Fatal methanol poisoning with paroxysmal sympathetic hyperactivity, and putaminal hemorrhage: a case report and brief literature review

Methanol poisoning is a widespread issue worldwide. In this case report, we describe a patient with methanol poisoning who experienced tonic spasms, cerebellar and putaminal hemorrhages, and severe neurological complications. Additionally, this report emphasizes the potential link between methanol poisoning and paroxysmal sympathetic hyperactivity (PSH). A 31-year-old male was referred to the emergency department with blurred vision, epigastric pain, nausea, vomiting, restlessness, and severe respiratory distress. Two days ago, he drank a locally prepared alcoholic beverage while having dinner. The initial laboratory data showed metabolic acidosis with a high anion gap. The patient was transferred to the intensive care unit (ICU) with a GCS of 4/15. General supportive treatment (normal saline, DVT prophylaxis, stress ulcer prophylaxis, etc.), sodium bicarbonate, ethanol, dialysis, methylprednisolone, and folic acid were initiated for poisoning management. In the brain CT scan, cerebellar and putamen hemorrhage, and brain edema were reported. We stopped heparin due to the brain hemorrhage, but after a few days, DVT occurred. During hospitalization, the patient experienced several brief and spontaneous tonic spasms with diaphoresis, tachycardia, and tachypnea, so paroxysmal sympathetic hyperactivity (PSH) was suspected. He was treated with midazolam and metoprolol for PSH treatment. Unfortunately, the patient developed sepsis and died after 53 days of stay in the ICU. This study highlights that exposure to methanol can result in a range of neurological complications. The administration of heparin in cases of methanol poisoning remains controversial and requires careful evaluation. Furthermore, paroxysmal sympathetic hyperactivity is an uncommon complication that can result from cerebral injury attributed to methanol poisoning.