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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [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] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Crenshaw BL, McMartin KE. Calcium Oxalate Monohydrate is Associated with Endothelial Cell Toxicity But Not with Reactive Oxygen Species Accumulation. Cardiovasc Toxicol 2020; 20:593-603. [PMID: 32588315 DOI: 10.1007/s12012-020-09584-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
One characteristic of ethylene glycol overdose is a cardiopulmonary syndrome including hypertension and pulmonary edema with pathology indicating damage to the endothelium of heart, lung and brain vessels. The mechanism of the cardiopulmonary toxicity is unknown, but has been linked with accumulation of the metabolite calcium oxalate monohydrate (COM) in the endothelium. These studies have evaluated the hypothesis that COM or the oxalate ion produces endothelial damage in vitro and that damage is linked with induction of reactive oxygen species (ROS). In cultured human umbilical vein endothelial cells (HUVEC), COM, but not the oxalate ion, produced cytotoxicity in a dose- and time-dependent manner. Using three ROS-sensitive dyes, HUVEC exposed to COM did not significantly increase ROS production. Additionally, co-treatment with three antioxidants that operate by different mechanisms did not reduce COM cytotoxicity. As such, an increase in ROS production does not explain cell death in endothelial cells. Aluminum citrate, uniquely among citrate compounds, significantly reduced COM cytotoxicity to endothelial cells and thus may act as an adjunct therapy for ethylene glycol poisoning to reduce endothelial damage. These results imply that accumulation of COM in endothelial cells is an important aspect of the cardiopulmonary toxicity from ethylene glycol.
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Affiliation(s)
- Brian L Crenshaw
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, 71130-3932, USA
| | - Kenneth E McMartin
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, 71130-3932, USA.
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Basal Ganglion Hemorrhage as Delayed Complication of Diethylene Glycol Ingestion. Am J Forensic Med Pathol 2017; 38:39-42. [PMID: 28085681 DOI: 10.1097/paf.0000000000000295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Diethylene glycol (DEG), an organic compound (HOCH2CH2)2O is a commonly used solvent. Mass poisoning outbreaks have been reported because of frequent contaminations. A PubMed search for diethylene resulted in 795 publications with 151 specifically discussing the toxicity. Of the 151 reported toxicity reviews/case reports, only 6 publications discussed the long-term neurological effects of diethylene toxicity. We report a fatal case of oral ingestion of DEG with complications from delayed toxicity. She died 7 days after the second admission. Autopsy disclosed a right basal ganglia hemorrhage within the brain and microscopic deposits of polarizable crystals into small cerebral blood vessels. Both kidneys illustrate tubular necrosis with scattered tubular deposition of polarizable calcium oxalate crystals. PubMed search leads to only 2 reported cases of basal ganglia hemorrhage (based on radiological findings) after ethylene glycol intoxication. Our case is the first reportable case of basal ganglia hemorrhage after DEG ingestion.
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Boukobza M, Baud FJ, Gourlain H, Champion S, Malissin I, Mégarbane B. Neuroimaging findings and follow-up in two cases of severe ethylene glycol intoxication with full recovery. J Neurol Sci 2015; 359:343-6. [PMID: 26671139 DOI: 10.1016/j.jns.2015.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 11/04/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Monique Boukobza
- Medical and Toxicological Intensive Care Unit, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France.
| | - Frédéric J Baud
- Medical and Toxicological Intensive Care Unit, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France; Université Paris Sorbonne Cité, Paris Diderot, Paris, France; UMR-8536, Université Paris Descartes, Paris, France.
| | - Hervé Gourlain
- Laboratory of Toxicology, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France.
| | - Sébastien Champion
- Medical and Toxicological Intensive Care Unit, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France.
| | - Isabelle Malissin
- Medical and Toxicological Intensive Care Unit, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France.
| | - Bruno Mégarbane
- Medical and Toxicological Intensive Care Unit, Assistance Publique, Hôpitaux de Paris, Groupe Hospitalier Lariboisière, Saint Louis, Paris, France; Université Paris Sorbonne Cité, Paris Diderot, Paris, France; INSERM U1144, Paris, France.
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Zoja R, Andreola S, Gentile G, Palazzo E, Piga M, Rancati A. Histopathological findings of medico-legal significance in delayed death from ethylene glycol poisoning. AUST J FORENSIC SCI 2013. [DOI: 10.1080/00450618.2012.702787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Beatty L, Green R, Magee K, Zed P. A systematic review of ethanol and fomepizole use in toxic alcohol ingestions. Emerg Med Int 2013; 2013:638057. [PMID: 23431453 PMCID: PMC3574646 DOI: 10.1155/2013/638057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/25/2012] [Indexed: 11/26/2022] Open
Abstract
Objectives. The optimal antidote for the treatment of ethylene glycol or methanol intoxication is not known. The objective of this systematic review is to describe all available data on the use of ethanol and fomepizole for methanol and ethylene glycol intoxication. Data Source. A systematic search of MEDLINE and EMBASE was conducted. Study Selection. Published studies involving the use of ethanol or fomepizole, or both, in adults who presented within 72 hours of toxic alcohol ingestion were included. Our search yielded a total of 145 studies for our analysis. There were no randomized controlled trials, and no head-to-head trials. Data Extraction. Variables were evaluated for all publications by one independent author using a standardized data collection form. Data Synthesis. 897 patients with toxic alcohol ingestion were identified. 720 (80.3%) were treated with ethanol (505 Me, 215 EG), 146 (16.3%) with fomepizole (81 Me, 65 EG), and 33 (3.7%) with both antidotes (18 Me, 15 EG). Mortality in patients treated with ethanol was 21.8% for Me and 18.1% for EG. In those administered fomepizole, mortality was 17.1% for Me and 4.1% for EG. Adverse events were uncommon. Conclusion. The data supporting the use of one antidote is inconclusive. Further investigation is warranted.
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Affiliation(s)
- Lorri Beatty
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Robert Green
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
- Division of Critical Care Medicine, Department of Anesthesia, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Kirk Magee
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Peter Zed
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada V6T 1Z3
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Park SY, Kim YN, Kim NY. The analysis of ethylene glycol and metabolites in biological specimens. ANALYTICAL SCIENCE AND TECHNOLOGY 2011. [DOI: 10.5806/ast.2011.24.2.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Reddy NJ, Sudini M, Lewis LD. Delayed neurological sequelae from ethylene glycol, diethylene glycol and methanol poisonings. Clin Toxicol (Phila) 2011; 48:967-73. [PMID: 21192754 DOI: 10.3109/15563650.2010.532803] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Ethylene glycol, diethylene glycol and methanol are widely available chemicals and are found in a variety of common household products including antifreeze, windshield washer fluid, brake fluid and lubricants. Following ingestion of these glycols and methanol, patients frequently develop an early neurological syndrome consisting of inebriation, ataxia, and if severe, seizures and coma. Though uncommon, a neurological syndrome may also develop as a delayed complication. METHODS Using Pub Med 438 references were identified of which 45 were relevant. FEATURES Ethylene glycol poisoning has produced cranial nerve deficits (usually VII nerve dysfunction) after a delay of 5-20 days, Parkinsonism and cerebral edema. Diethylene glycol ingestion has been associated with the development of optic nerve injury, cranial nerve deficits, quadraparesis and peripheral neuropathy. Methanol poisoning has led to Parkinsonism and polyneuropathy. MECHANISMS OF TOXICITY Oxalate crystal deposition likely causes the cranial neuropathies related to ethylene glycol and 2-hydroxyethoxyacetic acid is thought to be the causal moiety in cranial neuropathies resulting from diethylene glycol toxicity. Formic acid is implicated in the optic nerve damage associated with methanol. CONCLUSIONS Uncommonly, delayed neurological syndromes may develop as complications of poisoning due to ethylene glycol, diethylene glycol and methanol; the onset of such neurological damage is often days or even weeks post-ingestion. Further research is required to explain why the facial nerve is the cranial nerve most commonly involved and why the basal ganglia are predisposed to injury.
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Affiliation(s)
- Nandi J Reddy
- Section of Clinical Pharmacology and Toxicology, Department of Medicine, Dartmouth Medical School & Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Wollersen H, Erdmann F, Risse M, Dettmeyer R. Oxalate-crystals in different tissues following intoxication with ethylene glycol: three case reports. Leg Med (Tokyo) 2009; 11 Suppl 1:S488-90. [PMID: 19251453 DOI: 10.1016/j.legalmed.2009.01.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 01/14/2009] [Indexed: 11/28/2022]
Abstract
Three alcoholics (62 years, 47 years, 83 years) died between 11 and 18 h after ingestion of ethylene glycol (EG). One person committed suicide. Observed symptoms of intoxication were seizures, respiratory depression, arrhythmias and hypotonia. All died in hospital after failed attempts at resuscitation, one person did so after an 11h dialysis treatment. EG was detected in blood in concentrations of between 1 and 3mg/L (toxic range: >0.3mg/L). One case presented a blood alcohol concentration (bac) of 1.14 per thousand. Further toxic substances were not found. Using special staining techniques, oxalate crystals were found in samples from the kidneys, explaining renal failure, and in the medial layer of cerebral vessels.
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Affiliation(s)
- Heike Wollersen
- Institute of Forensic Medicine, University of Giessen, Frankfurter Str. 58, 35392 Giessen, Germany.
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Stapenhorst L, Hesse A, Hoppe B. Hyperoxaluria after ethylene glycol poisoning. Pediatr Nephrol 2008; 23:2277-9. [PMID: 18696123 DOI: 10.1007/s00467-008-0917-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 04/13/2008] [Accepted: 05/19/2008] [Indexed: 12/12/2022]
Abstract
Treatment of otherwise lethal ethylene glycol poisoning depends on rapid diagnosis, aggressive supportive care, appropriate use of alcohol dehydrogenase inhibitors and, in selected patients, hemodialysis. Next to that, specific measures to prevent renal or systemic calcium-oxalate deposition are important. We report the case of a 12-year-old girl who ingested more than five times the lethal dosis of ethylene glycol in a suicide attempt. At admission her serum ethylene glycol concentration was 88 mg/dl. Under treatment by ethanol infusions to block the alcohol dehydrogenase and by hemodialysis to eliminate ethylene glycol and its toxic metabolites, this level decreased to below 15 mg/dl within 36 h. The plasma oxalate level, however, rose to a maximum of 89 micromol/l (normal <6.3 +/- 1.1) on day 3 and only normalized on day 7 after ingestion. In addition, urinary oxalate excretion was elevated (maximum 1.16 mmol/1.73 m(2)/24 h). Both lead to calcium-oxalate oversaturation and hence to the risk of local (renal) or systemic crystal deposition. Therefore, alkaline citrate was given as a preventive measure to increase urinary oxalate solubility, but nephrocalcinosis still developed. Metabolic acidosis, hypocalcaemia, and neurological symptoms had not occurred. Four weeks after discharge, both plasma and urinary oxalate levels were normal.
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Affiliation(s)
- Ludwig Stapenhorst
- Department of Pediatrics, University Children's Hospital, 50924, Cologne, Germany.
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Froberg K, Dorion RP, McMartin KE. The Role of Calcium Oxalate Crystal Deposition in Cerebral Vessels During Ethylene Glycol Poisoning. Clin Toxicol (Phila) 2008; 44:315-8. [PMID: 16749551 DOI: 10.1080/15563650600588460] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Ethylene glycol (EG) poisoning can lead to serious morbidity or death, which occurs following conversion of ethylene glycol to toxic metabolites. These metabolites affect multiple organ/systems leading to metabolic acidosis, cardiopulmonary depression, acute renal failure and central nervous system deficits. Treatment consists of correcting metabolic acidosis with bicarbonate administration, dialysis to remove toxic metabolites and administration of fomepizole or ethanol to prevent conversion of EG to toxic intermediates. Occasionally in the literature, fatal cases of EG poisoning have been described in which calcium oxalate crystal deposition has occurred in the walls of CNS vessels, sometimes with associated neuropathy. We describe a case of fatal EG poisoning in which the development of rapid cerebral edema was documented by CT scan and was accompanied by definitive evidence of birefringent crystals within walls of CNS blood vessels, with associated inflammation and edema. This case and others in the literature suggest that cerebral edema, and perhaps injury to other organs, could result from oxalate crystal deposition in small blood vessels in the brain and other organs.
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Affiliation(s)
- K Froberg
- Department of Pathology, University of Minnesota School of Medicine, Duluth, USA
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12
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Takahashi S, Kanetake J, Kanawaku Y, Funayama M. Brain death with calcium oxalate deposition in the kidney: Clue to the diagnosis of ethylene glycol poisoning. Leg Med (Tokyo) 2008; 10:43-5. [DOI: 10.1016/j.legalmed.2007.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 05/21/2007] [Accepted: 05/28/2007] [Indexed: 11/27/2022]
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Reddy NJ, Lewis LD, Gardner TB, Osterling W, Eskey CJ, Nierenberg DW. Two cases of rapid onset Parkinson's syndrome following toxic ingestion of ethylene glycol and methanol. Clin Pharmacol Ther 2007; 81:114-21. [PMID: 17186009 DOI: 10.1038/sj.clpt.6100013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Ethylene glycol and methanol are toxic alcohols commonly found in a variety of commercial products. We report two cases, one associated with ethylene glycol and one with methanol poisoning, which both led to acute hemorrhagic necrosis of the basal ganglia and resulted in acute Parkinson's syndrome. It is unlikely that oxalate crystal deposition is the only mechanism for such basal ganglia necrosis, because similar findings were seen following methanol intoxication. We discuss other possible mechanisms that may contribute towards this unusual neurotoxicity. Both of our patients survived their toxic ingestions, but then developed acute Parkinson's syndrome within 10 days of the ingestion. However, the patient who ingested methanol developed respiratory muscle stiffness/weakness, which responded poorly to anti-Parkinsonian drug therapy. Treatment with carbidopa/levodopa improved cogwheel rigidity and bradykinesia in both patients. We conclude that acute Parkinsonism is one of the lesser-recognized devastating complications of both ethylene glycol and methanol poisoning.
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Affiliation(s)
- N J Reddy
- Section of Clinical Pharmacology and Toxicology, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abstract
We report a case of a 75-year-old hypertensive, diabetic man who presented to the emergency room with symptoms and signs of nausea, acute intoxication, significant alteration in mental status with rapid neurologic deterioration, and blunt impact injuries sustained during a recent altercation with a 36-year-old female companion-caretaker. He denied a history of ethanol abuse or other recent toxic ingestion and had not been diagnosed with or treated for depression. Hospital laboratory tests revealed a metabolic acidosis and a negative urine toxicology screen. He was diagnosed with toxic encephalopathy with metabolic acidosis secondary to metformin. Despite treatments including hemodialysis, he expired after approximately 28 hours of hospitalization. A postmortem anatomic examination revealed recent blunt-impact injuries and cardiac and renal pathology. A subsequent histologic examination revealed the presence of calcium oxalate crystals in the kidneys and brain, in addition to cardiac and renal pathology. Comprehensive forensic toxicologic testing was performed on antemortem and postmortem samples and revealed lethal levels of ethylene glycol. The cause of death was as a result of acute intoxication by ethylene glycol with another condition of multiple blunt impacts to the head, trunk, and extremities. The manner of death was ruled as homicide. A trial by jury, involving the female companion-caretaker, resulted in her conviction, and she was sentenced to 23 years to life in prison. In this report, we present an unusual case of homicidal ethylene glycol intoxication in which legal proceedings have occurred.
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15
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Hantson P, Duprez T. The Value of Morphological Neuroimaging after Acute Exposure to Toxic Substances. ACTA ACUST UNITED AC 2006; 25:87-98. [PMID: 16958556 DOI: 10.2165/00139709-200625020-00003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Many toxic agents induce brain dysfunction and/or lesions. Modern neuroimaging techniques, such as CT and more recently magnetic resonance imaging (MRI), are able to demonstrate toxic brain lesions at both early and delayed phases of disease progression. In the early phase, neuroimaging enables the detection of acutely injured brain areas responsible for sudden onset of neurological dysfunction, but the severity and the extension of brain lesions on neuroimages do not necessarily parallel the severity of the clinical status. In the chronic phase, when neurological dysfunction has become permanent, neuroimaging allows precise identification of neuroanatomical sequelae that do not necessarily match the severity of the chronic neurological impairment. Papers in the medical imaging literature have dealt mainly with the brain changes induced by 'chronic exposure' to toxic substances such as solvents or heavy metals. This article selectively reviews the main radiological changes observed on CT/magnetic resonance (MR) neuroimages after 'acute exposure' to industrial products (methanol [methyl alcohol], ethylene glycol), environmental agents (cyanide, carbon monoxide), pharmaceuticals (insulin, valproic acid) and illicit substances (heroin, cocaine). Different kinds of lesions, which lack specificity for toxic injury, can be observed on radiological images, but deep grey matter lesions with symmetrical distribution throughout basal ganglia are most often seen. However, such findings have also been reported after anoxic-ischaemic insults or during severe metabolic disturbances. Lesions in the white matter may also be present in the case of acute exposure to toxic agents. The true prognostic value of toxic-induced brain changes in the acute phase in CT or MR studies is unclear, although serial MRI may add new information as may quantitative or molecular imaging techniques such as the MR diffusion-weighted imaging or MR spectroscopy.
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Affiliation(s)
- Philippe Hantson
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium.
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Wolff M, Schaefer N, Rabe C, Spengler U, Hirner A. Successful transplantation of a liver from a donor with fatal ethylene glycol poisoning. Liver Transpl 2005; 11:990-2. [PMID: 16035082 DOI: 10.1002/lt.20530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Martin Wolff
- Department of Surgery, University of Bonn, Germany.
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Musshoff F, Padosch S, Steinborn S, Madea B. Fatal blood and tissue concentrations of more than 200 drugs. Forensic Sci Int 2004; 142:161-210. [PMID: 15172079 DOI: 10.1016/j.forsciint.2004.02.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.
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Affiliation(s)
- F Musshoff
- Institute of Legal Medicine, Rheinische Friedrich-Wilhelms-University, Stiftsplatz 12, Bonn 53111, Germany.
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