We present a case of a 50-year-old male patient, with a 20-year history of addiction to alcohol as well as recent ingestion of an amount of cologne water instead of alcohol for economic reasons. He presented in our Tunis Centre d’assistance médicale d’urgence’s emergency department, in April 2020, with blurred vision and diplopia 21 hours after the ingestion of one liter of an unusual, commercialized liquor containing 70% formalin. A few hours later, he lapsed into a coma and had respiratory distress with SpO₂ of 77%. Mechanical ventilation was required for advanced airway management and he was transferred into our ICU. Investigations showed severe metabolic acidosis: pH = 6.87, PaCO₂ = 25 mmHg, HCO₃- = 4.6 mmol/L and elevated anion gap of 27mEq/L with hyperlactatemia of 5 mmol/L. Toxicology and drug screen in blood samples revealed high methanol levels of 6.23 g/L. The patient was given 40% ethanol as a bolus of 0.6 g/kg and a maintenance dose of 100 mg/kg/h in association to 42‰ bicarbonate perfusion, two hemodialysis sessions of six hours each, blood pump speed of 200 mL/min, adjuvant treatment with intravenous folic acid 200 mg daily and intravenous Vitamin B1 300 mg daily.

Brain MRI performed on the seventh day showed bilateral symmetrical putaminal signal anomalies (Figure 1) consisting of heterogeneous hyperintensities in T1, T2 and Fluid-attenuated inversion recovery (FLAIR) sequences containing low signal regions on T2* weighted gradient echo and low apparent diffusion coefficient (ADC) value regions on diffusion weighted images. These findings represent the putaminal hemorrhagic necrosis. MRI showed also diffuse bilateral symmetrical extensive white matter abnormal signal intensity showing a T2/FLAIR hyperintensity, a T1 hypointensity with low ADC values on diffusion weighted images and respecting sub-cortical U-fibers (Figure 2). There was no hemorrhagic stigma in the white matter. There was no restricted diffusion in the retrobulbar segment of the optic nerves. Written informed consent for publication of their clinical details and clinical images was obtained from the patient’s family.

The electroencephalogram done on day 26 showed a slow disorganized, non-reactive pattern, indicating diffuse brain suffering. The patient did not demonstrate neurological recovery. On day 32, refractory hypoxia under mechanical ventilation leaded to his death.