{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,18]],"date-time":"2026-10-18T01:27:39Z","timestamp":1792286859559,"version":"4.4.0"},"reference-count":30,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2021,1,7]],"date-time":"2021-01-07T00:00:00Z","timestamp":1609977600000},"content-version":"unspecified","delay-in-days":6,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2020,11,30]]},"published-print":{"date-parts":[[2021,1]]},"abstract":"<jats:p>\n                    A 75-year-old woman was admitted to a regional hospital with an acute kidney injury (AKI) and nausea on a background of recent treatment for\n                    <jats:italic>Staphylococcus aureus<\/jats:italic>\n                    bacteraemia secondary to pneumonia. The treatment thereof resulted in a high anion gap metabolic acidosis (HAGMA). The pneumonia was initially treated with intravenous piperacillin and tazobactam and the patient transferred to a tertiary hospital. There, the diagnosis of\n                    <jats:italic>S. aureus<\/jats:italic>\n                    bacteraemia secondary to a pulmonary source was confirmed and treatment was changed to intravenous flucloxacillin and the patient was discharged to hospital in the home (HITH is a service that allows short-term healthcare at home to be provided to people who would otherwise need to be in hospital) to complete the antibiotic course. Five weeks after commencing flucloxacillin, the patient was referred back to hospital with nausea and worsening kidney function with an associated significant HAGMA. The patient has a background of chronic kidney disease and chronic back pain for which she was taking long-term paracetamol. The HAGMA was determined to be due to a pyroglutamic acidosis (PGA), deemed secondary to the combined use of paracetamol and flucloxacillin. This was subsequently confirmed with a plasma pyroglutamic acid concentration level of 7467 \u00b5mol\/L (reference range 20\u201350 \u00b5mol\/L) and a urinary level of 1700\u2009mmol\/mol creatinine (&lt;110\u2009mmol\/mol creatinine). To our knowledge, this is the highest plasma and urinary levels published to date. Furthermore, considering the common use of paracetamol and penicillins, it is important to recognise HAGMA as a potential complication of co-administration of paracetamol and iso-oxylopenicillin. The HAGMA resolved after cessation of flucloxacillin despite the continuation of paracetamol and without administration of N-acetylcysteine. PGA-related HAGMA appears to be a unique potential side effect of iso-oxylopenicillin rather than other beta-lactams.\n                  <\/jats:p>","DOI":"10.1136\/bcr-2020-237536","type":"journal-article","created":{"date-parts":[[2021,1,8]],"date-time":"2021-01-08T15:26:36Z","timestamp":1610119596000},"page":"e237536","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":16,"title":["Flucloxacillin and paracetamol induced pyroglutamic acidosis"],"prefix":"10.1136","volume":"14","author":[{"given":"Anis","family":"Zand Irani","sequence":"first","affiliation":[{"name":"Gympie Hospital, Queensland Health, Gympie, Queensland, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grace","family":"Borchert","sequence":"additional","affiliation":[{"name":"School of Medicine, Griffith University, Gold Coast, Queensland, Australia"},{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brendan","family":"Craven","sequence":"additional","affiliation":[{"name":"Gympie Hospital, Queensland Health, Gympie, Queensland, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Holly","family":"Gibbons","sequence":"additional","affiliation":[{"name":"Gympie Hospital, Queensland Health, Gympie, Queensland, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,1,8]]},"reference":[{"key":"2026060104450604000_14.1.e237536.1","doi-asserted-by":"crossref","first-page":"892","DOI":"10.1016\/S0140-6736(08)61398-7","article-title":"Gold mark: an anion gap mnemonic for the 21st century","volume":"372","author":"Mehta","year":"2008","journal-title":"The Lancet"},{"key":"2026060104450604000_14.1.e237536.2","doi-asserted-by":"crossref","DOI":"10.1136\/bcr-2019-233306","article-title":"Acquired pyroglutamic acidosis due to long-term dicloxacillin and paracetamol use","volume":"13","author":"Zand Irani","year":"2020","journal-title":"BMJ Case Rep"},{"key":"2026060104450604000_14.1.e237536.3","first-page":"351","article-title":"Guilty as charged: unmeasured urinary anions in a case of pyroglutamic acidosis","volume":"66","author":"Rolleman","year":"2008","journal-title":"Neth J Med"},{"key":"2026060104450604000_14.1.e237536.4","unstructured":"Tummers S , Oei S , Nooteboom F , et al . 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