Simple diagnostic tests to detect toxic alcohol intoxications

An enzymatic assay with formate oxidase for point-of-care diagnosis of methanol poisoning

Gas chromatographic analysis for quantification of plasma methanol requires laboratory equipment and personnel, and it is typically unavailable in short time notice, especially in low- and middle-income countries. Detection of formate with the enzyme formate oxidase (FOX) is a promising method that can make the diagnosis of methanol poisoning simple and fast. The aims of this study were to test the sensitivity and specificity of a modified FOX-enzyme and to test the specificity of a point-of-care (POC)-model containing FOX-enzyme with samples from patients with metabolic acidosis. The sensitivity and specificity of FOX-enzyme in aqueous solution were evaluated with a spectrometer and by visual detection for colour change. Formate concentrations between 1 and 20 mmol/L were used to test sensitivity, and 18 potentially interfering substances were tested for specificity. The sensitivity of the FOX-enzyme was 100% and the specificity 97%. When specificity of the POC-model was tested, no false positives were detected. As such, the sensitivity and specificity of this modified FOX-enzyme for detection of formate were high. The results with this enzyme confirm the potential for its use in formate analysis as a fast diagnosis of methanol poisoning.

Screening Methanol Poisoning with a Portable Breath Detector

Methanol poisoning outbreaks after consumption of adulterated alcohol frequently overwhelm health care facilities in developing countries. Here, we present how a recently developed low-cost and handheld breath detector can serve as a noninvasive and rapid diagnostic tool for methanol poisoning. The detector combines a separation column and a micromachined chemoresistive gas sensor fully integrated into a device that communicates wirelessly with a smartphone. The performance of the detector is validated with methanol-spiked breath of 20 volunteers (105 breath samples) after consumption of alcoholic beverages. Breath methanol concentrations were quantified accurately within 2 min in the full breath-relevant range (10-1000 ppm) in excellent agreement (R² = 0.966) with benchtop mass spectrometry. Bland-Altman analysis revealed sufficient limits of agreement (95% confidence intervals), promising to indicate reliably the clinical need for antidote and hemodialysis treatment. This simple-in-use detector features high diagnostic capability for accurate measurement of methanol in spiked breath, promising for rapid screening of methanol poisoning and assessment of severity. It can be applied readily by first responders to distinguish methanol from ethanol poisoning and monitor in real time the subsequent hospital treatment.

Long-term changes of salivary exoglycosidases and their applicability as chronic alcohol-drinking and dependence markers

OBJECTIVES

Investigation of long-term dynamic changes of salivary activity/output of exoglycosidases, deglycosylation processes and their applicability as alcohol markers.

METHODS

Exoglycosidase (α-fucosidase (FUC), β-galactosidase (GAL), β-glucuronidase (GLU), β-hexosaminidase (HEX, HEX A and HEX B isoenzymes) and α-mannosidase (MAN)) activities were measured in the saliva of healthy social drinking controls (C), alcohol-dependent non-smokers (ANS) and alcohol-dependent smokers (AS) at the 1st, 15th, 30th and 50th day of abstinence after chronic alcohol drinking.

RESULTS

The activity of exoglycosidases was 2-3-fold (MAN), 2-6 fold (FUC), 8-25-fold (HEX A) and 19-40-fold (GLU) higher in the ANS and AS groups than in controls, and had good/excellent sensitivity, specificity and accuracy. The higher outputs of exoglycosidases were in the AS and ANS groups than in controls at the 1st day (GLU, HEX A) and at the 50th day (GLU, FUC, MAN) of abstinence. We found numerous correlations between alcohol-drinking days with GLU and HEX A, alcohol amounts with HEX A and duration of alcohol dependence with FUC and MAN activity/output.

CONCLUSIONS

Salivary exoglycosidases/deglycosylation processes were still very high up to 50 days after the end of alcohol consumption. We found markers of chronic alcohol consumption (HEX A), alcohol dependence (FUC and MAN) and chronic alcohol consumption and dependence (GLU).

Detection and quantitative determination of diethylene glycol in ethyl alcohol using gamma- ray spectroscopy

Determination of the toxic diethylene glycol contamination in ethyl alcohol demands a rapid, accurate and reliable method. Diethylene glycol (DEG) ingestion, accidental or intentional, can lead to death. Clinical and analytical methods used to detect diethylene glycol in alcohol require several hours to days due to tedious instrument handling and measurements. Enzymatic assays face difficulty due to analytic problems. As an alternative method of data analysis, we have used γ-ray spectroscopic method to estimate the diethylene glycol contamination in alcohol by monitoring the variation in the linear and mass attenuation coefficients. This method is simple, robust, portable and can provide reliable and quantitative information about the ethyl alcohol adulterated with diethylene glycol which is of broader interest to society.

Diagnosis of toxic alcohols: limitations of present methods

CONTEXT

Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxications are associated with cellular dysfunction and an increased risk of death. Adverse effects can develop quickly; thus, there is a need for methods for rapidly detecting their presence.

OBJECTIVE

To examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure.

METHODS

I searched MEDLINE for articles published between 1969 and 2014 using the terms: toxic alcohols, serum osmolality, serum osmol gap, serum anion gap, metabolic acidosis, methanol, ethylene glycol, diethylene glycol, propylene glycol, and fomepizole. Each article was reviewed for additional references.

RESULTS

The diagnosis of toxic alcohol exposure is often made on the basis of this history and physical findings along with an increase in the serum osmol and anion gaps. However, an increase in the osmol and/or anion gaps is not always present. Definitive detection in blood requires gas or liquid chromatography, laborious and expensive procedures which are not always available. Newer methods including a qualitative colorimetric test for detection of all alcohols or enzymatic tests for a specific alcohol might allow for more rapid diagnosis.

CONCLUSIONS

Exposure to toxic alcohols is associated with cellular dysfunction and increased risk of death. Treatment, if initiated early, can markedly improve outcome, but present methods of diagnosis including changes in serum osmol and anion gap, and use of gas or liquid chromatography have important limitations. Development of more rapid and effective tests for detection of these intoxications is essential for optimal care of patients.

Diethylene glycol poisoning from transcutaneous absorption

A case of transcutaneous diethylene glycol poisoning with severe acute kidney injury, but a positive outcome, is described. A man without significant medical history was admitted to our hospital due to anuria, gastrointestinal symptoms, and hypertension. Ultrasonography excluded vascular damage and postrenal obstruction. Laboratory tests showed acute kidney injury and metabolic acidosis with increased anion gap; hemodialysis therapy was started. The brother of the patient reported that the patient had been smearing his skin with brake fluid containing diethylene glycol to treat a "dermatitis." Only supportive therapy was given due to the lack of a specific antidote. Continuous venovenous hemofiltration was performed. The kidney biopsy showed acute toxic proximal tubulonecrosis, without deposition of oxalate crystals. His neurologic condition worsened dramatically; supportive care was continued. Over time, acute kidney injury and neurologic damage gradually improved; 33 days after admission, he went to a rehabilitation unit for 5 months, with complete clinical recovery. Historically, diethylene glycol has been the cause of large-scale poisonings from ingestion of contaminated drugs. The clinical evolution is unpredictable. Treatment is not well defined; early hemodialysis treatment reduces levels of toxic metabolites, and fomepizole could be useful in cases with an early diagnosis. A comparison of the characteristics of diethylene glycol versus ethylene glycol poisoning is given.

Challenges in the diagnosis of ethylene glycol poisoning

Ethylene glycol poisoning, while uncommon, is clinically significant due to the associated risk of severe morbidity or lethality and it continues to occur in many countries around the world. The clinical presentation of ethylene glycol toxicity, while classically described in three phases, varies widely and when combined with the range of differential diagnoses that must be considered makes diagnosis challenging. Early and accurate detection is important in these patients, however, as there is a need to start antidotal treatment early to prevent serious harm. In this article, we will review the literature and provide guidance regarding the diagnosis of ethylene glycol poisoning. While gas chromatography is the gold standard, the usefulness of this test is hampered by delays in access due to availability. Consequently, there are several surrogate markers that can give an indication of ethylene glycol exposure but these must be interpreted with caution and within the clinical context. An in-depth review of these tests, particularly the detection of a raised osmolar gap or an raised anion gap acidosis, will form the main focus of this article.

Salivary hexosaminidase in smoking alcoholics with bad periodontal and dental states

BACKGROUND

A sensitive alcohol marker, β-hexosaminidase (HEX), in the saliva of alcoholics, is investigated for the first time.

METHODS

The activity, specific-activity and output of total HEX and its isoenzymes HEX A and HEX B were measured in the saliva of healthy controls (C), alcohol-dependent non-smokers (ANS), and alcohol-dependent smokers (AS).

RESULTS

We observed a significantly increased activity/specific-activity and output of HEX A in the ANS and AS groups, due to the inflammatory state of the oral-cavity/salivary-glands. Significantly increased activity of HEX A contributed to an increase in the salivary activity of the total HEX in the ANS group. A significant decrease in the activity/specific-activity of HEX B in AS seemed to be due to HEX B inactivation by cigarette smoke. We noticed a tendency for deteriorated dental state (lower decayed-missing-filled-teeth index - DMFT), worse periodontal state (higher gingival index - GI and papilla-bleeding index - PBI) in AS, and worse periodontal state (higher GI) in ANS, as compared to the controls. We found no differences in the salivary protein concentrations between all groups and decreased salivary flow in both alcoholic groups as compared to the controls. In alcoholics, the area under the curve (AUC) for HEX A activity/specific-activity was significantly greater than for HEX and HEX B. The salivary HEX A activity/specific-activity had good/excellent sensitivity and specificity in smoking and non-smoking alcoholics, whereas salivary HEX and HEX B had poor/fair sensitivity and specificity.

CONCLUSIONS

Salivary HEX A may be helpful in the diagnosis of chronic alcohol intoxication, even in smokers.

Ethylene glycol poisoning: quintessential clinical toxicology; analytical conundrum

Ethylene glycol poisoning is a medical emergency that presents challenges both for clinicians and clinical laboratories. Untreated, it may cause morbidly or death, but effective therapy is available, if administered timely. However, the diagnosis of ethylene glycol poisoning is not always straightforward. Thus, measurement of serum ethylene glycol, and ideally glycolic acid, its major toxic metabolite in serum, is definitive. Yet measurement of these structurally rather simple compounds is but simple. This review encompasses an assessment of analytical methods for the analytes relevant for the diagnosis and prognosis of ethylene glycol poisoning and of the role of the ethylene glycol metabolites, glycolic and oxalic acids, in its toxicity.