Fatal poisoning with diethylene glycol in an unusual setting

Thrombotic Microangiopathy and Acute Tubular Injury After Diethylene Glycol Ingestion: A Kidney Biopsy Teaching Case

We present a rare and unusual case of thrombotic microangiopathy (TMA) in a patient who ingested chafing fuel containing diethylene glycol. The patient showed a typical clinical course of initial gastrointestinal symptoms followed by acute kidney injury (AKI) and peripheral sensorimotor neuropathy. A kidney biopsy showed TMA and diffuse acute tubular injury. Diethylene glycol is widely used as a solvent in numerous consumer products, including brake fluid, antifreeze, chafing fuel, and artificial fog solutions. Diethylene glycol has been implemented in mass poisonings, and the incidence of AKI in diethylene glycol poisonings is linked to high-mortality rates. TMA, a pathologic lesion observed in a wide spectrum of diseases, is triggered by endothelial injury. Our case shows that TMA should be considered as a possible life-threatening complication in the setting of acute diethylene glycol poisoning. Direct toxic injury to endothelial cells by diethylene glycol is a possible mechanism. It is therefore plausible that patients with a genetic predisposition to endothelial injury may develop TMA following diethylene glycol exposure.

Renal toxicity caused by diethylene glycol: an overview

Diethylene glycol (DEG) is nephrotoxic, potentially resulting in high morbidity and mortality. Its main nephrotoxic by-product is diglycolic acid (DGA). This narrative overview summarizes selected literature with a focus on clinical findings, pathophysiology, diagnosis including morphological features of renal biopsies, and management. The kidney injury in DEG poisoning is secondary to proximal tubular necrosis caused by DGA. Marked vacuolization and edema of epithelial cells obstruct the lumen, reducing urine flow and, consequently, resulting in anuria and uremia. The clinical alterations due to DEG poisoning are dose-dependent. Patients may present with gastrointestinal symptoms and anion gap metabolic acidosis, followed by renal failure, and, later, encephalopathy and neuropathy. Although this three-phase pattern has been described, signs and symptoms may be overlapping. Data about DEG intoxication is scarce. Sometimes the diagnosis is challenging. The management includes supportive care, gastric decontamination, correction of acid-base disorders, and hemodialysis. The understanding of the metabolic processes related to DEG poisoning may contribute to its management, preventing death, serious sequels, or irreversible lesions.

Diethylene glycol and its metabolites induce cell death in SH-SY5Y neuronal cells in vitro

Diethylene glycol (DEG) intoxication results in metabolic acidosis, renal and hepatic dysfunction, and late-stage neurotoxicity. Though the renal and hepatic toxicity of DEG and its metabolites 2-hydroxyethoxyacetic acid (2-HEAA) and diglycolic acid (DGA) have been well characterized, the resultant neurotoxicity has not. SH-SY5Y neuroblastoma cells were incubated with all 3 compounds at increasing concentrations for 24, 48, or 120 h. At all 3 time points, 50 mmol/L DGA and 100 mmol/L DEG showed significant Annexin V and propidium iodide (PI) staining with additional concentrations showing similar staining patterns at 24 h (100 mmol/L DGA) and 48 h (50 mmol/L DEG, 100 mmol/L DGA). Only the 200 mmol/L 2-HEAA concentration induced SH-SY5Y cell death. Interestingly at 24 and 48 h, 100 mmol/L DEG induced significant increases in apoptotic cell death markers, which progressed to necrosis at 120 h. Similar to DEG, 50 mmol/L DGA induced significant increases in SH-SY5Y cell apoptosis and necrosis markers at both 24 and 48 h. As expected, high DGA concentrations (100 mmol/L) at 120 h induced significant SH-SY5Y cell necrosis with no apoptosis detected. However, at 120 h lower DGA concentrations (20 mmol/L) significantly increased oligonucleosome formation alone and in combination with 2-HEAA or DEG. Taken together, these results indicate that DGA and DEG at threshold concentrations induce neurotoxicity in SH-SY5Y cells.