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CASE TWO : A 35-yr-old woman was admitted to the hospital with a 2-week history of pneumonia that was unsuccessfully treated at home with oral ciprofloxacin. Fever, green sputum, a relentless cough and diffuse chest pain (related to the cough) required frequent and increasing use of diphenhydramine (200 mg/day), codeine (150 mg/day) and acetaminophen (4 g/day). Her past medical history was negative except for mild intermittent alcohol abuse. Increasing lethargy and dyspnea prompted her family to bring her to the emergency room. Past Medical History: negative except for the excess alcohol intake. She denied drug abuse, intake of other medications and previous surgery. On admission the patient was confused, disoriented and had a productive cough. Physical Examination: BP 125/85 mmHg, Pulse: 80/min, Respirations. 20/min, Temp 100.6 F (38.1 C); She was lethargic but otherwise well oriented; well nourished and without edema, cyanosis or clubbing. Right lower lobe consolidation was noted, abdominal and neurological examinations were normal. The remainder of the examination was not contributory. Chest x-ray revealed a cavitating right lower lobe abscess in an area of consolidation. Laboratory Studies: The patient's sputum culture grew-out staphylococcus Aureus. Hematocrit 34 %, Hemoglobin 11 g/dL, WBC 21,000 cells/cu l, Platelets normal Na 135 mEq/L, K 4.5 mEq/L, Cl 97 mEq/L, HCO 3 7 mEq/L; Calcium 10.2 mg/dL, Pi 5.0 mg/dL, Uric acid 9.5 mg/dL; Serum osmolality 293 mOsm/L Serum creatinine 1.4 mg/dL, BUN 30 mg/dL, Glucose 126 mg/dL Arterial Blood Gases (room air): pH 7.17, pCO 2 18 mmHg, HCO 3 6.4 mEq/L, pO 2 , 100 mm Hg Serum lactate 3.1 mEq/L, Ketones negative at 1:1 dilution of serum Urine: pH 5.5, Ketones trace positive, no protein or blood; Sediment: a rare uric acid and a rare calcium oxalate crystal were seen. Which ONE of the following disorders is the MOST LIKELY cause of this patient's metabolic disturbances?
Heterozygous ornithine transcarbamylase deficiency
Ethylene glycol poisoning
D-Lactic acidosis