Correspondence

Intoxication of a Hospitalized Patient with an Isopropanol-Based Hand Sanitizer

N Engl J Med 2007; 356:530-531February 1, 2007

Article

To the Editor:

A 43-year-old man with alcoholism was admitted to the hospital with chest pain, for which the workup was unremarkable. At discharge, the patient became acutely hypotensive and delirious. He was afebrile, oxygenating well, and had a nonfocal neurologic examination. Intravenous fluids and vasopressors were administered. The results of routine laboratory tests were normal, as were the results of arterial blood gas and serum ethanol measurements, toxicology screening, blood and urine cultures, and computed tomography of the head. Urinalysis showed a trace of acetone. The following day, the patient was hemodynamically stable, but his mental status did not improve. Because of a sweet, ketotic odor in the room, tests of serum isopropyl alcohol (isopropanol) and acetone levels were ordered. Before those results were obtained, the patient was seen in the bathroom drinking the alcohol-based hand wash from its dispenser.

The patient's isopropanol level was 13.6 mg per deciliter, and his acetone level was 269.4 mg per deciliter (normal range, 0 to 1.9 for both). When asked why he ingested the hand cleaner, he pointed to the label, which read, “Active ingredient 63% v/v isopropyl alcohol.” He explained that this percentage is higher than that in vodka.

Ingestion of approximately 200 ml of isopropanol can be lethal owing to depression of both the central nervous system and myocardial function.1 A plasma concentration above 400 mg per deciliter is considered to be life-threatening.2 Unlike methanol and ethylene glycol, isopropanol is more toxic than its metabolites; hence, alcohol dehydrogenase inhibitors should not be given.3 Hemodialysis removes both isopropanol and acetone.1 Since in our patient, most of the isopropanol had already been converted to acetone (probably owing to the first-order kinetic metabolism),4 we decided not to pursue dialysis and instead continued with supportive therapy. He recovered fully.

Ingestion of methanol, ingestion of ethylene glycol, and ingestion of isopropanol all lead to an elevated plasma osmolal gap. However, isopropanol does not cause metabolic acidosis with an elevated anion gap.1 Primary alcohols are metabolized to aldehydes, followed by oxidation to carboxylic acids; deprotonation then causes acidosis with conjugate bases that elevate the anion gap. Secondary alcohols, such as isopropanol, oxidize to ketones, such as acetone, which under physiologic conditions cannot be further oxidized to acid.

Isopropanol-containing hand sanitizers are ubiquitous. Physicians should be aware of the potential for isopropanol intoxication, especially among alcoholics, in the hospital setting. Perhaps changing the description on the container from isopropyl alcohol to isopropanol or propane-2-ol would decrease the attraction of these hand sanitizers for potentially dangerous abuse.

Ashkan Emadi, M.D., Ph.D.
LeAnn Coberly, M.D.
University of Cincinnati, Cincinnati, OH 45267-0557
emadia@email.uc.edu

4 References

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Citing Articles (12)

Citing Articles

1. 1

   D. Carignan, O. Desy, P. O. de Campos-Lima. (2012) The Dysregulation of the Monocyte/Macrophage Effector Function Induced by Isopropanol Is Mediated by the Defective Activation of Distinct Members of the AP-1 Family of Transcription Factors. Toxicological Sciences 125:1, 144-156
   CrossRef

2. 2

   Joanna Hockenhull, Waljit Dhillo, Rebecca Andrews, Sue Paterson. (2012) Investigation of markers to indicate and distinguish death due to Alcoholic Ketoacidosis, Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State using post-mortem samples. Forensic Science International 214:1-3, 142-147
   CrossRef

3. 3

   Nicole J. Gormley, Alvin C. Bronstein, Joseph J. Rasimas, Maryland Pao, Angela T. Wratney, Junfeng Sun, Howard A. Austin, Anthony F. Suffredini. (2012) The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Critical Care Medicine 40:1, 290-294
   CrossRef

4. 4

   S. Koball, J. Schipper, M. Hinz. (2011) Mischintoxikationen mit Propanol und Ethanol. Intensivmedizin und Notfallmedizin 48:5, 439-442
   CrossRef

5. 5

   Jeffrey S. Engel, Henry A. Spiller. (2010) Acute Ethanol Poisoning in a 4-Year-Old as a Result of Ethanol-Based Hand-Sanitizer Ingestion. Pediatric Emergency Care 26:7, 508-509
   CrossRef

6. 6

   Bruno Mégarbane, Antoine Villa. (2010) Poisoning with Ethanol and 2-Propanol-Based Hand Rubs: Give Caesar What Belongs to Caesar!. Neurocritical Care
   CrossRef

7. 7

   Eliane M. Billaud, Sandrine Lefeuvre, Amélie Passeron, Agnès Lillo-Lelouet, Christine Le Beller. (2010) Solution hydro-alcoolique: risque d’intoxication par ingestion. Annales de Toxicologie Analytique 22:1, 45-47
   CrossRef

8. 8

   Arun R. Mahankali Sridhar, Lisa L. Willett, Analia Castiglioni, Gustavo Heudebert, Michael Landry, Robert M. Centor, Carlos A. Estrada. (2009) Scholarship Opportunities for Trainees and Clinician Educators: Learning Outcomes from a Case Report Writing Workshop. Journal of General Internal Medicine 24:3, 398-401
   CrossRef

9. 9

   D. Steinmann, T. Faber, V. Auwärter, C. Heringhaus. (2009) Akute Intoxikation mit Isopropanol. Der Anaesthesist 58:2, 149-152
   CrossRef

10. 10

    J.A. Stockman. (2008) The Attitude of Physicians Toward Cold Remedies for Upper Respiratory Infection in Infants and Children: A Questionnaire Survey. Yearbook of Pediatrics 2008, 509-511
    CrossRef

11. 11

    Scott G. Weiner. (2007) Changing Dispensers May Prevent Intoxication From Isopropanol and Ethyl Alcohol-Based Hand Sanitizers. Annals of Emergency Medicine 50:4, 486
    CrossRef

12. 12

    Gita Thanarajasingam, Daniel A. Diedrich, Paul S. Mueller. (2007) Intentional Ingestion of Ethanol-Based Hand Sanitizer by a Hospitalized Patient With Alcoholism. Mayo Clinic Proceedings 82:10, 1288-1289
    CrossRef