Delayed Diagnosis Salicylate Toxicity With Confirmed Cerebrospinal Fluid Salicylate Concentration: A Case Report of Altered Mental Status Without Neuroglycopenia and With Coagulopathy

Salicylate toxicity usually occurs as a result of elevated serum salicylate concentrations. Salicylate concentrations can be measured in cerebrospinal fluid (CSF), but the interpretation of these values is less well understood. Two phenomena believed to be associated with salicylate toxicity are neuroglycopenia and salicylate-induced coagulopathy, but these cases are typically not well-characterized. We report a case of delayed diagnosis of salicylate toxicity that was complicated by coagulopathy and had a quantifiable CSF salicylate concentration. An 18-year-old female patient presented with abdominal pain and an altered mental state; she had previously presented at another hospital one day prior. She did not initially report salicylate overdose. A lumbar puncture was performed 4.5 hours after emergency department (ED) presentation to rule out meningitis. Due to additional history, a serum salicylate concentration obtained at 25 hours led to a result of 48.8 mg/dL (therapeutic range: 15-30 mg/dL). Hemodialysis (HD) was performed 37 hours after ED presentation due to the altered mental state. Prior to HD, the patient had a prothrombin time of 63 seconds (reference range: 11-13 seconds), international normalized ratio of 5.52 (reference range: 0.8-1.1), and activated partial thromboplastin time of 40.2 seconds (reference range: 25-35 seconds). After the case conclusion, waste CSF was tested and the CSF salicylate concentration was 23 mg/dL; the corresponding CSF and serum glucose concentrations were 60 mg/dL (reference range: 50-75 mg/dL) and 87 mg/dL (reference range: 70-99 mg/dL), respectively. This is a case of delayed diagnosis salicylate poisoning complicated by coagulopathy, without neuroglycopenia. Although we do not recommend routine CSF testing in salicylate toxicity cases, analysis of CSF could shed insight into salicylate-induced encephalopathy. This case illustrates that prompt recognition and treatment of toxicity is key, as delayed diagnosis can increase morbidity and mortality.