Pseudo-normal osmolal and anion gaps following simultaneous ethanol and methanol ingestion

Methanol, ethylene glycol, and isopropyl alcohol are associated with acute intoxication. The diagnosis is dependent upon high anion-gap metabolic acidosis, and an osmolal gap between the calculated and the measured osmolality. Normal anion gap has been reported in some cases of concomitant methanol and ethanol ingestion, where the high serum levels of ethanol inhibited the metabolism of methanol by alcohol dehydrogenase. The osmolal gap in these cases was higher than expected for methanol, and served as a constant marker for a metabolic derangement. Herewith, we present a patient who presented with normal osmolal and anion gaps 36 h after ethanol and methanol ingestion, yet progressively developing ocular toxicity. Normal anion and osmolal gaps should not rule out earlier methanol poisoning.