Case 1: Mysteriously Rising Salicylate Levels in a 15-year-old Girl

Presentation

A 15-year-old girl with a history of depression and self-harm is found surrounded by empty pill bottles approximately 1 hour after ingestion. She admits to taking approximately 25 tablets of aspirin (acetylsalicylic acid) 325 mg (135 mg/kg), 2,000 mg of ibuprofen, and “a few stomach pills” with the intent to commit suicide. Two hours after ingestion, she notes abdominal pain but is otherwise alert, oriented, and breathing comfortably at a community hospital. Her initial serum salicylate level is 32.5 mg/dL 4 hours after ingestion. She is transferred to a tertiary facility, where she notes abdominal pain, nausea, and now ringing in her ears.

On examination, she has a temperature of 97.8°F (36.6°C), blood pressure of 101/60 mm Hg, pulse of 112 beats/min, and respiratory rate of 18 breaths/min. She answers questions appropriately. Abdominal examination elicits diffuse mild tenderness, normal bowel sounds, and no masses. Motor and sensory examination findings are normal, and she exhibits normal reflexes.

Laboratory findings reveal a serum bicarbonate level of 21 mEq/L (21 mmol/L), a negative acetaminophen level, a urine drug screen positive for cannabinoids, and, 6 hours after ingestion, a serum salicylate level of 40.7 mg/dL. Nine and 11 hours after ingestion, the serum salicylate level remains at 40.7 mg/dL.

The patient is admitted to the PICU for intravenous (IV) fluid administration, alkalinization, and observation. She becomes tachypneic. A repeated salicylate level determined 14 hours after ingestion is 45.0 mg/dL. An abdominal radiograph is taken (Fig 1) that helps to make the diagnosis.