Glycerol intolerance in a child with intermittent hypoglycemia

Glycerol intoxication syndrome in young children, following the consumption of slush ice drinks

INTRODUCTION

Slush ice drinks are commonly available refreshments, aimed at children and young people. Glycerol is used to maintain the slush effect in the absence of a high sugar content.

OBJECTIVE

To describe a series of children who became acutely unwell shortly after consuming a slush ice drink; their presentation mimics specific inherited metabolic diseases (IMDs).

METHODS

A retrospective case review of 21 children who presented to centres across the UK and Ireland from 2009 through 2024 was carried out.

RESULTS

Almost all of the children (93%) became unwell within 60 min of slush ice drink consumption. None had any relevant past medical history. The median age at presentation was 3 years 6 months (range 2 years - 6 years 9 months). Presenting features include acute decrease in consciousness (94%), hypoglycaemia (95%), metabolic (lactic) acidosis (94%), pseudohypertriglyceridaemia (89%) and hypokalaemia (75%). Glyceroluria was present in all acute urine organic acid samples. No underlying IMD was found in the 14 patients who underwent further enzymatic or genetic testing. The majority (95%) subsequently avoided slush ice drinks and did not have reoccurrence.

CONCLUSION

Consumption of slush ice drinks containing glycerol may cause a clinical syndrome of glycerol intoxication in young children, characterised by decreased consciousness, hypoglycaemia, lactic acidosis, pseudohypertriglyceridaemia and hypokalaemia. This mimics inherited disorders of gluconeogenesis and glycerol metabolism. Clinicians and parents should be alert to the phenomenon, and public health bodies should ensure clear messaging regarding the fact that younger children, especially those under 8 years of age, should avoid slush ice drinks containing glycerol.

Quantitative Investigation on Exposure to Potentially Harmful Excipients by Injection Drug Administration in Children Under 2 Years of Age and Analysis of Association with Adverse Events: A Single-Center, Retrospective Observational Study

INTRODUCTION

Potentially harmful excipients (PHEs) for children have been reported and the need for information collection has been advocated. However, studies on the actual occurrence of adverse events are limited. This study investigated the quantitative exposure of PHEs via injection and their association with adverse events in children under 2 years of age.

MATERIALS AND METHODS

As a single-center observational study, children aged 0-23 months received injectable drugs from April 1, 2018, to March 31, 2023 were included. Information on PHE exposure and adverse events after administration were extracted from medical records. Sodium benzoate, benzyl alcohol, ethanol, glycerol, lactose, polyethylene glycol paraben, polysorbate, propylene glycol, sorbitol, sucrose, sulfite, and thimerosal were selected as PHEs.

RESULTS AND DISCUSSION

6265 cases, 333,694 prescriptions, and 368 drugs (264 ingredients) were analyzed. The median age was 0.63 years (interquartile range [IQR] 0.1-1.1). 72,133 prescriptions, 132 drugs and 99 ingredients contained PHE; 2,961 cases exposed to PHE and 1825 cases exceeding permitted daily exposure. The drug with the highest number of exposure cases was hydroxyzine, and the highest number of prescriptions was heparin (both drugs contain benzyl alcohol). In association between adverse events and PHE exposure, higher doses in cases of adverse event occurrence were found in benzyl alcohol, glycerol, polyethylene glycol, and polysorbate exposed cases. Among thimerosal-exposed cases, "developmental delay" was more frequent in exposed cases, but the causal relationship was unknown. Further investigation is needed to clarify the relationship between adverse events and PHE exposure. Additionally, more precise information on PDE for pediatrics including neonates is necessary.

Pediatric hypoglycemia

Hypoglycemia in the pediatric population is a common finding important to recognize and manage to prevent brain injury. Recent advances in molecular genetics have provided new insight into its biochemical and physiologic basis and have led to more appropriate and specific treatment. Although a major cause of brain injury in pediatrics, the ability to predict the long-term outcome in these patients remains difficult. Identification of these at-risk individuals is important. The physiologic adaptations associated with transition from fetal to neonatal life are now better understood thus allowing for improved surveillance and management. Despite these advances, analytical limitations of point-of-care testing instruments at low glucose concentration continue to persist, This review aims to address these questions and provide an overview of pediatric hypoglycemia and the molecular pathways involved.

The treatment of leg telangiectasia

Leg telangiectasia is more difficult to treat than facial telangiectasia. Investigations may be needed to elucidate the origin of the telangiectasia. In cases of venous insufficiency, investigation of venous haemodynamics is desirable. Treatment is primarily by sclerotherapy, including foam sclerotherapy. Light and laser treatments are also effective, especially for telangiectasia up to 1 mm in diameter. New developments incorporate longer pulse durations, such as frequency-doubled neodynium YAG and diode lasers as well as intense pulsed light. After all treatment methods, compression for 48 h using pads, bandages or hosiery is recommended. As with all cosmetic procedures, patients need to be tutored comprehensively about anticipated results and possible complications or side-effects.

Issues in the formulation of drugs for oral use in children: role of excipients

An ideal oral drug for children should be effective, well tolerated, be of low cost and have good palatability, i.e. acceptable taste, after-taste and smell. Many of the drugs used for children are not available in suitable forms (such as chewable or liquid). Liquid forms may need to be prepared using appropriate excipients at the time of dispensing by the pharmacist. Modern medications are complex mixtures containing many other components besides the active ingredient. These are called 'inert ingredients', or excipients, and consist of bulk materials, flavorings, sweeteners and coloring agents. These excipients increase the bulk, add desirable color, mask the unpleasant taste and smell, and facilitate a uniform mixture of the active ingredient in the final marketed preparation. Unlike the active ingredients, excipients are not well regulated in most countries. Although mostly well tolerated, some adverse events and idiosyncratic reactions are well known for a variety of excipients. These components play a critical role, especially in liquid and chewable preparations that are mostly consumed by infants and children. This article reviews excipients commonly used in pediatric oral preparations.

Fructose-1,6-diphosphatase deficiency and glyceroluria: one possible etiology for GIS

Fructose-1,6-diphosphatase (FDPase) deficiency is characterized by episodes of lactic acidemia, hypoglycemia, and ketonuria. Liver biopsy and subsequent enzyme analysis most reliably make the diagnosis. Review of the literature reveals 85 cases. Glycerol intolerance syndrome (GIS) is less well defined. There are only a handful of cases reported. We describe a patient with FDPase deficiency and significant glyceroluria and propose that GIS may be caused by partial deficiency of FDPase.

A report of acute ethanol poisoning in a child: mouthwash versus cologne, perfume and after-shave

The ingestion of ethanol-containing products, such as cologne, perfume and after-shave, in children under six years of age is common, but serious poisoning is rarely reported. Thus, it has been recently suggested that children ingesting up to 3.5 ounces of these products may be safely observed at home as long as they remain asymptomatic. While it may be assumed that products with a significantly lower alcohol content represent a much smaller poisoning hazard, mouthwashes are a relatively frequent cause of serious poisoning in children. In the following case report, 75 milliliters of mouthwash caused hypoglycemia, coma and manifestations of tonic seizure activity. Because of the palatable nature of mouthwash, wine and liquor, it appears that children are more apt to drink large quantities, consuming dangerous amounts of ethanol. The apparent safety of cologne, perfume, and after-shave may be due to a lack of palatability as well as the irritant nature of high concentrations of ethanol. This case suggests that consumer items such as mouthwash should be packaged in child-resistant containers.

Organic acidurias: a review. Part 1

Organic acidemias are disorders of intermediary metabolism that lead to accumulation of organic acids in biologic fluids, disturb acid-base balance, and derange intracellular biochemical pathways. Their clinical presentation reflects the resultant systemic disease and progressive encephalopathy. While in some organic acidemias, disturbed acid-base metabolism is the predominant presenting feature, in others it is less prominent or even absent. The etiologies of the more than 50 different phenotypes include impaired metabolism of branched-chain amino acids, vitamins, glucose, lipids, glutathione, and gamma-aminobutyric acid and defects of oxidative phosphorylation. Most organic acidemias present with neurologic manifestations, which include acutely or subacutely progressive encephalopathy that involves different parts of the nervous system. The age of presentation and the associated systemic, hematologic, and immune findings provide additional guidelines for differential diagnosis. We summarize major organic acidemias, while emphasizing their usual and unusual neurologic presentations.

Porin interaction with hexokinase and glycerol kinase: metabolic microcompartmentation at the outer mitochondrial membrane

Porin is the pore-forming protein involved in the movement of adenine nucleotides across the outer mitochondrial membrane (OMM). Hexokinase and glycerol kinase interact with porin on the outer surface of the OMM in a manner which provides these enzymes with preferred access to the ATP generated in the mitochondrion. We review recent evidence which permits refinement of our knowledge of these proteins and their interactions at the OMM. The involvement of this system in metabolic microcompartmentation is discussed, as well as possible pathological consequences of its disruption in malignancy and genetic deficiencies of hexokinase, glycerol kinase, and porin.

Glycerol oxidation in discrete areas of rat brain from young, adolescent, and adult rats

We have reported previously that the oxidation rate of [1,3-14C] glycerol to 14CO2 is lower in whole brain homogenates from neonatal rats and increases about 30% during the suckling period to adult levels. To determine whether there are developmental changes in glycerol oxidation in discrete regions of brain, we examined the oxidation of glycerol by homogenates of hypothalamus, cerebellum, brain stem, hippocampus, and cerebral cortex of young (4-6 days) and older (18-20 days) pups and adult (greater than 90 day) rats. The oxidation was measured at both low (0.2 mM) and high (2.0 mM) concentrations of glycerol, since the oxidation of glycerol by brain tissue has been shown to exhibit biphasic kinetics. At each age, and with both concentrations of glycerol, there were significant differences among the discrete brain regions. Although the rate of glycerol oxidation increased with age in most areas of brain, each brain region had a distinct developmental profile. In the hypothalamus, the oxidation of glycerol increased significantly between 4-6 days and adult levels at 18-20 days. The oxidation of glycerol was essentially the same in homogenates of cortex from young and older pups, but it was significantly increased in adults. In contrast with other brain regions, the oxidation of glycerol by brain stem was highest at 4-6 days and significantly decreased with age. The developmental profile of glycerol oxidation in hippocampus and cerebellum was particularly complex, since it increased with age at low, but not at high, concentrations of glycerol. This developmental pattern in hippocampus and cerebellum could be related to changes in the biphasic kinetics of glycerol oxidation and suggests that glycerol metabolism is different in these two areas of brain compared with other areas of brain.

Fructose-1,6-diphosphatase deficiency: glycerol excretion during fasting test

A Turkish boy had suffered since the age of 10 months from recurrent attacks of severe metabolic acidosis and hypoglycaemia precipitated by moderate respiratory tract infections. A liver biopsy showed lack of fructose 1,6-diphosphatase and absence of phosphorylase. The patient died in shock following fructose ingestion. Upon fasting, acidosis with increased lactate and glycerol excretion was found. Findings indicate that, in this inherited disorder of gluconeogenesis, lactic acidosis combined with increased glycerol excretion upon fasting are of diagnostic importance.

Regulation of gluconeogenesis by glycerol and its phosphorylated derivatives

Glycerol, glycerol-3-phosphate (G3P), and dihydroxyacetone phosphate (DHAP) were evaluated as inhibitors of gluconeogenesis on rat liver enzymes in vitro, and for their effects on glucose formation in vivo in well-nourished and malnourished rats. DHAP was more potent as an inhibitor than G3P on fructose-1,6-diphosphatase (FDPase), phosphoenolpyruvate carboxykinase (PEPCK), and glucose-6-phosphatase (G6Pase). The I50 for DHAP was 2, 8, and 9 x 10(-3) M, respectively. No effect was observed on rat liver pyruvate carboxylase (PC). Glycerol was a weak inhibitor of FDPase and PEPCK, but did not inhibit PC and G6Pase. In vivo, when G3P was injected before a parenteral L-alanine (Ala) challenge, it produced a hypoglycemic effect in malnourished rats and a lesser, but noticeable, blood glucose level reduction in well-fed animals. Glycerol caused a smaller reduction in glucose formation from Ala. No comparable effects were observed after a fructose pretreatment. These results underscore the potential hypoglycemic effects of phosphorylated glycerol metabolites and identify the steps in gluconeogenesis where this action is exerted. The study also stresses the nutritional component in the glycerol intolerance syndrome, apparent from the far more severe effects observed in malnourished rats given G3P or glycerol prior to Ala.

Glycerol-induced hypoglycemia: a syndrome associated with multiple liver enzyme deficiencies. Clinical and in vitro studies

A 4 10/12 yr-old white male presented with a history of occasional grand mal seizures and hypoglycemic episodes after overnight fasting. Upon evaluation, he became hypoglycemic after 1 g/kg oral glycerol challenge (plasma glucose: 31 mg/dl in 45 min), but had normal glucose, alanine and fructose tolerance tests. He responded well to a glucagon challenge after 11 hr fast but he became hypoglycemic and could not normalize his blood glucose after a 2nd glucagon stimulation test after 17 hr of fasting. Studies conducted on a percutaneous liver biopsy, and compared with 3 non-hypoglycemic controls, showed reduced activities (20%-30% of normal) of alpha-glycerophosphate dehydrogenase, alpha-glycerophosphate oxidase and fructose-1,6-diphosphatase. Alpha glycerophosphate in the patient's liver was elevated. Two types of electrophoresis showed absence of one enzymatically active zone and overall decrease of staining intensity for alpha-glycerophosphate dehydrogenase. Other liver enzymes tested were normal. The 50% inhibition of the patient's liver fructose-1,6-diphosphatase by alpha-glycerophosphate occurred, in vitro, or lower concentration than in controls (11 versus 22-40 mM). Electron microscopy revealed hepatocytes with moderately swollen mitochondria that very occasionally contained dense inclusions in the inner mitochondrial matrix. After discharge from the hospital, the patient followed a normal course, with a regimen of multiple snacks and avoidance of high-fat food in the morning.

Glycerol oxidation in rat brain: subcellular localization and kinetic characteristics

The oxidation of [1,3-14C] glycerol to 14CO was measured in slices, whole homogenates, and subcellular fractions of rat brain. In all of these tissue preparations, the Lineweaver-Burk plots of glycerol oxidation were biphasic, yielding two apparent Km and V values. Similar kinetic characteristics were obtained with brain homogenates from guinea pig, mouse, rabbit, monkey, and pig. In other tissues of the rat, including heart, kidney, liver, and skeletal muscle, the Lineweaver-Burk plots for glycerol oxidation were not biphasic but were linear. Heating the brain homogenates for five minutes at 5 degrees C caused a 50% decrease in the rate of oxidation of glycerol without a change in the biphasic double reciprocal plot. The addition of purified glycerol kinase (EC 2.7.1.30) to the homogenate caused an increase in the rate of oxidation and resulted in linear Lineweaver-Burke plot. Brain mitochondria were prepared by two different methods, both of which yielded an enrichment of glycerol oxidation. In contrast, the rate of glucose oxidation was higher in homogenates than in mitochondria, and glucose competed with glycerol as substrate only extramitochondrially. The effects of various metabolic inhibitors suggested the participation of intact, coupled mitochondria, of glycolytic enzymes, and of electron transport in the oxidation of glycerol. The data support the primary localization of glycerol oxidation in nonsynaptic mitochondria in brain and the presence in that organelle of enzymes of the Embden-Meyerhoff pathway or an as yet unidentified system for oxidizing this compound.