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OtherClinical Chemist

Plasma Abnormalities Following Overdose

Daniel D. Rhoads, Richard A. Sivak, Octavia M. Peck Palmer
DOI: 10.1373/clinchem.2013.219212 Published June 2014
Daniel D. Rhoads
University of Pittsburgh Medical Center, Pittsburgh, PA;
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Richard A. Sivak
University of Pittsburgh Medical Center, Pittsburgh, PA;
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Octavia M. Peck Palmer
University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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  • For correspondence: palmerom@upmc.edu
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Case Description

A 62-year-old female with a history of schizophrenia was found unresponsive after ingesting supratherapeutic amounts of diltiazem and valsartan. At presentation to the emergency department, she was hypotensive and bradycardic. Eight hours later, a blood sample (Fig. 1A) was drawn for chemistry analysis and ultracentrifuged to clarify the turbidity (Fig. 1B). However, the lab was unable to assay the plasma sample. Multiple samples yielded similar findings. Plasma samples obtained the following day were appropriate for analysis.

Figure1
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Questions

  1. What interfering substances are causing the plasma's strawberry milk appearance?

  2. What off-label medication was administered to this patient?

  3. What drug(s) may be responsible for causing the abnormal appearance of her plasma?

The answers are below.

Answers

The combination of lipemia and hemolysis caused the plasma's strawberry milk appearance. Lipid emulsion is designed to be infused slowly as part of a total parenteral nutrition regimen. However, this patient received a 120-mL IV bolus of lipid emulsion off-label for its “lipid sink” action against supratherapeutic levels of lipid soluble drugs, such as diltiazem (1). Both lipid emulsion and diltiazem can cause erythrocyte fragility, which may account for the in vivo hemolysis (2–5).

Footnotes

  • Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.

  • Authors' Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure form. Disclosures and/or potential conflicts of interest:

  • Employment or Leadership: R.A. Sivak, UPMC Presbyterian Hospital Lab.

  • Consultant or Advisory Role: None declared.

  • Stock Ownership: None declared.

  • Honoraria: None declared.

  • Research Funding: None declared.

  • Expert Testimony: None declared.

  • Patents: None declared.

  • Received for publication November 20, 2013.
  • Accepted for publication December 11, 2013.
  • © 2013 The American Association for Clinical Chemistry

References

  1. 1.↵
    1. Bologa C,
    2. Lionte C,
    3. Coman A,
    4. Sorodoc L
    . Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose: case report. Am J Emerg Med 2013;3:1154.e3–4.
    OpenUrl
  2. 2.↵
    1. Watts TJ
    . The in vitro hemolytic effect of diltiazem on erythrocytes exposed to varying osmolarity. Toxicol Mech Methods 2010;20:435–9.
    OpenUrlCrossRefPubMed Order article via Infotrieve
  3. 3.
    1. Grunbaum AM,
    2. Gilfix BM,
    3. Gosselin S,
    4. Blank DW
    . Analytical interferences resulting from intravenous lipid emulsion. Clin Toxicol 2012;50:812–7.
    OpenUrlCrossRef
  4. 4.
    1. McGrath KM,
    2. Zalcberg JR,
    3. Slonim J,
    4. Wiley JS
    . Intralipid induced haemolysis. Br J Haematol 1982;50:376–8.
    OpenUrlCrossRefPubMed Order article via Infotrieve
  5. 5.↵
    1. Jaben EA,
    2. Koch CD,
    3. Karon BS
    . Lipid emulsion solution: a novel cause of hemolysis in serum and plasma blood samples. Clin Biochem 2011;44:254–6.
    OpenUrlCrossRefPubMed Order article via Infotrieve
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Clinical Chemistry: 60 (7)
Vol. 60, Issue 7
July 2014
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Plasma Abnormalities Following Overdose
Daniel D. Rhoads, Richard A. Sivak, Octavia M. Peck Palmer
Clinical Chemistry Jul 2014, 60 (7) 1020-1021; DOI: 10.1373/clinchem.2013.219212
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Plasma Abnormalities Following Overdose
Daniel D. Rhoads, Richard A. Sivak, Octavia M. Peck Palmer
Clinical Chemistry Jul 2014, 60 (7) 1020-1021; DOI: 10.1373/clinchem.2013.219212

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