(1348) Not So "Fun Dip": Citric Acid Overdose Causing Hyperkalemic Emergency

Introduction: Citric acid is a common organic acid typically found in citrus fruits such as lemons, limes, and oranges. Citric acid overdoses are rare, as it is difficult to ingest a lethal amount. There are two reported case studies of citric acid overdoses leading to metabolic acidosis. We report a 68-year-old woman who presented with citric acid overdose inducing metabolic acidosis and severe hyperkalemia.

Description: A 68-year-old female with history of chronic obstructive pulmonary disease, hypertension, type II diabetes mellitus, and chronic kidney disease (CKD) stage II presented to the emergency department for a chief complaint of shortness of breath. Electrocardiogram (EKG) was performed, showing peaked T waves. A basic metabolic panel was then obtained, showing a potassium of 9.0 mEq/L, an acute kidney injury (AKI) with a serum creatinine of 1.78mg/dL, and a non-anion gap metabolic acidosis with a bicarbonate (HCO3-) of 10mmol/L. Patient was found to be eating multiple lemonade packets a day by dipping her fingers into the powder and sucking it off her fingers. She was subsequently admitted to the medical intensive care unit.

Discussion: The patient was dehydrated, on an aldosterone receptor blocker, with a history of CKD stage II and a pre-renal AKI secondary to volume depletion. The packets of lemonade powder are made from crystalized lemon with the primary ingredient being citric acid. She therefore loaded herself with citric acid in a dehydrated state, inciting an acute metabolic acidosis, which then resulted in acute severe hyperkalemia. Citric acid is thought to cause metabolic acidosis via an indirect cellular mechanism involving cellular anion exchangers for chloride and HCO3- ions. Metabolic acidosis is a known cause of hyperkalemia due to transcellular shifts of potassium. The patient was treated with hyperkalemia protocol, including intravenous calcium gluconate, albuterol, furosemide, insulin, and glucose. Her acidosis and hyperkalemia quickly resolved within six hours of treatment without complication.