In the present patient, the clinicians noted that the calculated plasma
osmolality (2 × Na + glucose/18 + BUN/2.8) of 248
mOsm/kg was considerably lower than the measured plasma osmolality of
288 mOsm/kg indicating the presence of an osmolal gap. The combination
of hyponatremia, elevated osmolal gap, acidosis, hypocalcemia,
hyperammonemia, hemolytic anemia, and thrombocytopenia after
cystoscopy, suggested the diagnosis of glycine toxicity, although
sepsis could not be excluded. The patient was initially started on
antibiotics and dopamine with careful correction of his electrolyte
abnormalities. He subsequently required dobutamine and norepinephrine.
Dialysis could not be performed because of persistent hypotension. A
cystogram was negative for bladder perforation, but positive blood
cultures for Escherichia coli, suggested loss of bladder
wall integrity. Adult respiratory distress syndrome, renal failure, and
small bowel ischemia complicated the patient’s course, and he died on
day 14 of his hospitalization.