The Poison Review

Current Management of Salicylate-Induced Pulmonary Edema. Glisson JK et al. South Med J March 2011;104:225-232.

Abstract

This paper, which deals with an extremely important topic, is so scattershot and poorly planned that it ends up being a severe disappointment.  The authors state that their goal was identify all relevant publications in the English language reporting cases of saliclate-induced pulmonary edema in adults > 19 years of age.  Unfortunately, they do not describe the methods they used to select relevant articles, and some of their results make it seem they used no methods at all.  For example, their reference #38 presented a case of pulmonary edema that the authors report occurred after ingestion of a single tablet of aspirin.  Unless that tablet was the size of a burrito, I’m not sure why this case was included .

The authors do make one important point, however.  This is that salicylate toxicity — especially chronic salicylate toxicity — can easily be missed if the clinician reaches premature closure and anchors his or her diagnosis on a seemingly more probable disease process.  Salicylate toxicity can cause altered mental status, fever, hyperglycemia, pulmonary edema, hypotension, metabolic acidosis (usually with a high anion gap), and coagulopathy.  I am aware of cases — some of which ended in fatality — where the diagnosis was delayed because the initial diagnosis was viral pneumonia, diabetic ketoacidosis, or sepsis, and salicylate toxicity was not considered until late in the game.  Of course, reaching an accurate diagnosis is often made more difficult because of salicylate-induced encephalopathy.  The key to not missing the correct diagnosis lies in paying careful attention to the electrolytes and anion gap in any sick patient (especially when obtaining a detailed history is not possible), and considering the entire differential for high-anion-gap metabolic acidosis as reflected in the mnemonic A CAT PILES MUD:

• A – aspirin
• C – cyanide, carbon monoxide
• A – acetaminophen (massive)
• T – theophylline
• P – paraldehyde, propylene glycol
• I – INH, ibuprofen
• L – lactic acidosis
• E - ethylene glycol
• S – sepsis
• M – methanol, metformin
• U – uremia
• D – diabetic ketoacidosis, alcoholic ketoacidosis