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Salicylate toxicity from chronic bismuth subsalicylate use
  1. Sheliza Halani1 and
  2. Peter E Wu1,2,3
  1. 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Division of Clinical Pharmacology and Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Dr Sheliza Halani; sheliza.halani{at}


A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10–2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.

  • drugs and medicines
  • poisoning
  • pharmacology and therapeutics
  • toxicology
  • unwanted effects / adverse reactions

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  • Contributors SH and PEW contributed equally to the gathering of details of case presentation, literature review, manuscript preparation, editing and final review of case report for submission. PEW also provided supervision and guidance to SH throughout the process of case review and manuscript development. SH and PEW have approved the manuscript for submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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