Severe Anion Gap Metabolic Acidosis From Isopropyl Alcohol and Alcoholic Ketoacidosis: A Diagnostic Challenge.

Metabolic acidosis, characterized by a decrease in blood pH due to acid accumulation or base deficit, is a life-threatening condition requiring prompt diagnosis and intervention. We describe a rare case of a 44-year-old man with severe alcohol use disorder who presented with altered mental status, acute respiratory distress, and severe wide anion gap metabolic acidosis (AGMA). Initial management with intravenous fluids, bicarbonate, and empiric fomepizole failed to improve his condition, prompting emergent hemodialysis. Volatile alcohol screening subsequently revealed elevated acetone and isopropanol levels, confirming isopropyl alcohol toxicity. This case highlights the diagnostic challenges of volatile alcohol ingestion in AGMA and highlights the importance of considering mixed etiologies, particularly in patients with alcohol use disorder. The synergistic effects of alcoholic ketoacidosis and isopropyl alcohol toxicity led to an unusually severe presentation. Hemodialysis resulted in rapid clinical improvement, and the patient was ultimately discharged in stable condition. This case emphasizes the need for a systematic diagnostic approach, early recognition of toxic alcohol ingestion, and timely intervention in complex acid-base disturbances.