A rare presentation of methanol toxicity.

Dear Sir,

We read with great interest the article entitled “A rare presentation of methanol toxicity” by Gupta et al.,[1] Indeed the presentation of methanol toxicity can be variable, with high anion gap metabolic acidosis, visual abnormalities, obtundation, and neurological deficit often associated with death.

We also came across a case recently, which was associated with acute onset blindness with encephalopathy after consumption of methanol wherein MRI findings showed bilateral putaminal hemorrhagic necrosis. Patient, however, showed remarkable recovery on follow-up visits.

The reported patient here had sudden onset vision loss after consumption of country liquor. Curiously, fundus findings suggestive of presence of any optic atrophy have not been mentioned. Also the possible explanation of sluggishly reacting pupils in the above patient is not clear.

It would have been extremely helpful if the value of P100 latencies on visual evoked response had been mentioned. Also the prolonged latencies were due to demyelination or falsely positive due to cortical blindness the patient was having, has not been clearly ascertained. The patient had infarcts in areas supplied by various vessels and the mechanism given by authors is cerebral vasospasm but specifically which vessel is involved has not been mentioned, also the lacunae was that, it had not been confirmed by either CT angiography/MR angiography or Digital subtraction angiography. The reported patient is of 51 years of age, so possibility of other vascular risk factors cannot be denied but the authors did not consider either echocardiography or Carotid Doppler in their patient; therefore, looking into the possibility of infarcts involving multiple territory a cardio-embolic source rather than concomitant country liquor consumption is highly likely. Hence, whether the infarcts were due to methanol intoxication or just an incidental finding is still not clear.

The characteristic neuroimaging findings of bilateral hemorrhagic necrosis, cerebral and intra-ventricular hemorrhage, cerebellar necrosis, and diffuse cerebral edema have been described as sequelae to severe methanol intoxication. Putaminal hemorrhagic necrosis results from direct toxic effect of methanol metabolites and metabolic acidosis. It often has poor prognosis, i.e., either death or vegetative state.[234]

In a country like ours where easy availability of spurious liquor has been a concern, this article highlighted about the variable presentation of methanol poisoning and that timely institution of treatment can be indeed life-saving.