What does this research mean for the field?

Acquired pyroglutamic acidosis is a likely cause of unexplained high anion gap metabolic acidosis in patients with multiple co-morbidities. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

What question did this study set out to answer?

To highlight a case of suspected acquired pyroglutamic acidosis in a patient with multiple co-morbidities and unexplained metabolic acidosis.

March 8, 2026

Suspected pyroglutamic acidosis in a complex patient: A case report

Key Points

To highlight a case of suspected acquired pyroglutamic acidosis in a patient with multiple co-morbidities and unexplained metabolic acidosis.
Case report of a 35-year-old female with multiple co-morbidities
Analysis of clinical conditions and treatment history, focusing on paracetamol use
Observation of acidosis improvement after discontinuation of paracetamol.
Patient exhibited high anion gap metabolic acidosis despite clinical improvements
Marked improvement in acidosis noted upon stopping paracetamol use
Case suggests pyroglutamic acidosis as an underrecognized cause of metabolic acidosis.

Abstract

We present the case of a 35-year-old female with multiple co-morbidities who developed unexplained high anion gap metabolic acidosis (HAGMA) despite marked improvement in sepsis parameters and other clinical conditions. Given the presence of known predisposing factors such as chronic therapeutic paracetamol (acetaminophen) use, chronic kidney disease, female gender, acute serious illness, undernutrition, and a dramatic improvement in acidosis following discontinuation of paracetamol without other overt explanations, we suspect acquired pyroglutamic acidosis (5-oxoproline acidosis) despite a lack of laboratory confirmation of 5-oxoproline. This case underlines the importance of recognizing this underdiagnosed cause of HAGMA.

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