Acute Methyl Salicylate Toxicity Complicating Herbal Skin Treatment for Psoriasis

Bell AJ, Duggin G

Case presentation A 40-year-old man presented to the emergency room complaining of six hours of intractable vomiting, tinnitus, and drowsiness. He was also flushed and sweaty with an unusual odor and generalized erythema. The patient was clinically dehydrated and demonstrated mild epigastric tendencies. Past medical history was significant only for psoriasis. The patient reported visiting a Chinese herbalist earlier in the day for skin treatment that consisted of being sprayed with a dark substance and a total body application of a yellow sulphur-containing cream followed by a body wrap of plastic cling film. Symptoms began within an hour and did not abate upon removal of the plastic wrap and three showers. An IV of normal saline was started, and one dose of metoclopramide was administered. Urinalysis on first available urine showed sg 1.025, pH 6.5, 4 + ketones. Electrolyte profile revealed an increased anion gap (23 mmol/L) and mild elevation of serum creatinine. Arterial blood gas showed metabolic acidosis superimposed on respiratory alkalosis (pH 7.44, pCO2 26 mmHg, pO2 71 mmHg, HCO3-17.9 mmol/L, BE -4.0, Sat 93.6%). Blood sugar was normal, and ECG showed right bundle branch block. Salicylate level was 48.5 mg/dL at presentation. The level declined with treatment, and the patient was discharged in four days. Discussion Salicylates are commonly found in many OTC medications, prescription medications, and Chinese medicated oils. Although widely used, topical salicylates rarely produce systemic toxicity; however, this case presents that potential. Because methyl salicylate or oil of wintergreen is in liquid form and has high lipid solubility, it has the potential to produce acute, severe systemic salicylate toxicity. The authors conclude that this patient's toxic reaction was contributed to by the highly concentrated preparation of methyl salicylate, the presence of psoriasis, total body surface area application, and the use of an occlusive dressing, resulting in classic symptoms of salicylism. The large number of salicylate-containing preparations available and the potential for severe poisoning make this case worthy of note. Emerg Med (Fremantle) 2002 June;14(2):188-90. Return to Top