BRIEF OBSERVATION

Pseudohyperchloremia and Negative Anion

Gap − Think Salicylate!
Michael R. Wiederkehr, MD,a,b Raul Benevides Jr, MD,c Carol A. Santa Ana, BS,d Michael Emmett, MDb,e,f
a
Nephrology Division, Baylor University Medical Center, Dallas, Texas; bTexas A&M School of Medicine, Bryan; cDepartment of Pathology,
Baylor University Medical Center, Dallas Texas; dGI Lab; eInternal Medicine, Baylor University Medical Center, Dallas, Texas; fInternal
Medicine, UT Southwestern School of Medicine, Dallas, Texas.

ABSTRACT

BACKGROUND: Pseudohyperchloremia results in a very low or negative anion gap. Historically, the most com-
mon cause of this artifact was bromide poisoning. Bromide salts have been removed from most medications
and bromism has become very uncommon. More recently, the introduction of chloride ion selective sensing
electrodes (Cl-ISE) has generated a new cause of pseudohyperchloremia—salicylate poisoning. We describe 5
such patients and quantitate the error generated by this measurement artifact.
METHODS: The magnitude of artifactual hyperchloremia generated by high salicylate levels was quantified
in 5 patients by measuring chloride concentration with several Cl-ISEs from different manufacturers and
with Cl-ISEs of different “ages,” and comparing these results to measurements with a chloridometer (cou-
lometric titration), which is free of the salicylate artifact.
RESULTS: Cl-ISEs from different manufacturers generated a wide range of artifactual chloride concentra-
tion elevation. Furthermore, the same Cl-ISE generated increasingly severe pseudohyperchloremia as it
was repeatedly reused over time and “aged.”
CONCLUSIONS: Salicylate interferes with measurement of the blood chloride concentration when a Cl-ISE is
used. The severity of this artifact is related to the salicylate level, the specific Cl-ISE, and the “age” of the elec-
trode. Toxic blood salicylate levels can generate marked pseudohyperchloremia, and consequently, an artifac-
tual very small or negative anion gap. The large anion gap metabolic acidosis typical of salicylate poisoning is
masked by this artifact. Salicylate has become the most common cause of pseudohyperchloremia, and physi-
cians should immediately consider salicylate poisoning whenever the combination of hyperchloremia and a
very small or negative anion gap is reported by the laboratory.
Ó 2021 Elsevier Inc. All rights reserved.  The American Journal of Medicine (2021) 134:1170−1174

KEYWORDS: Anion gap; Metabolic acidosis; Pseudohyperchloremia; Salicylate poisoning

INTRODUCTION marked pseudohyperchloremia when they presented to the

High blood salicylate levels alter the permeability character-
izes of the chloride ion selective sensing electrodes used by
virtually all clinical laboratories and artifactually raises the
chloride concentration (Cl). Salicylate has now replaced bro-
mide as the most common cause of pseudohyperchloremia.
We describe 5 patients with salicylate poisoning who had
Funding: None.
Conflicts of interest: None.
Authorship: All authors had full access to the data and participated in
the preparation of the manuscript.
Requests for reprints should be addressed to Michael Emmett, MD,
Internal Medicine, Baylor University Medical Center, 3500 Gaston Ave-
nue, Dallas, TX 75246.
E-mail address: MichaeI.Emmett@BSWHealth.org
emergency department. Cl was measured in a central hospital
laboratory with an autoanalyzer that measures Cl with indirect
chloride ion selective electrode (Cl-ISE) technology. Pseudo-
hyperchloremia was suspected because Cl was raised far out
of proportion to the sodium concentration and this reduced the
anion gap (AG) to the very low or markedly negative range.
We then documented the existence of pseudohyperchloremia,
and the degree of the error, by reanalyzing the blood Cl utiliz-
ing an analytic technique not subject to this error.
This artifact has several very important clinical conse-
quences. First, it can serve as a major clue to the presence
of otherwise unrecognized salicylate poisoning. The
diagnosis of salicylate poisoning may be initially missed,
and delays in diagnosis can contribute to morbidity and

0002-9343/© 2021 Elsevier Inc. All rights reserved.

https://doi.org/10.1016/j.amjmed.2021.03.017
Wiederkehr et al Pseudohyperchloremia and Negative Anion Gap 1171

mortality.1,2 Suspicion of pseudohyperchloremia should period of many weeks. The salicylate-generated pseudohyper-
immediately trigger measurement of a salicylate level. chloremia error becomes increasingly severe as the Cl-ISE
Second, pseudohyperchloremia will mask the presence of a ages.
high AG metabolic acidosis, which develops in most The initial Cl-ISE device used in this study was the Roche
patients with salicylate poisoning. Monitoring changes in Cobas Integra Analyzer (indirect Cl-ISE; Roche Diagnostics,
bicarbonate concentration and the AG are important guide- Rotkreuz, Switzerland). We also measured Cl with the Abbott
posts to therapy, and pseudohyperchloremia will confound i-Stat (direct Cl-ISE; Abbott, Princeton, NJ), the Beckman-
these parameters. This becomes more Coulter Chemistry Analyzer CX (indi-
complicated as the salicylate levels CLINICAL SIGNIFICANCE rect Cl-ISE; Beckman-Coulter, Inc.,
rise and fall during the hospitalization Brea, Calif), and the Roche Diagnos-
and cause wide artifactual excursions  Whenever chloride concentration is tics AVL 9180 (direct Cl-ISE).
of Cl and the AG. increased and the anion gap is very Coulometric Titration:
Pseudohyperchloremia was sus- small or negative, consider pseudohy- 3. Chloridometers measure Cl with
pected in the 5 patients we studied perchloremia. coulometric titration. The chlor-
due to marked hyperchloremia and  Immediately obtain a salicylate level. idometer utilized in this study
a very small or negative AG. When If possible, remeasure chloride concen- was the Labconco Digital Chlor-
the possibility of pseudohyperchlor-
tration with another analytical instru- idometer (Model 442-5000;
emia was raised, a salicylate level Kansas City, Mo).
ment, preferably using a new chloride
was measured and the serum speci-
men was re-analyzed with a labora- ion selective electrode or a non-ion Whenever a patient’s clinicians,
tory technique that is not affected selective electrode methodology. or the laboratory personnel, sus-
by salicylate. We utilized a chlorid-  If salicylate poisoning is identified, pected that pseudohyperchloremia
ometer that measures Cl with coulo- anion gap metabolic acidosis may be might exist (because the Cl was
metric titration, deemed the “gold masked by pseudohyperchloremia. disproportionally increased com-
standard” for chloride analysis. The  If salicylate is not identified, consider pared with sodium, generating a
initial blood specimens were also less common causes of pseudohyper- surprisingly small or negative
re-analyzed with a variety of other chloremia, such as bromism or thiocya- AG), the initial serum or plasma
chloride analyzers, including both nate toxicity. specimen was re-analyzed with
direct and indirect Cl-ISEs from other Cl analyzers, including direct
various manufacturers, and Cl-ISEs and indirect Cl-ISEs and the Lab-
of different use “ages” (we define “age” of multiple use conco chloridometer.
Cl-ISE as the number of days of continuous use). Salicylate levels were measured with a salicylate
hydroxylase methodology. Salicylate is reduced in the pres-
ence of Nicotinamide adenine dinucleotide hydrogen
MATERIALS AND METHODS
(NADH) to form catechol and Nicotinamide adenine dinu-
Blood Cl was measured with 3 different analytical methods:
cleotide (NAD). Conversion of Nicotinamide adenine dinu-
Ion Selective Electrodes:
cleotide hydrogen (NADH) to Nicotinamide adenine
1. Direct chloride ion-selective electrode (Direct Cl-ISE). dinucleotide (NAD) is measured by the decrease in light
The undiluted specimen is placed in the analyzer and Cl absorbance at 340 nm. The decrease is proportional to the
measured with a Cl-ISE. The electrodes in most, but not concentration of salicylate in the sample.
all of these devices, are used only one time.
2. Indirect chloride ion-selective electrode (Indirect Cl- RESULTS
ISE). The specimen is first diluted and then placed into We identified 5 patients with pseudohyperchloremia and
an analyzer that utilizes a Cl-ISE to measure Cl. The Cl- remeasured their initial Cl with a chloridometer utilizing cou-
ISE electrodes in these devices are used repeatedly over lometric titration, and in addition, measured Cl with various
a period of weeks or longer.3,4 direct and indirect Cl-ISEs. Their clinical course is briefly
reviewed below and laboratory results are shown in Table 1.
Over 99% of central laboratories in the United States utilize Patient 1:
indirect analyzers incorporating indirect ISE technology.4 A Cl- A 42-year-old woman with no prior medical history. Pre-
ISE incorporates a membrane that usually contains quaternary sented 16 hours after a suicide attempt with dyspnea, tinnitus,
ammonium salts and estimates the specimen’s chloride ion nausea, tachypnea, tachycardia, and lethargy. She had
activity with potentiometric measurements.4 Chloride activity is ingested twenty 325-mg aspirin tablets. Salicylate level
then converted to Cl. High levels of salicylate, as well as non- peaked at 70.4 mg/L (therapeutic 10-25 mg/dL; toxic 70 mg/
chloride halides, such as bromide and iodide, can generate spu- dL). Evaluation revealed respiratory alkalosis and metabolic
rious high Cl. Thiocyanate can also generate this artifact. A acidosis, and severe hyperchloremia at 170 mEq/L with AG
very important aspect of the salicylate-related error is that the 47. She underwent emergency hemodialysis, improved, and
same Cl-ISE is usually re-used for many analytic runs over a was discharged with outpatient Psychiatry follow-up.
1172 The American Journal of Medicine, Vol 134, No 9, September 2021

Table 1
Case # Age (Years)/Sex Salicylate (mg/dL) pH/pCO2/ (HCO3 ) ISE (Cl ) Apparent (AG) Coulometric Titration True (AG)
True (Cl )
1 42/F 70.4 7.53/12/15 170 47 98 25
2 53/M 69.7 7.05/69/18 186 63 94 29
3 75/F 84.4 7.38/25/15 132 1 106 25
4 72/F 93.7 7.40/13/8 148 10 108 30
5 68/M 44.8 7.37/23/21 111 6 88 24

Patient 2: the chloridometer, their true Cl ranged from 88 to

A 53-year-old man with a history of bipolar disorder. Pre-
sented with severe respiratory distress, tachycardia, tachypnea,
pulmonary crackles, and low-grade fever. Chest radiograph
confirmed diffuse infiltrates. Evaluation showed combined
metabolic and respiratory acidosis with hypoxemia, and severe
hyperchloremia, at 186 mEq/L, with AG 63. Salicylate level
was 70 mg/dL. He required endotracheal intubation and urgent
hemodialysis, but suffered an asystolic cardiac arrest and
could not be resuscitated.
Patient 3:
A 75-year-old woman with a history of hypertension,
diabetes mellitus, and an unspecified psychiatric disorder.
Presented with nausea and vomiting to an outside facility.
The family reported suicidal ideation and an empty bottle
of aspirin that had contained 100 tablets of 500-mg enteric-
coated aspirin. The salicylate level was 96 mg/dL. She
required endotracheal intubation, received activated char-
coal, and transferred to our institution. The initial salicylate
level was 84.4 mg/dL, Cl 132 mEq/L, and AG 1. She
was treated with aggressive intravenous NaHCO3/NaCl,
slowly improved, and eventually was discharged with Psy-
chiatry follow-up.
Patient 4:
A 72-year-old woman presented with 24 hours of
altered mental status and tachycardia. She had been tak-
ing aspirin for relief of headaches and osteoarthritis, but
the amount was unknown. She had a mixed respiratory
alkalosis and metabolic acidosis, and salicylate level was
93.7 mg/dL, Cl 148 mg/dL, and AG 10. She required
endotracheal intubation and aggressive IV NaHCO3/NaCl,
and improved.
Patient 5:
A 68-year-old man with a history of advanced tonsillar
carcinoma and prior suicide attempt presented with acutely
altered mental status, and a mixed respiratory alkalosis and
metabolic acidosis. Salicylate level was 44.8 mg/dL, Cl
111 mEq/L, and AG +6. He was treated with aggressive IV
NaHCO3/NaCl, and improved.
In each case, the initial Cl was measured by our central
laboratory with a Roche Cobas Integra Analyzer, which uti-
lizes indirect/reusable Cl-ISE technology. Subsequently,
serum Cl was re-measured with a Labconco chloridometer,
as shown in Table 1. Initial serum Cl, measured with the
Cl-ISE, ranged from 111 to 186 mEq/L, and the initial AG,
calculated with these Cl, ranged from 63 to +6 mEq/L.
However, when the same specimens were reanalyzed with
108 mEq/L, and their true AG from +24 to +30 mEq/L.
Recognition of pseudohyperchloremia and re-measurement
of the Cl led to a diagnosis of high AG metabolic acidosis
in each case, whereas this was not evident prior to re-mea-
surement.
The admission Cl of patient #1 was also re-analyzed
using several different direct and indirect Cl-ISE analyzers,
as well as multiple times with the same Roche Cobas Inte-
gra Analyzer but incorporating Cl-ISEs of various ages, as
shown in Table 2. This patient’s “true” Cl measured with a
chloridometer (coulometric titration) was 98 mEq/L. The
Cl result using a 3-day-old Cl-ISE (Roche Cobas Integra
Analyzer) was increased by 7 mEq/L to 105 mEq/L, but the
15- and 21-day-old Cl-ISEs generated Cl results of
170 mEq/L and 237 mEq/L (over twice the true Cl level).
DISCUSSION
Historically, the most common and well-recognized cause
of pseudohyperchloremia was chronic bromism caused by
the ingestion of various soluble bromide salts.5 For over
130 years, bromide salts were the most commonly utilized
active ingredient in a variety of tranquilizers, sedatives, and
anticonvulsants. Many formulations were available over the
counter without prescription. Some patients developed a
physiologic addiction to bromide and ingested the drug
daily, generating a psychiatric, neurologic, gastroenterolog-
ical, and dermatologic disorder called chronic bromism.5
The renal tubules reabsorb bromide slightly more avidly
than chloride, so that over time bromide replaces a large
fraction of the chloride in the extracellular fluid
Table 2
Chloride Analyzer Chloride mEq/L
Roche Cobas Integra Analyzer 103
(3-day-old electrode)
Roche Cobas Integra Analyzer 170
(15-day-old electrode)
Roche Cobas Integra Analyzer 237
(21-day-old electrode)
Abbot i-Stat (Direct Cl-ISE) 118
Beckman-Coulter Chemistry Analyzer 104
CX (Indirect Cl-ISE)
AVL analyzer (Direct Cl-ISE) 105
Cotlove Calorimeter 98
CI-ISE = chloride ion selective electrode.
Wiederkehr et al Pseudohyperchloremia and Negative Anion Gap
compartment. Plasma bromide reacts more strongly than
equal concentrations of chloride in almost all Cl assay sys-
tems used by clinical laboratories. Therefore, 1 mEq/L bro-
mide may be interpreted as 4-5 mEq/L of “Cl,” generating
pseudohyperchloremia.5 Other halide ions including iodide
have similar effects. Bromides have been removed from
most prescription and over-the-counter drugs in the
United States, and bromism has become very uncommon
in the United States. However, bromide salts are still
occasionally used to treat otherwise refractory seizures,6
and 2 bromide-containing medications still commonly
used in the United States are pyridostigmine bromide,
and dextromethorphan hydrobromide, and each has been
associated with bromism.7-9
Salicylate may generate marked pseudohyperchloremia
whenever Cl is measured with a Cl-ISE, and salicylate poi-
soning has now replaced bromism as the most common
cause of this artifact.10 Cl-ISEs from different manufactures
produce errors of different magnitude, and the magnitude of
the error is also dependent on the “age” of the Cl-ISEs when
they are reused (Table 2).
Salicylate poisoning generates a spectrum of acid-base
disorders.11 They include:
1. High AG metabolic acidosis due to the accumulation of
a variety of metabolic organic acids including ketoacids,
lactic acid, and salicylic acid itself. Salicylic acid (MW
138) has an acid dissociation constant (pKa) of 2.8.
Therefore, at a toxic level of 70 mg/dL, salicylate will
directly reduce the HCO3, and reciprocally increase the
AG by 5 mEq/L.
2. Respiratory alkalosis because of direct stimulation of the
central nervous system respiratory center by toxic salic-
ylate levels.
3. Metabolic alkalosis due to the frequent development of
nausea and vomiting.
4. Respiratory acidosis can develop with very severe salic-
ylate poisoning that requires endotracheal intubation.
A patient’s arterial blood pH may be acid, normal, or
alkaline, depending on the existence and relative severity of
each of these 4 disorders. Patient age also has a major
impact on the relative severity of metabolic acidosis and
respiratory alkalosis. Acidemia is more common and severe
in young children, while respiratory alkalosis and alkalemia
typically dominates in older children and adults. However,
regardless of the blood pH and relative severity of the vari-
ous acid-base disorders, most salicylate-poisoned patients
develop a large AG, reflecting the presence of metabolic
acidosis. Pseudohyperchloremia artifactually reduces the
AG toward zero or generates a negative value, and thereby,
masks the existence of high AG metabolic acidosis.
We have searched the published medical literature for
prior reports of pseudohyperchloremia due to salicylate and
identified 15 cases. Ten are fully reported,12-18 3 are brief
editorial letters,19,20 and 2 are abstracts only.21,22 In none of
these cases was pseudohyperchloremia confirmed, or was
1173
the degree of the error quantitated, by re-measuring Cl with
an analytic methodology known to be free from salicylate
interference (ie, analysis by chloridometer). Our study is
the first to systematically measure Cl with both Cl-ISEs,
which are susceptible to the salicylate artifact, and with a
chloridometer utilizing coulometric titration that is unaf-
fected by salicylate interference.
Pseudohyperchloremia should be suspected whenever
the Cl is elevated and the AG approaches 0 or has a nega-
tive value, especially in clinical conditions that usually ele-
vate the AG. This artifact has important diagnostic and
therapeutic implications. First, salicylate poisoning is often
not recognized when patients present to the hospital, and
missing this diagnosis can contribute to patient morbidity
and mortality. For example, the diagnosis of salicylate poi-
soning was initially missed in 27% of patients hospitalized
at an academic medical center with this disorder.1 Another
study of fatal salicylate poisoning found that 26% of the
patients who died never had the correct diagnosis estab-
lished prior to their death.2 Second, unrecognized pseudo-
hyperchloremia masks the existence of high AG metabolic
acidosis. Accurate identification of the complex acid-base
disorders generated by salicylate poisoning is essential for
directing appropriate therapy. A large AG should raise the
possibility of lactic acidosis or ketoacidosis complicating
salicylate acidosis. Therefore, recognizing pseudohyperchlore-
mia is essential to an early suspicion of salicylate poisoning
and thus, expediting life-saving interventions.
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