Citric acid ingestion: A life-threatening cause of metabolic acidosis

We present a case that illustrates the acute (<6 hours) metabolic and hemodynamic effects of the ingestion of a massive oral citric acid load. The principal findings included metabolic acidosis accompanied by an increase in the plasma anion gap that was not caused by -lactic acidosis, hyperkalemia, and the abrupt onset of hypotension. A unique feature was a dramatic clinical improvement when ionized calcium was infused. The case illustrates the importance of considering the properties of the conjugate base (anion) of the added acid because, in this instance, the citrate anion had a unique and life-threatening consequence (lower ionized calcium level) that was rapidly reversible. [DeMars CS, Hollister K, Tomassoni A, Himmelfarb J, Halperin ML. Citric acid ingestion: a life-threatening cause of metabolic acidosis. Ann Emerg Med. November 2001;38:588-591.]