Successful treatment of severe lactic acidosis caused by a suicide attempt with a metformin overdose.

Metformin-associated lactic acidosis is a very rare but critical condition. It is seen in patients with type 2 diabetes mellitus who take metformin and attempt suicide with a metformin overdose. Here, we report a 43-year-old woman with type 2 diabetes mellitus and chronic renal insufficiency who developed hypoglycemia, hypothermia, tachycardia and lactic acidosis after a suicide attempt with a metformin overdose. She was successfully treated by continuous venovenous hemofiltration, and adequate hemodynamic and ventilatory support. Although metformin does not usually cause hypoglycemia when administered as monotherapy, hypoglycemia can occur in a condition coexistent with lactic acidosis secondary to metformin overdose. Metformin intoxication should be suspected when patients present with high anion gap metabolic acidosis after attempting suicide by ingesting drugs, particularly when comorbidities such as renal failure are present. Early diagnosis and rapid correction of the metabolic acidosis using hemodialysis or hemofiltration, together with concomitant cardiovascular support, and maintenance of blood glucose and core body temperature, provide the possibility of a positive outcome.

Pyogenic liver abscess associated with septic pulmonary embolism.

BACKGROUND: Septic pulmonary embolism (SPE) is one of the metastatic foci of pyogenic liver abscess. The purpose of this study was to investigate the clinical presentations of, and management options for patients with pyogenic liver abscess complicated with SPE. METHODS: A retrospective chart review was conducted from January 1, 1999 to December 31, 2005 inclusively, in a medical center in northern Taiwan. We collected and analyzed the clinical presentations, diagnostic modalities, treatment programs and prognoses for all pyogenic liver abscess patients with SPE. RESULTS: The association between liver abscess affected with the complication of SPE and diabetes mellitus was significant. There were 9 patients who had pyogenic liver abscess with SPE. Abnormal chest radiograph (CXR) findings with multiple ill-defined peripheral round densities were noted in all patients. Seven patients were diabetic, fever occurred in 5 patients, respiratory symptoms were noted in 6 patients, and abdominal pain occurred in 3 patients. Endophthalmitis coexisted in 3 patients, meningitis in 1 patient, and necrotizing fasciitis in 2 patients. Microbiological studies revealed Klebsiella pneumoniae in 9 patients. Computed tomography (CT) demonstrated metastatic nodules in both lung lobes, some of which featured cavitation, in all 9 patients. Three patients soon advanced to acute respiratory failure, and later died due to acute respiratory distress syndrome and/or septic shock. The remaining 6 patients survived without complication during their hospital course. CONCLUSION: There is diagnostic value in performing a chest CT scan in diabetic patients who have liver abscess plus abnormal CXR findings with multiple ill-defined peripheral round densities, in order to detect SPE, which has a relatively poor outcome in patients with liver abscess.

Treatment of massive retroperitoneal hemorrhage from adrenal metastasis of hepatoma.

Spontaneous rupture of metastatic adrenal tumor with massive retroperitoneal hemorrhage and shock is an uncommon clinical event. Herein, we report a case of hepatocellular carcinoma (HCC), where left hepatic lobectomy and right adrenalectomy for metastatic HCC were performed in April and August 2002, respectively. Subsequently, the patient presented to the emergency room with acute-onset severe left flank and back pain in March 2004, accompanied by a falling hemoglobin level. Computed tomography revealed a 7-cm left adrenal tumor mass with retroperitoneal hemorrhage. The ruptured adrenal tumor was further confirmed by selective angiography, which demonstrated that the bleeder was supplied by the left suprarenal artery. Transarterial embolization (TAE) to stop tumor bleeding was performed successfully. The patient then underwent tumor resection with left adrenalectomy 5 days after the embolization, with pathology subsequently revealing metastatic HCC. The recurrent intrahepatic HCC was controlled with TAE, and the patient underwent hormone replacement therapy with prednisolone 10 mg/day. Metastatic adrenal tumor bleeding should be suspected in hepatoma patients who suffer abrupt flank pain and shock. Hemodynamically unstable patients require supportive transfusions and urgent surgical exploration. Angiographic embolization, if deemed feasible, may be a valuable adjunct for achievement of hemostasis prior to definite surgery.