A man drank two liters of moonshine in two hours. This is what happened to his eyes.
"CS" is a 31 year old man presenting to the emergency room with body pain, nausea, and blurred vision.
He tells the admitting nurse that he slept poorly the previous night,
and suffered severe abdominal cramps before seeing his vision distort and warp.
You see, that previous night, CS was participating with friends in a New Year's Eve BYOB Power Hour
where each person would bring their own bottle of liquor,
and take a half shot on the minute, every minute, for a whole hour.
CS didn't want to just bring his own liquor: he was going to make his own liquor.
He received a distillation kit a few weeks prior as an early Christmas gift from his girlfriend
He had brewed his own beer before,
but wanted to move towards moonshine, or homemade whiskey,
from grains after seeing some videos on the Internet.
Unlicensed distillation is federally unlawful, but he thought to take his chances.
He was sure he followed the directions to ferment and distill correctly, and didn't do anything wrong.
As the batch was made, CS began the New Year celebrations with friends.
He didn't like the taste of his moonshine and was pretty vocal about it.
After all it was 160 proof, or 80% alcohol,
double his friends' store-bought, 80 proof liquor.
He was a good sport and partied on with his friends,
and they were having a great time celebrating the New Year's,
and CS proceeded to finish all two liters of moonshine that he brought within two hours.
As the night continued CS felt increasingly ill.
His vision started vignetting, darkening and blurring on the sides.
His sense of sound began to flow into a sea of molasses as it slowed and warped.
He thought because he drank 160 proof moonshine that he was just more drunk than normal
He went to bed not eating anything, but also not feeling great,
and as he got started the next day his vision quickly went dark,
and he called for an ambulance where he's brought to the emergency room where we are now.
Before the nurse can do a physical exam on CS, he has to use the restroom.
He was in for about 10 minutes, the bathroom door still closed.
Medical staff thought to ask and see if anything was wrong,
and when they received no response, they entered and found him on the floor
foaming at the mouth and seizing as he was huddled over the toilet.
As the seizure resolves, he's unresponsive,
pupils dilated and unreactive to light,
respiratory rate: 28 breaths per minute, double that of normal.
His Glasgow Coma Scale, an objective measure of his consciousness and indicator of brain injury,
is rated at just four: one point above complete unresponsive coma.
There's indication here that he has severe acute brain injury, but something's wrong.
If CS is suffering from just alcohol or more formally ethanol intoxication, then the seizure doesn't make sense;
ethanol is a nervous system depressant,
meaning that it slows down the brain and displaces excitatory neurotransmitters.
Because he was convulsing during the seizure,
we classify it as Generalized Tonic-Clonic;
"tonic" and "clonic" deriving from ancient Greek words,
"tonos" and "clonus" which mean
"to stretch" with "violent and confused motion";
"generalized" meaning that the seizure, which is a state of excessive excitation, is affecting the entire brain.
This is opposite of nervous system depression,
so we can say with certainty that ethanol is not directly responsible for his seizure.
A blood test reveals that the pH of CS' blood is 6.5,
that's eight times more acidic than normal,
and he's transferred to the intensive care unit,
as he's suffering from Metabolic Acidosis;
"osis" meaning abnormal state,
and acid being a chemical that donates hydrogen ions,
something, when in large abundance, can impair the normal function of your body;
"metabolic" meaning that it's deriving from
cellular processes that produce energy or breakdown substances.
With a pH of 6.5, we can conclude that CS is suffering
from profound acidemia, an acid presence in blood.
If, since last night nothing entered CS' body,
except for two litres of moonshine and water,
neither of which are strong acids,
and nothing left his body except for some urine,
then how is it possible for so much acid to be in his blood?
Was there something else in that moonshine?
Well, there's a bit of basic biochemistry to be known here:
to make moonshine, CS used yeast to ferment oat sugar, or glucose.
Fermentation is the anaerobic, or without oxygen, consumption of glucose,
producing an unrefined beer called a wash.
Because glucose is a chain of six carbons,
the yeast will produce alcohol chains of less than five,
after we account for carbon dioxide produced.
This means that ethanol, at two carbons,
is very common, yielding at 10% to 15% in wash,
but it also means that, the one carbon methanol
(which is not safe for human consumption) is produced, too.
And even worse: CS used his distillation kit to produce his concentrated 80% ethanol drink.
Distillation separates chemicals, and is started by heating the wash.
Ethanol boils at 173°F (78.3°C at atmospheric pressure),
which means at this temperature,
its vapor pressure is equal to the pressure exerted on it by the surrounding atmosphere,
meaning it will phase shift from liquid into gas.
Because water boils at 212°F (100°C),
then heating to 173°F (78°C) boils the ethanol, but not water,
turning the alcohol into gas,
which will rise up in the still,
where it's collected, condensed, and cooled back into
liquid in a separate container, creating Moonshine.
The problem with this is that methanol's boiling point is 149°F (65°C), lower than ethanol's.
So heating to 173°F (78°C) boils it too, and collects and concentrates it into the moonshine.
Methanol collects in the head, or the first part of the distillate, and it's apparent that CS drank a lot of it
because a blood test reveals that the methanol concentration in his body is
420 milligrams per deciliter, more than ten times the minimum documented lethal dose.
Methanol doesn't look much different from ethanol physically and chemically
Estimating his blood volume at 6 liters because of his weight of 80 kilograms measured at admission
This means that there are 25 grams of methanol floating around in his blood
Given that the density of methanol is about 0.8 grams per milliliter this means that there is about 30 milliliters or two tablespoons full in his blood at the moment
Like ethanol, methanol is also a weak acid, but 30 milliliters alone isn't enough to cause profound acidemia
It's also physiologically inactive by itself in humans
So how could it be causing these problems in CS?
Well let's go back to the name of his condition: Metabolic Acidosis
If methanol isn't a strong acid then how exactly is methanol getting metabolized?
In humans, alcohols are metabolized twice. Mainly in the liver
It appears that humans evolved this mechanism because the bacteria in your gut ferments sugars
That's the same fermentation that CS 's yeast did with oat sugar and means that small amounts of alcohol,
about three grams, are produced in your gut every day.
The first step of alcohol metabolism is where an enzyme called alcohol dehydrogenase
Converts it to aldehyde. Ethanol becomes Ethanal
Which is responsible for hangovers and flushing while drunk.
Methanol becomes methanal, which is Formaldehyde
Used to embalm mummies and is a likely carcinogen, this first step is fast and causes a buildup of aldehyde in the body
Explaining delayed onset of hangover after a night of drinking. The second step is when aldehyde dehydrogenase converts aldehyde to
Carboxylic acid so ethanal is metabolized to ethanoic acid which is vinegar
But methanal is metabolized to methanoic acid which is a major poison.
But it's not the acid moiety of methanoic acid causing CS' metabolic acidosis
But rather the effect that it exerts on the body
Your cells need oxygen to produce energy. The enzyme cytochrome oxidase is a major part of this
metabolism and relies heavily on oxygen to function.
Methanoic acid binds into cytochrome oxidase and doesn't let oxygen in and forces the cell to operate
anaerobically and produce less energy, all without oxygen.
When cells are asphyxiated like this they produce lactic acid from the glucose that they're trying to metabolize into energy
This is methanoic acid being produced from methanol metabolism
That's choking his cells of oxygen and forcing them to produce acid causing CS's metabolic acidosis and profound acidemia
In looking at his physical condition. Where would this starvation of oxygen have the greatest impact?
Well, it's probably not the muscles since they're designed to tolerate lactate which is produced during exercise when a transient oxygen deficiency is common
It couldn't be the liver as it can process and break down some of these acids.
But how about the brain?
The brain is metabolically active and short amounts of time with ischemic event when oxygen flow or utilization is blocked can cause excitotoxicity
An over excitation of the brain, which includes seizure
A brain MRI for CS reveals hypoxia or low oxygen in the basal ganglia which connects major parts of the brain together
Methanoic acid is known for its selective absorption into eye tissue
And the optic nerve where it builds up,
starves the cells of oxygen and causes them to necrosis or die as they literally digest themselves from inside out.
Hyperemia or an abundant presence of blood was found in CS's eye along with edema or fluid swelling all explaining
why CS's vision was deteriorating since he started drinking and suddenly lost his vision as he presented to the emergency room.
If left untreated, he will first go permanently blind as his optic nerve is choked out and depraved of oxygen causing irreversible nerve damage.
After that his brain will begin to hemorrhage and bleed out and necrose as it starts for oxygen
and swims in a pool of its own dead cells.
The notion of enzymatic activity modulating or causing toxicity by its action or lack thereof is a recurring physiologic theme.
Both carbon monoxide and cyanide have the same mechanism as methanoic acid. They block oxygen from binding to cytochrome oxidase
preventing cells from using oxygen causing an overproduction of lactic acid causing metabolic acidosis necrosis and eventually death.
Medicines are sometimes given in pro drug form meaning that they're inactive when taken orally,
but metabolized by the liver into active form. For example the blood pressure medication enalapril is converted to biologically active
which inhibits the angiotensin converting enzyme, preventing activation of the hormone angiotensin I to its vasoactive form, lowering blood pressure.
This specific use case in humans derived from the Brazilian Pit Viper, whose venom was designed to fatally lower blood pressure of its prey,
typically of small mammalian descent, meaning that the idea of enzymatic activity transcends species
When dogs eat chocolate they consume theobromine a chemical similar to caffeine that causes tremors and acts as a stimulant
Humans metabolize theobromine in the liver enzymes but dogs do not have these enzymes. So they break it down very slowly, if at all.
Meaning that the theobromine accumulates causing over stimulation, increasing heart contractility,
increasing adrenaline levels causing hyperthermia, rigidity, tremors, seizures, and death.
With methanol the exact opposite is happening.
Methanol is physiologically inert and only produces mild sedation.
It's already water soluble meaning that it can dissolve in the urine as is and be excreted by the kidneys,
but its metabolites are poisonous.
If enzymes can be competitively inhibited like cytochrome oxidase
Is there a way that we could prevent methanol from binding to alcohol dehydrogenase and stop it from being metabolized?
Yes.
Ethanol binds to alcohol dehydrogenase with a greater affinity than methanol
And it does so competitively meaning that it will prevent methanol from ever binding to the enzymes active site preventing it from metabolizing
This explains partly why CS's symptoms were more mild while he was still drunk the previous night with ethanol still in his blood and
It means that the antidote for his poisoning is
more ethanol
He's put on dialysis as well as given sodium bicarbonate, a base to correct his acidosis.
A 10% ethanol IV infusion is administered
Plasma methanoic acid concentrations were monitored and shown to fall after ethanol administration
Along with spontaneous resolution of his metabolic acidosis and improvements in his mental status
as documented in the literature of the elimination half-life of methanol in the body after discontinuation of dialysis was 54 hours.
As the methanol dissolved in CS's urine, it was excreted through the kidneys unmetabolized
Halting the production of methanoic acid if caught early
Can reverse the ischemic and hypoxic damage caused by the poison as enzymes are not consumed in the chemical reactions in which they participate
C'S story is a fine example for reasons why alcohol distillation without permit is federally unlawful in the United States
It's a common international travel tip to be careful of cheap liquor and some country's because it could have been bootlegged and adulterated to be
contaminated with methanol; poisoning hundreds if not thousands of people as the toxicity and irreversible injury can happen in as little as a couple milliliters
Furthermore ethanol was used as car fuel at one point in time.
It's vapors generated during distillation are spontaneously combustible.
Because distillation requires heat, poorly sealed stills will explode.
U.S. alcohol tax revenue including all states in 2015 was counted at $7 billion, or 0.2% of the $3.25 trillion total federal revenue of that year.
Even if personal distillation were lawful, popular, and taxed, is not likely home production would even come close to matching the volume produced industrially
So isolating the reason for distillation laws to just saying that the government cannot tax it is incomplete,
and neglects the fact that this has potential to harm a large number of people chemically through methanol poisoning,
and physically through ethanol vapors.
With proper treatment and monitoring in the intensive care unit,
and a strong lesson learned at why making moonshine is dangerous and unlawful by him and all his friends,
CS was able to make a full recovery
Thank you so much for watching. Take care of yourself and be well.