High anion gap metabolic acidosis caused by penicillin G: A case report

Nohara Shizuka, Akebo Hiroyuki, Sada Ryuichi, Tsugihashi Yukio, Minoda Saki, Miyake Hirofumi, Ishimaru Hiroyasu, Hatta Kazuhiro

doi:10.12936/tenrikiyo.23-003

<p>Penicillins may cause hypokalemic metabolic acidosis. On the other hand, it has been reported that the simultaneous use of penicillins and acetaminophen may cause the accumulation of pyroglutamic acid (PGA; also known as 5-oxoproline), thereby leading to the development of high anion gap metabolic acidosis (HAGMA). We report a case of HAGMA that was considered to be caused by penicillin G (PCG) alone. A 59-year-old man presented with severe pain, swelling, and redness of his left leg. He was diagnosed with necrotizing fasciitis associated with septic shock syndrome, which was caused by Streptococcus pyogenes. He immediately underwent excisional debridement of the affected tissues, and was treated using high-dose PCG, clindamycin, corticosteroid, and γ globulins. As his condition was complicated by acute kidney failure, we initiated continuous hemodiafiltration (CHDF). On the 5th day of admission, his kidney function recovered and CHDF was withdrawn. Paradoxically, he thereafter developed rapidly-worsening HAGMA, requiring daily hemodialysis to treat severe acidosis. He had no ketoacidosis, lactic acidosis, or exposure to toxic agents. On the 11th day of admission, as accumulation of PGA induced by PCG was suspected, we withdrew all antibiotics except for clindamycin, resulting in the gradual resolution of HAGMA. This case suggests that HAGMA can be caused by PCG alone and withdrawal of causative drugs should be considered whenever this condition is suspected.</p>

High anion gap metabolic acidosis caused by penicillin G: A case report

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