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CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 278-280

Pitfalls of Sanitizer Use in the COVID-19 Era: A Case Report of Hand Sanitizer-Induced Blindness due to Contamination by Methanol


1 Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Delhi, India
2 Department of Biochemistry, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, Delhi, India

Date of Submission09-May-2022
Date of Acceptance23-Aug-2022
Date of Web Publication07-Dec-2022

Correspondence Address:
Sunita Aggarwal
Director Professor, Room No. 122, BL Taneja Block, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_31_22

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  Abstract 


The COVID-19 pandemic has boosted the availability of hand sanitizers worldwide, which have become ubiquitous. Their widespread utility has also contributed to increased accidental or intentional sanitizer ingestion. We describe the case of a young male who presented with an unintentional ingestion of hand sanitizer. On examination, he had a depressed sensorium, and further evaluation revealed severe metabolic acidosis. The patient was suspected of ethanol toxicity and underwent hemodialysis with concurrent bicarbonate replacement. However, the presence of bilateral visual loss, characteristic Computed Tomography (CT) brain finding of hemorrhagic putaminal necrosis, and normal serum ethanol levels prompted a search for methanol in the sanitizer. Specific biochemical tests confirmed this for methanol, and a diagnosis of sanitizer-induced methanol poisoning was made.

Keywords: COVID-19, methanol, blindness


How to cite this article:
Aggarwal S, Vijayakumar S, Singh R, Koner BC, Saijpaul R, Kumar N, Kumar A, Mittal T. Pitfalls of Sanitizer Use in the COVID-19 Era: A Case Report of Hand Sanitizer-Induced Blindness due to Contamination by Methanol. MAMC J Med Sci 2022;8:278-80

How to cite this URL:
Aggarwal S, Vijayakumar S, Singh R, Koner BC, Saijpaul R, Kumar N, Kumar A, Mittal T. Pitfalls of Sanitizer Use in the COVID-19 Era: A Case Report of Hand Sanitizer-Induced Blindness due to Contamination by Methanol. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 1];8:278-80. Available from: https://www.mamcjms.in/text.asp?2022/8/3/278/362893




  Introduction Top


The rising awareness regarding hand hygiene during the Corona Virus Disease 2019 (COVID-19) pandemic has led to the rampant global use of hand sanitizers. While most sanitizers contain ethanol as the main component, rigorous scrutiny has yielded traces of methanol in many products. Methanol is also a contaminant in other alcoholic beverages and is known to cause an array of toxic adverse effects, ultimately leading to death if untreated. In this case report, we describe the case of a patient who presented with accidental ingestion of a sanitizer and developed symptoms of methanol toxicity.


  Case History Top


A 23-year-old male presented to the emergency with an alleged history of ingestion of hand sanitizer 12 hours back, after which he had multiple episodes of vomiting and a gradual decrease in alertness. On arrival, the patient’s pulse rate was 96 bpm, respiratory rate was 24/minute, Blood Pressure (BP) was 126/70 mm Hg, and SpO2 was 95% on room air; he also had an acidotic pattern (deep labored) of breathing. His Glasgow Coma Scale (GCS) was E2V2M5; the pupils were of average size but sluggishly reactive to light, while the rest of the neurological examination was unremarkable. Arterial blood gas analysis showed severe high anion gap metabolic acidosis with a pH of 6.8 and bicarbonate of 4 mEq/L with an anion gap of 32 mEq/L. The patient was started on bicarbonate supplementation and resuscitated with intravenous fluids. The sanitizer bottle he had consumed was brought, and the composition on the label was determined as ethanol (70%) and chlorhexidine (2.5%). The patient was suspected of ethanol poisoning, and a hemodialysis session was done because of severe metabolic acidosis. A blood sample for serum ethanol levels was also sent.

The patient’s general condition and sensorium improved after hemodialysis. Upon eliciting a history from himself, he admitted that he was an alcoholic and accidentally ingested around 20 to 30 mL of the bottle. He also complained of bilateral complete loss of vision; visual acuity examination demonstrated that only light perception was present in both eyes. However, this seemed less likely in the clinical picture of ethanol toxicity. The serum ethanol levels also were within the standard limit (3 mg/dL; normal: <10 mg/dL). Hence, further efforts were undertaken to find the substance which mimicked ethanol toxicity.

The patient’s metabolic acidosis resolved during the hospital stay, and he improved clinically. A noncontrast Computed Tomography (CT) scan of the head showed bilateral hypodense areas with a hyperdense center in the putamen suggestive of hemorrhagic necrosis [Figure 1]. Because of the findings of bilateral visual loss, high anion gap metabolic acidosis, and an average serum ethanol level, a search for methanol in the sanitizer was initiated.
Figure 1 Noncontrast CT head film showing bilateral hemorrhagic infarcts in the putamen.

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An iodoform test was done to differentiate between ethanol and methanol, which showed that methanol was present in addition to ethanol in the sanitizer. A confirmatory qualitative test was done using the Deniges method, which was also positive for methanol [Figure 2]. The patient was diagnosed with methanol poisoning. He was later discharged and advised follow-up in ophthalmology for visual acuity testing.
Figure 2 Deniges qualitative method for detection of methanol.

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  Discussion Top


The gaining popularity of alcohol-based sanitizers over soaps for disinfection is due to their efficacy, broader antimicrobial spectrum, and convenience of use. There are broadly two types of hand sanitizers: alcohol-based sanitizers containing ethyl alcohol (ethanol), isopropyl alcohol, or 2-propanol, whereas nonalcohol-based preparations contain benzalkonium chloride or other compounds. The Food and Drug Administration stipulates that alcohol content should be between 60% and 95% for alcohol-based sanitizers. Methyl alcohol (methanol) is not a component owing to its adverse effects.

Acute methanol intoxication initially produces nausea, vomiting, and abdominal pain followed by blindness and neurological symptoms such as headache, confusion, ataxia, seizures, drowsiness, coma, and death, in untreated cases. Symptoms follow a latent period of 6 to 12 hours, probably due to the time taken to build up metabolites. Radiological studies such as CT and Magnetic Resonance Imaging (MRI) demonstrate features consistent with bilateral putaminal necrosis with varying degrees of hemorrhage.[1]

Methanol is metabolized serially by alcohol and aldehyde dehydrogenase into formaldehyde and formate, respectively, which inhibits mitochondrial oxidation causing tissue hypoxia and lactic acidosis, contributing to high anion gap metabolic acidosis. Formate is also postulated to cause direct damage to the optic nerve, which results in blindness. The presence of unionized methanol also elevates the serum osmolal gap (normal range: 10–20 mOsm/kg).

Management of suspected methanol poisoning encompasses the overarching goals of preventing its conversion into toxic metabolites and enhancing clearance. It involves aggressive measures to neutralize metabolic acidosis and mitigate damage to the Central Nervous System (CNS) and optic nerve. Bicarbonate administration counteracts metabolic acidosis, whereas fomepizole, an alcohol dehydrogenase inhibitor, prevents an accumulation of formate. Hemodialysis is indicated in severe metabolic acidosis or serum methanol level of >50 mg/dL.[2]

There have been many reports of sanitizer ingestion worldwide; children and chronic alcohol abusers are mainly at risk for intoxication. The clinical presentation is mainly due to ethanol toxicity with symptoms of CNS depression, lactic acidosis, and in severe cases, hypotension and respiratory arrest.[3] However, there is a paucity of data ascribing methanol toxicity due to sanitizer ingestion. In a recent report by the Center for disease control and prevention (CDC), 15 patients presented with ingestion of hand sanitizer and exhibited symptoms suggestive of methanol toxicity. They also had severe metabolic acidosis and blindness and were eventually diagnosed with methanol poisoning.[4] In our patient, although the initial clinical picture was indicative of ethanol toxicity, the development of blindness hinted at the possibility of methanol intoxication, and on further investigation, the diagnosis of sanitizer-induced methanol poisoning was established. The probable reason for this might be due to contamination of the sanitizer by methanol.


  Conclusion Top


It is imperative to ensure quality control in the manufacture and sale of alcohol-based sanitizers to prohibit contamination by toxic substances such as methanol. Unnecessary use of sanitizers must also be avoided. A high index of suspicion must be kept for methanol in patients presenting with unknown substance poisoning with classical symptoms and signs of toxicity. Early diagnosis and aggressive management are critical to avoiding permanent neurological disability and mortality.

Acknowledgments

The authors thank the Department of Biochemistry, Maulana Azad Medical College, for their valuable contribution in this case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blanco M, Casado R, Vázquez F, Pumar JM. CT and MR imaging findings in methanol intoxication. AJNR Am J Neuroradiol 2006;27:452–4.  Back to cited text no. 1
    
2.
Kraut JA, Mullins ME. Toxic alcohols. N Engl J Med 2018;378:270–80.  Back to cited text no. 2
    
3.
Wilson ME, Guru PK, Park JG. Recurrent lactic acidosis secondary to hand sanitizer ingestion. Indian J Nephrol 2015;25:57–9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Yip L, Bixler D, Brooks DE et al. Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol − Arizona and New Mexico, May-June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1070–3.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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