A Case of Salicylate Toxicity Presenting with Acute Focal Neurologic Deficit in a 61-Year-Old Woman with a History of Stroke

Abstract

BACKGROUND Over-the-counter medications that contain aspirin are widely used, and patients generally regard them as safe. However, the side effects of salicylate toxicity can be severe, and delay in the diagnosis may increase the risk of mortality. Neurologic symptoms are a common presenting feature of salicylate toxicity in the elderly, and their recognition may allow earlier diagnosis. This report is of a case of a 61-year-old woman who presented with acute focal neurologic deficit associated with salicylate toxicity and who had a previous history of stroke. CASE REPORT A 61-year-old woman presented to the Emergency Department after awakening with left-sided weakness. She had a history of ischemic stroke with an associated seizure disorder. The patient denied recent seizure, and brain magnetic resonance imaging (MRI) showed no evidence of an acute stroke. Following her arrival, she became acutely confused and complained of tinnitus, shortness of breath, and blurred vision. On direct questioning, she gave a history of excessive use of salicylate for the previous two to three weeks. Her initial serum salicylate level was significantly increased at 78.1 mg/dl (upper therapeutic limit, 19.9 mg/dl). She recovered completely following treatment with oral activated charcoal, intravenous sodium bicarbonate, and potassium replacement. CONCLUSIONS This case demonstrates that physicians should consider salicylate toxicity as a possible cause of exacerbation of neurological deficit in elderly patients.

Figure 1.

Brain magnetic resonance imaging (MRI) of a 61-year-old woman with a history of stroke and acute neurologic deficit due to salicylate toxicity. Axial T2 fluid-attenuated inversion recovery (FLAIR) MRI (A) and diffusion-weighted MRI (B) demonstrate a chronic cerebral infarct in the territory of the right middle cerebral artery. The findings show liquefactive volume loss and encephalomalacia on FLAIR imaging without hyperintensity on diffusion-weighted imaging. There is no evidence of cerebral edema.

Figure 2.

Salicylate levels measured at five points over 25 hours of a 61-year-old woman with a history in stroke and acute neurologic deficit due to salicylate toxicity. The initial serum salicylate level was significantly increased at 78.1 mg/dl (upper therapeutic limit, 19.9 mg/dl), indicating salicylate toxicity. Serum salicylate levels are shown to decrease following treatment that included intravenous sodium bicarbonate, which began at hour 7.