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A 49-year-old man consulted the emergency department with a brief history of moderate headache, anomia and ataxia. There was no fever, and no evidence of infection, trauma or alcohol intake. His medications included mirtazepin and escitalopram for a history of depression. On first examination, the patient was confused and incoherent without focal neurologic signs. Electrocardiogram, head CT-scan, chest X-ray and lumbar puncture showed no abnormalities. Initial laboratory findings (haematology, serum electrolytes, creatinine, urea, glucose, C-reactive protein, ethanol) were within normal limits. A moderate leucocytosis of 13.3 g/l was noted. Could this be basilartype migraine or something else? In the course of the following hours, the patient developed hyperventilation. Why is he hyperventilating? Could it be a psychogenic cause? Blood gas analysis showed a pronounced metabolic acidosis (pH 7.2, base excess −18.4 mmol/l, serum bicarbonate 6.2 mmol/l). What would be your next step? Giving a bicarbonate infusion? Measure the anion and the osmolar gap.

Sweet and sour--a patient with life-threatening metabolic acidosis and acute renal failure