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Ezhilarasu P, Srinivasan R. Beyond the Usual Suspects: Ethylene Glycol Poisoning Complicated by Rare Neurological Sequelae. Cureus 2024; 16:e57868. [PMID: 38725760 PMCID: PMC11081402 DOI: 10.7759/cureus.57868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
Ethylene glycol poisoning is a known clinical entity with established diagnostic and management protocols. However, instances presenting with rare neurological complications pose diagnostic challenges and necessitate prompt recognition and intervention. This report details the case of ethylene glycol poisoning in a 38-year-old male patient who initially presented with a history of brake oil consumption at his residence, followed by a delayed presentation with vomiting, abdominal pain, and reduced urine output, and subsequently developed unusual neurological sequelae, including unsteadiness, hearing difficulties, and an inability to close his eyes. Diagnostic assessment revealed cerebellar ataxia with bilateral sensory-neural hearing loss and facial nerve palsy. The patient was subsequently managed primarily for ethylene glycol poisoning, with conservative management for the neurological sequelae, and improved with no residual deficits. This case underscores the importance of promptly managing ethylene poisoning to prevent complications and sequelae as well as reduce morbidity for patients.
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Affiliation(s)
- Preetham Ezhilarasu
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Ragunanthanan Srinivasan
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
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2
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Ross JA, Borek HA, Holstege CP, King JD. Toxic Alcohol Poisoning. Emerg Med Clin North Am 2022; 40:327-341. [DOI: 10.1016/j.emc.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
This article reviews the background, metabolism, clinical effects, and treatment of toxic alcohols, specifically ethylene glycol, methanol, diethylene glycol, propylene glycol, and isopropyl alcohol. This article also reviews the importance of an anion gap metabolic acidosis in relation to toxic alcohols and explores both the utility and the limitations of the osmole gap in patient management.
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Affiliation(s)
- Jennifer A Ross
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA
| | - Heather A Borek
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA
| | - Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
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4
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Loriaux D, Bergin SP, Patel SM, Tucker J, Barkauskas CE. Ethylene Glycol Toxicity in the Setting of Recurrent Ingestion: A Case Report and Literature Review. Cureus 2019; 11:e4375. [PMID: 31218140 PMCID: PMC6553679 DOI: 10.7759/cureus.4375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ethylene glycol (EG) poisoning is a toxicologic emergency requiring high clinical suspicion and early diagnosis to prevent life-threatening complications. Direct EG quantification methods involve cumbersome and time-consuming laboratory tests of limited utility in the emergency setting. Accordingly, the osmolal gap is frequently employed as a surrogate screening method in cases of suspected toxic alcohol poisoning. However, the osmolal gap has several inherent limitations to be considered when used as a diagnostic tool for EG toxicity. Although many of these limitations are widely acknowledged, the clinical finding of a normal serum osmolal gap in the setting of recurrent toxic alcohol exposure is an observation that has remained largely unexplored. The purpose of this case report is to characterize the accelerated osmolal gap to anion gap conversion that may occur in the setting of chronic toxic alcohol abuse.
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Affiliation(s)
- Daniel Loriaux
- Internal Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
| | - Stephen P Bergin
- Internal Medicine - Critical Care, Duke University Medical Center, Durham, USA
| | - Sweta M Patel
- Internal Medicine - Critical Care, Duke University Medical Center, Durham, USA
| | - Jesse Tucker
- Internal Medicine - Critical Care, Duke University Medical Center, Durham, USA
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Ng PCY, Long BJ, Davis WT, Sessions DJ, Koyfman A. Toxic alcohol diagnosis and management: an emergency medicine review. Intern Emerg Med 2018; 13:375-383. [PMID: 29427181 DOI: 10.1007/s11739-018-1799-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 02/01/2018] [Indexed: 11/28/2022]
Abstract
Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.
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Affiliation(s)
- Patrick Chow Yuen Ng
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Brit J Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - William Tyler Davis
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| | - Daniel J Sessions
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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A Case of Chronic Ethylene Glycol Intoxication Presenting without Classic Metabolic Derangements. Case Rep Nephrol 2014; 2014:128145. [PMID: 25215251 PMCID: PMC4158266 DOI: 10.1155/2014/128145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/07/2014] [Indexed: 11/17/2022] Open
Abstract
Acute ethylene glycol ingestion classically presents with high anion gap acidosis, elevated osmolar gap, altered mental status, and acute renal failure. However, chronic ingestion of ethylene glycol is a challenging diagnosis that can present as acute kidney injury with subtle physical findings and without the classic metabolic derangements. We present a case of chronic ethylene glycol ingestion in a patient who presented with acute kidney injury and repeated denials of an exposure history. Kidney biopsy was critical to the elucidation of the cause of his worsening renal function.
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Effect of Low-Osmolality Intravenous Contrast on Serum Osmolal Gap in Adults. J Emerg Med 2013; 45:53-6. [DOI: 10.1016/j.jemermed.2012.11.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/27/2012] [Accepted: 11/18/2012] [Indexed: 11/20/2022]
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8
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Acute kidney injury with oxalate deposition in a patient with a high anion gap metabolic acidosis and a normal osmolal gap. J Nephropathol 2013. [DOI: 10.5812/nephropathol.10657] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Alhamad T, Blandon J, Meza AT, Bilbao JE, Hernandez GT. Acute kidney injury with oxalate deposition in a patient with a high anion gap metabolic acidosis and a normal osmolal gap. J Nephropathol 2013; 2:139-43. [PMID: 24475441 DOI: 10.12860/jnp.2013.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 12/10/2012] [Accepted: 12/29/2012] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ethylene glycol ingestion can lead to acute kidney injury from tubular deposition of oxalate crystals. The diagnosis of ethylene glycol intoxication is based on a history of ingestion, clinical examination, high anion gap metabolic acidosis, high osmolal gap, and a measured serum level of ethylene glycol. However, depending on the delay in time from ingestion to arrival to a hospital, the osmolal gap may become normal, thereby creating a confusing clinic picture for the treating clinician. CASE A 71 year-old man with a history of alcohol abuse had been unconscious for an unknown period of time. Upon hospitalization, he was found to have a high anion gap metabolic acidosis but a normal serum osmolal gap and subsequently developed acute kidney injury. The serum lactic acid and glucose levels were unremarkable, and there were no ketones in the serum. Urine analysis showed numerous red blood cells and calcium oxalate crystals. The renal biopsy showed multiple oxalate crystals in the renal tubules demonstrating birefringence under polarized light. Given the history of alcohol abuse, the clinical presentation, the unexplained high anion gap metabolic acidosis, and the biopsy findings, ethylene glycol intoxication was deemed the most likely diagnosis. CONCLUSIONS In cases of ethylene glycol intoxication, a high serum osmolal gap is supportive of ethylene glycol intoxication, but a normal serum osmolal gap does not exclude the diagnosis, especially when the time of ingestion is unknown. Physicians should be aware of potentially normal serum osmolal gap values in cases of ethylene glycol intoxication.
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Affiliation(s)
- Tarek Alhamad
- Division of Nephrology, Department of Internal Medicine, Penn State College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Jimena Blandon
- Division of Nephrology & Hypertension, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Ana T Meza
- The University of Texas at El Paso, El Paso, Texas, USA
| | | | - German T Hernandez
- Division of Nephrology & Hypertension, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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Abstract
The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.
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Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
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Coulter CV, Farquhar SE, McSherry CM, Isbister GK, Duffull SB. Methanol and ethylene glycol acute poisonings – predictors of mortality. Clin Toxicol (Phila) 2011; 49:900-6. [DOI: 10.3109/15563650.2011.630320] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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12
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Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17:29. [PMID: 19563673 PMCID: PMC2720377 DOI: 10.1186/1757-7241-17-29] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 06/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature. METHODS An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.
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Affiliation(s)
- Jennifer S Boyle
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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Abstract
Emergency physicians are regularly called on to care for critically poisoned patients. This article reviews the general approach and management of the critically poisoned patient. Specific clinical characteristics are identified that may clue the clinician into a specific toxin class as a diagnosis. Appropriate testing in the poisoned patient is reviewed. Complications of poisoning that may bring a rapid demise of the critically ill poisoned patient are highlighted and the management of those complications is discussed.
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Eldridge DL. New trends in diagnostic investigations in poisoned patients. DRUG DISCOVERY TODAY. TECHNOLOGIES 2007; 4:e89-e108. [PMID: 24139381 DOI: 10.1016/j.ddtec.2008.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Abstract
This article examines the role of common laboratory tests in the evaluation of a poisoned patient. Numerous laboratory tests maybe useful to clinicians caring for poisoned patients. Clinicians should not order a broad range of tests indiscriminately, but rather thoughtfully consider appropriate tests. The results of the tests should be reviewed in the context of the clinical scenario.
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Affiliation(s)
- David L Eldridge
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Eldridge DL, Dobson T, Brady W, Holstege CP. Utilizing diagnostic investigations in the poisoned patient. Med Clin North Am 2005; 89:1079-105. [PMID: 16227055 DOI: 10.1016/j.mcna.2005.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Numerous diagnostic tests may be useful to clinicians caring for poisoned patients. Clinicians should not order a broad range of tests indiscriminately,but rather thoughtfully consider appropriate tests. The results'of the tests should be reviewed in the context of the clinical scenario.
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Affiliation(s)
- David L Eldridge
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Purssell RA, Lynd LD, Koga Y. The use of the osmole gap as a screening test for the presence of exogenous substances. ACTA ACUST UNITED AC 2005; 23:189-202. [PMID: 15862085 DOI: 10.2165/00139709-200423030-00005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The rapid and accurate diagnosis of toxic alcohol poisoning due to methanol (methyl alcohol) [MeOH] and ethylene glycol (EG), is paramount in preventing serious adverse outcomes. The quantitative measurement of specific serum levels of these substances using gas chromatography is expensive, time consuming and generally only available at major tertiary-care facilities. Therefore, because these toxic substances are osmotically active and the measurement of serum osmolality is easily performed and more readily available, the presence of an osmole gap (OG) has been adopted as an alternative screening test. By definition, the OG is the difference between the measured serum osmolality determined using the freezing point depression (Osm(m)) and the calculated serum molarity (Mc), which is estimated from the known and readily measurable osmotically active substances in the serum, in particular sodium, urea, glucose, and potassium and ethanol (alcohol). Thus, the OG=Osm(m)-Mc, and an OG above a specific threshold (the threshold of positivity) suggests the presence of unmeasured osmotically active substances, which could be indicative of a toxic exposure. The objectives of this study were to review the principles of evaluating screening tests, the theory behind the OG as a screening test and the literature upon which the adoption of the OG as a screening test has been based. This review revealed that there have been numerous equations derived and proposed for the estimation of the Mc, with the objective of developing empirical evidence of the best equation for the determination of the OG and ultimately the utility of OG as a screening test. However, the methods and statistical analysis employed have generally been inconsistent with recommended guidelines for screening test evaluation and although many equations have been derived, they have not been appropriately validated. Specific evidence of the clinical utility of the OG requires that a threshold of positivity be definitively established, and the sensitivity and specificity of the OG in patients exposed to either EG or MeOH be measured. However, the majority of studies to date have only evaluated the relationship between the Osm(m) (mmol/kg H2O) and the Mc (mmol/L) in patients that have not been exposed to either MeOH or EG. While some studies have evaluated the relationship between the OG and serum ethanol concentration, these findings cannot be extrapolated to the use of the OG to screen for toxic alcohol exposure. This review shows that there has not been an appropriately designed empirical evaluation of the diagnostic utility of the OG and that its clinical utility remains hypothetical, having been theoretically extrapolated from the non-poisoned population.
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Affiliation(s)
- Roy A Purssell
- Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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Abramson S, Singh AK. Treatment of the alcohol intoxications: ethylene glycol, methanol and isopropanol. Curr Opin Nephrol Hypertens 2000; 9:695-701. [PMID: 11128434 DOI: 10.1097/00041552-200011000-00017] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intoxications with ethylene glycol, methanol, and isopropanol are among the most common ingestions, in the treatment of which a nephrologist plays an important role. These three substances have the ideal characteristics for intervention by hemodialysis, and the three parent compounds and their metabolites are readily dialyzable. Two of the three substances, ethylene glycol and methanol, are metabolized to more toxic substances, so that an early treatment strategy that removes the parent compound or blocks its metabolism can prevent the development of many of the adverse events that are often seen in these ingestions. Fomepizole, an inhibitor of alcohol dehydrogenase, slows the metabolism of these substances and is now approved by the US Food and Drug Administration for use in ethylene glycol intoxication. The present review addresses recent advances in the diagnosis and treatment of intoxication with ethylene glycol, methanol and isopropanol.
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Affiliation(s)
- S Abramson
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Vanderpas J. [Diagnosis and treatment of an unusual cause of metabolic acidosis: ethylene glycol poisoning]. Acta Clin Belg 2000; 55:227. [PMID: 11036683 DOI: 10.1080/17843286.2000.11754302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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