(1449) Shadows in the Light: Moonshine’s White Lightning and Vision Loss

Introduction: Moonshine, a potent homemade alcohol up to 95% alcohol per volume known as 'White Lightning', poses risks including methanol toxicity. We report a case where dialysis, fomepizole, and corticosteroids were used in resolving symptoms.

Description: A 27-year-old-man with history of poly-substance use disorder and bipolar disorder presented with a 1-day history of progressive malaise, nausea, vomiting and photophobia 1 day after consuming moonshine mixed with juice.
Upon arrival, vitals were within normal limits except for mild sinus bradycardia (51) and neurologic exam was non-focal. Labs showed an anion gap of 22, pH of 7.0 with a pCO2 of 26, albumin-corrected anion gap ratio of 0.5 suggestive of pure high anion gap metabolic acidosis. Lactic Acid was 3. Initial measured osmolarity was 345 with an osmolar gap of 64, creatinine was 1.1 and bland urinalysis. Ethanol level was undetectable. Drug screen was positive for cannabinoids. Methanol and EG were sent to a special lab. Fomepizole and bicarbonate drip were started until he received hemodialysis (HD). Patient was also started on high dose folic acid, thiamine and pyridoxine. Due to persistence of light sensitivity, poison control recommended to continue HD until osmolar gap was < 5 despite resolving alkalosis and mild hypokalemia. After consult with a retina specialist, pulse corticosteroid therapy was initiated at a lower dose regimen due to history of psychiatric disease. This was further adjusted due to an episode of psychosis and agitation during his ICU stay. After persistence from the ICU team, a second session of HD was done on day 4 which resulted in complete symptom resolution. Methanol level was found to be severely elevated at a critical level (145 mg/dl; Toxic>20).

Discussion: Early recognition of methanol toxicity is crucial, especially when signs of end-organ damage are present such as acidosis and retinal toxicity, perceived as visual symptoms. Mainstay treatment includes competitive inhibition of alcohol dehydrogenase with intravenous (IV) fomepizole, or IV ethanol, to prevent formation of the toxic metabolite, formic acid. Equally effective, HD rapidly removes alcohols and should be performed as soon as possible. It may be reasonable to consider steroids, but routine use cannot be recommended based on current evidence.