This immediately increases his chances of death. As nurses scramble to terminate his seizures, 11 syringes of the sedative lorazepam are injected to finally shut down his seizures for the moment.
Conscious again now, AW is still incoherent. He clenches his sides in pain, and a blood test reveals that he has hypocalcemia.
Hypo: meaning low.
Calce: referring to calcium.
And emia: meaning presence in blood.
Low calcium presence in blood.
Because muscles need calcium to commit to a contraction and his calcium levels in blood are low, then he should have muscle problems like a twitching. But he doesn't. This absence of that twitching could mean that he has acidemia, an acid presence of blood. When the blood is more acidic, it subtly reshapes the proteins by allowing them to bind less ionized calcium, preventing tetany, or twitching. But if he has acid floating around in his blood, and the kidneys are supposed to be removing this acid, well this brings us to the next clue.
Urine analysis now confirms that AW is not only dehydrated and acidotic, but that he also has something called prerenal azotemia.
Azote an old term referring to nitrogen.
Emia, again, meaning presence in blood.
A nitrogen presence in blood.
Prerenal meaning there is something wrong in his body that's preventing blood flow to the kidneys.
The medical team realizes that this is not simply a case of alcohol withdrawal. Clearly, something else is wrong, and Sheila stays quiet as her husband lies in delirium.
Bacteria was found in his urine, meaning he has an infection somewhere along his urinary tract. Because AW is a man, and men have longer urinary tracts than women -- and longer tracts are less likely to be infected -- then it means when there is an infection, it's a big deal, and it could mean bacterial growth all the way up from his kidneys, which could explain the nitrogen.
As AW is started on antibiotics, his urine output dramatically declines to the point of zero.
Acid and waste build up in his blood.
His breaths become more distressed. His psychoactive disturbances more active.
Several hours after initially presenting to the emergency room, AW's body goes into multi-organ failure. And it's here that Sheila finally tells the medical team about the lava lamp that her husband drank before bedtime.
Laboratory tests are done on leftover parts from AW's lava lamp. Wax, kerosene, and polyethylene glycol are found, all dissolved in water.
Wax is, in general, non-toxic in humans. Kerosene, at least in the amount that could be found in a lava lamp, is not poisonous, but the polyethylene glycol, could be a problem.
Ethylene glycol is antifreeze.
The "eth" prefix means two carbons.
Glycol is an old name for glycerin, now referring to these two alcohol groups.
Poly means more than one ethylene glycol chained together, but exactly, how many more?
If it's poly, as in 3000, then what's antifreeze as a singular molecule becomes a commonly used laxative when chained together, 3000 times. Because oxygens interact with hydrogens on water, it draws fluid into the bowel, softening the stool, inducing a stretch reflex on the smooth muscle of the GI tract and promoting movement.
But if poly means less than ten ethylene glycols chained together, well... that's toxic and this low molecular weight polyethylene glycol is what's found in AW's lava lamp.
Do you remember the formal name for alcohol? Well, ethanol has that same "eth" prefix. The molecular structure looks a lot like ethylene glycol. In the body, ethanol is metabolized, or broken down by the liver into acetate, which is one half of vinegar, and the body does this so the molecule more easily dissolves in water, so it can concentrate in the urine, and be excreted from the body.
3,000 ethylene glycols chained together is too big to fit in the enzyme, so that passes through as a laxative, but when poly means less than ten ethylene glycols, well these are small enough to fit into the enzyme to produce oxalate, which is more water-soluble... so fine the body's doing its job, but when oxalate touches calcium in the blood, it reacts. And if AW is hypocalcemic, then we know now where that calcium is going.
The problem is that calcium oxalate doesn't dissolve in water. It becomes a solid. It's another name for a kidney stone.
So as more and more calcium in AW's blood is depleted by reacting with oxalate, solid crystals deposit in his tissues, blocking blood flow and causing multi-organ failure. As these crystals creep towards his kidneys, flow becomes blocked as they accumulate in his tubules, killing them, causing prerenal azotemia and causing parts of his kidneys to necrose or quite literally die. This damage may be irreversible, and if nothing is done to address this, AW will continue to swim in a pool of his own bodily waste.
The idea of clinical decline complicated by an incomplete patient history has always been a problem in medical practice.
An elderly man got syphilis when he was young, and it was dormant for decades. He presented to the emergency room one day with declining mental status and was found to have neurosyphilis where the bacteria entered his brain. He was treated with antibiotics and discharged days later, but with minimal improvements in mental status. A poorly gathered medical history neglected that he also had previous autoimmune disease where his immune system attacked his organs, including a part of his stomach that secretes proteins enabling his body to absorb vitamin B12. Without vitamin B12, the dorsal, or backside, and lateral, or away from the median, columns of the spinal cord begin to demyelinate. The resulting neuropsychiatric changes from the lack of B12 looked like the ones caused by neurosyphilis and were neglected by the medical team. The subsequent autoimmunity was not caught until it was too late, where thyroiditis and pancreatitis leading to type 1 diabetes had settled in, both permanent and irreversible problems, all from an uncoordinated gathering of past medical history.
In a woman who had cancer, immunotherapy was given, meaning her immune system was unleashed by medicines, allowing her own cells to attack the tumor. She had a complete response and was able to eliminate her cancer because of the medicine, but several months later, began experiencing delusions that developed into a psychosis. She had to be admitted to a psychiatric ward due to hallucinations, cognitive impairment, and disorganized speech. She was diagnosed with schizophrenia and given medicines to control her negative symptoms, but with little improvement. It wasn't until a chance endoscopy discovered that she had celiac disease, where a gluten allergy inflamed her bowels -- it may have come from the unleashed immune system that not only attacked the cancer cells, but also attacked her gastric parietal cells. The presence of gluten in her diet unleashed delusions and caused her cognitive impairment as an effect of celiac disease. And without a detailed history and knowledge of adverse events from previous treatments, she was misdiagnosed with refractory schizophrenia when it was really a neuropsychiatric manifestation of a gluten allergy.
In AW, if anything can be done, we can first rehydrate him with IV fluids.
Since his kidneys aren't working, we can divert his blood into a machine and filter it through there, a process called dialysis.
But this doesn't clear out the kidney stones.
It doesn't reverse the renal tubular necrosis and bring parts of his kidneys back to life.
And it doesn't stop any more oxalate from being made from the lava lamp liquid that AW drank. Which brings us to the final complication of this case.
Ethylene glycol and ethanol are metabolized by the same enzyme. In humans, that enzyme binds stronger to ethanol, meaning if we let AW drink again, we can stop the formation of oxalate and depletion of calcium. But, if we let him drink again, he's going to relapse again, he's going to go into withdrawal again at a later time, and it negates the initial reason why he thought to drink the lava lamp in the first place.
There's one final point to think about here. Do you remember the lorazepam used to terminate AW's status epilepticus? Well, lorazepam is a solid that doesn't dissolve in water. It's formulated with a solvent known as low molecular weight polyethylene glycol, meaning that his seizures from ethanol withdrawal prompted termination by a medicine containing the same compound that was poisonous in the lava lamp he drank, feeding the process forward as calcium oxalate crystals deposited and shut down his kidneys. At the point where status epilepticus emerged, it wasn't clear to the medical team that AW drank a lava lamp, and it wasn't clear that low molecular weight polyethylene glycol was the kidney toxin contained within, and stopping his seizures took first priority. Some patients with severe alcohol withdrawal may be hospitalized for several days, and given high doses of lorazepam, per hour. If they're put on nephrotoxic antibiotics during their stay, like AW was, then this alone could cause kidney damage. Eleven syringes worth of lorazepam likely pales in comparison to drinking a lava lamp, but subsequent doses for preventing ongoing seizures may be significant. But there isn't another anticonvulsant that doesn't have some form of alcoholic solvent, so there wasn't a better alternative.
There was no easy answer to treating AW, because his underlying issues simply weren't easy.
With a long hospital stay and supportive care from the medical team, AW sustained a recovery.
Thank you so much for watching. Take care of yourself. And be well.
"Dr. Bernard" is a licensed physician and clinical adjunct professor at the University of Illinois. See more of his videos on his .