Heavy aspirin use over several weeks mimicked psychiatric illness in a 65-year-old woman

"I'm seeing dead people," the woman told clinicians, according to Live Science's account of the case report ^[2]. She had arrived by ambulance and asked for a psychiatrist herself ^[1]. On one occasion she had fired a gun at what she saw ^[3]. The report does not describe what the hallucinations looked like ^[4].

The tablets she took were sold for back and body pain, at 500 milligrams each ^[8]. Her intake of roughly 75 milligrams per kilogram a day was about half the dose typically linked to acute salicylate poisoning ^[14]. That places the acute benchmark near 150 milligrams per kilogram a day ^[22]. Measured against acute-overdose figures, her history would look moderate. The authors took her case as a reminder that long-term aspirin toxicity may produce different symptoms than acute poisoning does ^[16].

At high doses, salicylates stimulate the medulla, the part of the brain that regulates breathing. The hyperventilation that follows sheds carbon dioxide and at first makes the blood more alkaline ^[15]. The drug also disrupts metabolism, so lactic acid builds up and the blood moves toward acidosis. Organ damage can occur once that acidosis overwhelms the alkalosis ^[15]. For the hallucinations, the authors propose that chronic exposure raises the odds of the drug crossing the blood-brain barrier ^[18]. A single case cannot test that idea.

Michigan's poison control center recommended intravenous sodium bicarbonate ^[11]. It makes blood and urine less acidic, and that lets the kidneys excrete more salicylate ^[11]. Her level fell by about 36% over the first 11 hours of treatment ^[21]. The evidence that aspirin caused the hallucinations comes down to timing: they went away as the drug was cleared. That comes from one patient, with no comparison case.

The workup that found the poisoning started with a judgement about her history. Because she had no psychiatric record, the team ran a medical assessment before calling psychiatry ^[6]. Older age is also a risk factor for severe outcomes of acute salicylate toxicity ^[14]. I think the case supports running a toxicology screen before a psychiatric referral when an older patient's first hallucinations have no psychiatric history behind them. It cannot show how often that screen would find aspirin. The authors also framed their advice around poisoning in general, with salicylates as one example ^[19].