LETTER TO THE EDITORS
Unrecognized of the salicylism toxicity with normal anion
Transcutaneous Severe
Salicylate Intoxication
in an Infant
To the Editors:
S alicylism, the syndrome of salicylic
acid toxicity, is a life-threatening condi-
tion; the laboratory findings include typi-
cally metabolic acidosis with high anion
gap and respiratory alkalosis. In young in-
fants, the salicylic ointments are currently
used in seborrheic dermatitis treatment,
a benign pathology typical of this age group.
We describe a case of acute aspirin toxicity
after topic treatment in an infant with unex-
pected normal anion gap metabolic acidosis.
A 2-month-old male infant was admit-
ted for a 12-hour clinic of fever, breathless-
ness, and irritability. Laboratory evaluation
showed metabolic acidosis (pH, 7.33; PCO2,
20 mm Hg; H CO 3 , 10.5 mM/L; base ex-
cess, −13 mM/L), with normal calculated
anion gap (3.5 mM/L) and hyperchloremia
(chloride, 129 mmol/L). The parents were
using a topic treatment for the crusta lactea
erroneously prescribed by their paediatri-
cian containing 50% salicylic acid, ap-
plied in occlusion on the scalp during
3 days before the hospital admission. A diag-
nosis of topical salicylate poisoning was
confirmed by standardized salicylate levels
of 42.5 mg/dL 48 hours after the last topi-
cal exposure. A specific treatment was started
with alkalinization of urine and forced diure-
sis. A control salicylate level 24 hours after
starting treatment was 24 mg/dL. The pa-
tient recovered fully without sequelae.
We present a rare case of difficult diag-
nosis considering the unrecognized pathway
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gap metabolic acidosis due to falsely ele-
vated chloride levels. The cause of hyper-
chloremia was a laboratory interference
determined by the increased serum sali-
cylate levels. This error seems to occur
with some ion-selective electrodes and may
be due to loss of selectivity over the opera-
tional life of the chloride electrode, as well
as competition between salicylate and chlo-
ride ions to bind to albumin.1,2 Currently,
new electrode technology is being developed
that should not be affected by this drug.
The literature suggests that a topical
product containing more than 4% to 10%
of salicylate could be toxic if applied on
large surface area.3,4 However, there are
certain factors that increase the percutane-
ous absorption of salicylate such as pro-
longed use, application in occlusion, and
skin inflammation. Infants are high-risk
patients considering the increased body
surface–weight ratio.4,5
The level at which salicylate toxic-
ity begins is 35 mg/dL, and the severe
salicylism appears with more than 50 to
75 mg/dL. Forty-eight hours since the last
application, our patient presented levels of
42.5 mg/dL, so we can easily conclude that
he was exposed to extremely high salicylate
plasma concentration.
Although the topical toxicity of the
salicylate is rare, young infants should be
considered a high-risk group. Our case un-
derlines that an increased anion gap, gener-
ally a hallmark of the severe salicylism,
failed as a reliable indicator of salicylate
intoxication.
José Luis Vázquez Martinez, PhD
Paediatric Intensive Care Unit
Hospital Universitario Ramón y Cajal
Madrid, Spain
Pediatric Emergency Care • Volume 31, Number 9, September 2015
Sinziana Stanescu, MD
Paediatric Intensive Care Unit
Hospital Universitario Ramón y Cajal
Madrid, Spain
sinzi.stanescu@gmail.com
Sara Castrillo Bustamante, MD
Pediatric Department
Hospital General de Segovia
Segovia, Spain
José Manuel Del Rey Sanchez, PhD
Department of Biochemistry
Hospital Universitario Ramón y Cajal
Madrid, Spain
César Pérez-Caballero Macarrón, PhD
Ana Coca Pérez, MD
Paediatric Intensive Care Unit
Hospital Universitario Ramón y Cajal
Madrid, Spain
Disclosure: The authors declare no
conflict of interest.
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