Methanol poisoning

Case contributed by Dr Jose Bacalla

Presentation

Presenting comatose to the emergency room

Patient Data

Age: 50 years
Gender: Male
CT

Diffuse symmetrical subcortical whiter matter hypoattenuation in keeping with a metabolic/toxic insult, most likely methanol poisoning. There is also bilateral putaminal and in less extension globus pallidus hypodensity, suggesting lentiform nuclei necrosis. No areas of hemorrhage are identified.

Subarachnoid spaces are effaced. No midline shift.

Case Discussion

Methanol metabolites are highly toxic and when absorbed cause interruption of the respiratory chain metabolism, leading to sistemic acidosis. Brain toxicity includes white matter myelin destruction and putaminal necrosis. The putaminal region is thougth to have higher metabolic demands, so it is specially fragile to any respiratory chain interruption 1. Globus pallidus, cerebellum and optic tracts are also involved. 

The white matter compromise is assumed to be caused by myelin destruction (related to formic acid, an intermediate metabolite) with or without axonal loss 2.

CT may be normal in the first hour after ingestion, so MRI can be helpful in this clinical setting. 

Brain damage tends to be permanent or only partially reversible.

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