hallmark of clinical presentations include severe wide anion gap metabolic acidosis with very high serum osmolar gap and visual complication . we report a case of severe methanol intoxication with bilateral putaminal hemorrhage , an uncommon serious complication . a 56-year - old man presented with altered mental status . arterial blood gas ( abg ) revealed severe anion gap metabolic acidosis with osmolal gap . clinicians should have high index of suspicion for putaminal hemorrhage when patients with recent methanol intoxication present with altered mental status . methanol or wood alcohol is commonly found as a component of household products including paint removers or windshield washer fluid . due to catastrophic consequences of methanol consumption we report a case of middle aged man presented with confusion , severe metabolic acidosis secondary to methanol intoxication . a repeat ct scan of brain revealed bilateral putaminal hemorrhage as a late complication of methanol poisoning . a 56-year - old man with history of episodic alcohol abuse and rectal adenocarcinoma status post - surgery and neoadjuvant chemoradiation therapy presented to emergency department with altered mental status . on admission , he was comatose with dilated pupils and minimal reaction to light . arterial blood gas ( abg ) revealed severe metabolic acidosis ; ph 6.89 , pco2 13 , po2 178 , hco3 < 3 . head computed tomography ( ct ) showed new hypodense lesions in basal ganglia bilaterally and old small vessel ischemia changes in periventricular matter [ figure 1a ] . ( a ) head computed tomography ( ct ) showed new hypodense lesions in basal ganglia bilaterally and old small vessel ischemia changes in periventricular matter . ( b ) new ct of head without contrast demonstrated new hyperdensities in putaminal area compatible with the diagnosis of putaminal hemorrhages emergent hemodialysis ( hd ) and treatment with intravenous fomepizole were initiated . ophthalmologist was consulted for visual defect and diagnosed the patient with legal blindness without other focal neurological deficit prior to discharge . type of alcohol , consumed by the patient , was still unknown . unfortunately , patient developed confusion and lethargy 2 weeks after discharge . new ct of head without contrast demonstrated new hyperdensities in putaminal area compatible with the diagnosis of putaminal hemorrhages [ figure 1b ] . bilateral putaminal hemorrhages , complication carrying very high morbidity , have been described in methanol intoxication and can be found in other diseases including inborn error metabolism , renal failure with severe metabolic acidosis , and ethylene glycol intoxication . the mechanism is currently presumed to be formic acid - induced retinal damage from animal models . there was one recent research demonstrating the role of intravenous erythropoietin with oral prednisolone to improve a visual acuity in the patients with optic neuropathy . clinicians should have high index of suspicion for putaminal hemorrhage when patients with recent methanol intoxication present with alter mental status , confusion or behavioral change .
context : methanol intoxication is a life - threatening condition . 
 hallmark of clinical presentations include severe wide anion gap metabolic acidosis with very high serum osmolar gap and visual complication.case report : we report a case of severe methanol intoxication with bilateral putaminal hemorrhage , an uncommon serious complication . a 56-year - old man presented with altered mental status . 
 fundus examination showed optic disc edema . 
 arterial blood gas ( abg ) revealed severe anion gap metabolic acidosis with osmolal gap . 
 head computed tomography ( ct ) showed hypodense lesions in basal ganglia bilaterally . 
 hemodialysis and intravenous fomepizole were initiated . 
 serum methanol level was significantly elevated . 
 unfortunately , patient was lethargic 2 weeks after discharge . 
 repeated ct of head demonstrated new putaminal hemorrhages.conclusion:bilateral putaminal hemorrhage is an uncommon but serious complication in methanol intoxication . 
 clinicians should have high index of suspicion for putaminal hemorrhage when patients with recent methanol intoxication present with altered mental status .