{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,29]],"date-time":"2025-08-29T00:03:37Z","timestamp":1756425817299,"version":"3.44.0"},"reference-count":11,"publisher":"BMJ","issue":"11","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2021,9,28]]},"published-print":{"date-parts":[[2021,11]]},"abstract":"<jats:p>MELAS, a mitochondrially inherited multisystem disorder, can present with acute stroke-like episodes. The literature thus far supports the use of L-arginine therapy in acute MELAS flares to alleviate and shorten the duration of symptoms. This is the case of a patient who presented with ataxia and worsening confusion on a background of genetically confirmed MELAS syndrome. In this instance, intravenous L-arginine therapy, along with corticosteroids, was administered in keeping with best practice. However, in a metabolically vulnerable patient, L-arginine therapy resulted in a further deterioration in his clinical status and the development of a non-anion gap metabolic acidosis.<\/jats:p>","DOI":"10.1136\/bcr-2021-245898","type":"journal-article","created":{"date-parts":[[2021,11,2]],"date-time":"2021-11-02T13:47:11Z","timestamp":1635860831000},"page":"e245898","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["MELAS syndrome: an acute stroke-like episode complicated by renal tubular acidosis"],"prefix":"10.1136","volume":"14","author":[{"given":"Dearbhail","family":"Ni Cathain","sequence":"first","affiliation":[{"name":"Beaumont Hospital, Dublin, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emmet","family":"Browne","sequence":"additional","affiliation":[{"name":"Beaumont Hospital, Dublin, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kieran","family":"Skehan","sequence":"additional","affiliation":[{"name":"Beaumont Hospital, Dublin, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karl","family":"Boyle","sequence":"additional","affiliation":[{"name":"Beaumont Hospital, Dublin, Ireland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,11,2]]},"reference":[{"key":"2025082801444520000_14.11.e245898.1","doi-asserted-by":"publisher","DOI":"10.1038\/gim.2014.177"},{"key":"2025082801444520000_14.11.e245898.2","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.pediatrneurol.2015.12.010","article-title":"Mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes (MELAS): a case report and critical reappraisal of treatment options","volume":"56","author":"Fryer","year":"2016","journal-title":"Pediatr Neurol"},{"key":"2025082801444520000_14.11.e245898.3","doi-asserted-by":"publisher","DOI":"10.1080\/13803395.2011.645016"},{"key":"2025082801444520000_14.11.e245898.4","doi-asserted-by":"publisher","DOI":"10.1212\/01.wnl.0000220197.36849.1e"},{"key":"2025082801444520000_14.11.e245898.5","doi-asserted-by":"publisher","DOI":"10.1196\/annals.1444.011"},{"key":"2025082801444520000_14.11.e245898.6","doi-asserted-by":"crossref","DOI":"10.1001\/jamaneurol.2015.5072","article-title":"Recommendations for the management of strokelike episodes in patients with mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes","volume":"73","author":"Koenig","year":"2016","journal-title":"JAMA Neurol"},{"key":"2025082801444520000_14.11.e245898.7","first-page":"008","article-title":"Arginine induced metabolic acidosis and acute kidney injury","volume":"5","author":"Batarseh","year":"2019","journal-title":"Int J Case Rep Short Rev"},{"key":"2025082801444520000_14.11.e245898.8","unstructured":"Ramy M , Khorsan R . Non anion gap metabolic acidosis induced during L-arginine therapy in a patient with mitochondrial encephalopathy lactic acidosis and stroke (MELAS). Proceedings of UCLA Health 2017;21."},{"key":"2025082801444520000_14.11.e245898.9","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1007\/BF00198298","article-title":"Pressor, renal and endocrine effects of L-arginine in essential hypertensives","volume":"48","author":"Pedrinelli","year":"1995","journal-title":"Eur J Clin Pharmacol"},{"key":"2025082801444520000_14.11.e245898.10","doi-asserted-by":"crossref","unstructured":"Batlle D , Hays S , Foley R . Proximal renal tubular acidosis and hypophosphatemia induced by arginine. In: Massry SG , Letteri JM , Ritz E , eds. Regulation of phosphate and mineral metabolism. Advances in experimental medicine and biology. 151. 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