Abstract: SA-PO0610
The Answer to This Metabolic Acidosis Lies in the Lungs
Session Information
- Fluid, Electrolyte, and Acid-Base Disorders: Case Reports - 2
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid, Electrolytes, and Acid-Base Disorders
- 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical
Authors
- Umar, Sumayya, St. Vincent's Medical Center, Bridgeport, Connecticut, United States
- Pena Zapata, Oscar Yasser, St. Vincent's Medical Center, Bridgeport, Connecticut, United States
- Singh, Shashwat, St. Vincent's Medical Center, Bridgeport, Connecticut, United States
Introduction
Distal RTA is characterized by impaired urinary acidification, causing hypokalemic non-anion gap metabolic acidosis. Toluene exposure is a recognized but underdiagnosed cause, and increasing vaping use has introduced novel inhalational toxic exposures that often go unrecognized.
Case Description
A 39-year-old woman presented with acute hypoxic respiratory failure. Initial oxygen saturation was 15%, for which she was emergently intubated. Initial laboratory tests showed severe hypokalemia (1.9) and metabolic acidosis consisting of both anion gap and non-anion gap components. Urine studies demonstrated a urine anion gap (40), and urine pH (7) remained inappropriately high despite acidemia.
She had a similar episode about a year ago, but her serum bicarbonate levels would normalize in between episodes. Autoimmune evaluation for distal RTA was unrevealing, and there was no exposure to medications classically associated with distal RTA.
She required mechanical ventilation for over 10 days. During this period, a CT scan of the chest showed diffuse bilateral ground-glass opacities. Upon review, she was found to have had similar findings in the past, with complete resolution of opacities in between. Given the transient nature of these findings, an inhalational injury was considered. After extubation, the patient disclosed that she was using a friend’s vape prior to admission, establishing toluene as the etiology of her distal RTA. She required several weeks of potassium citrate supplementation, with gradual correction of her potassium and bicarbonate levels.
Discussion
Toluene exposure commonly occurs through inhalation of vapors from paints, solvents, adhesives, gasoline, most commonly through occupational exposure, tobacco smoke, industrial emissions, and recreational solvent misuse (“huffing” or glue sniffing). Toluene has also been detected in some e-cigarette aerosols and liquids, representing an underrecognized source of exposure, as illustrated by our patient who developed distal RTA with severe metabolic acidosis.
CT scan of the lung showing bilateral GGO