Treatment of the alcohol intoxications: ethylene glycol, methanol and isopropanol

When Vaping Isn't Actually Safer: A Death From Toxic Alcohol Contaminated Vape Juice

ABSTRACT

Vape juice is a diluent for e-cigarette active ingredients, nicotine or tetrahydrocannabinol (THC). Lack of strict regulation in vape juice production is a concern as ingredients and their concentrations may vary widely from the labeling.A 43-year-old woman was transported via ambulance to the hospital after ingesting homemade vape juice, presenting unresponsive with decerebrate posturing. She reportedly made a tincture combining a vape juice purchased online (containing "ethylene glycol") and THC for "endometriosis-related pain relief." Laboratory evaluation revealed anion gap metabolic acidosis, elevated serum lactate, and high serum osmolality. Urine fluoresced under Wood's lamp, and fomepizole was administered as an ethylene glycol antidote, but she expired the following afternoon. Clinical serum toxicology results returned after death revealed 235 mg/dL of methanol, and no ethylene glycol.Autopsy findings included ischemic changes of the gastrointestinal tract and cerebral edema with herniation. Postmortem toxicology performed on hospital admission blood revealed methanol (220 mg/dL), propylene glycol (59 mg/dL), Δ-9 THC and metabolites, and medications administered during hospitalization. The medical examiner determined the cause of death to be methanol and propylene glycol toxicity.To our knowledge, this is the first report of accidental death from ingestion of vape juice contaminated with toxic alcohol.

Isopropyl Alcohol Intoxication Treated With Hemodialysis: A Case Report and Short Review

Isopropyl alcohol (IPA) is a common constituent of rubbing alcohol, household cleaning agents, and antiseptic agents. Ingestion of IPA usually leads to self-resolving mild symptoms in most cases but can result in severe symptoms, including central nervous system depression or hemodynamic instability. Treatment is mainly supportive, and hemodialysis is generally reserved for severe intoxication. Limited data are available on the use of hemodialysis to treat IPA intoxication. We are presenting a case of accidental ingestion of IPA in an elderly female with dementia leading to severe intoxication requiring hemodialysis at relatively non-toxic serum levels of IPA. The patient had a prompt recovery without any post-procedural or hospital-acquired complications.

Exploration of the Different Dimensions of Wurtzite ZnO Structure Nanomaterials as Gas Sensors at Room Temperature

In this work, we report on the synthesis of four morphologies of ZnO, namely, nanoparticles, nanorods, nanosheets, and nanoflowers, from a single precursor Zn(CH3COO)2·2H2O under different reaction conditions. The synthesised nanostructured materials were characterised using powder X-ray diffraction (XRD), Fourier transform infrared (FTIR) and Raman spectroscopy, UV-Vis, XPS analysis, transmission electron microscopy (TEM), scanning electron microscopy (SEM), and nitrogen sorption at 77 K. The XRD, FTIR, and Raman analyses did not reveal any significant differences among the nanostructures, but differences in the electronic properties were noted among the different morphologies. The TEM and SEM analyses confirmed the four different morphologies of the ZnO nanostructures. The textural characteristics revealed that the specific surface areas were different, being 1.3, 6.7, 12.7, and 26.8 m2/g for the nanoflowers, nanoparticles, nanorods, and nanosheets, respectively. The ZnO nanostructures were then mixed with carbon nanoparticles (CNPs) and cellulose acetate (CA) to make nanocomposites that were then used as sensing materials in solid-state sensors to detect methanol, ethanol, and isopropanol vapour at room temperature. The sensors' responses were recorded in relative resistance. When detecting methanol, 6 out of 12 sensors were responsive, and the most sensitive sensor was the composite with a mass ratio of 1:1:1 of ZnO nanorods:CNPs:CA with a sensitivity of 0.7740 Ω ppm-1. Regarding the detection of ethanol vapour, 9 of the 12 sensors were responsive, and the 3:1:1 mass ratio with ZnO nanoparticles was the most sensitive at 4.3204 Ω ppm-1. Meanwhile, with isopropanol, 5 out of the 12 sensors were active and, with a sensitivity of 3.4539 Ω ppm-1, the ZnO nanoparticles in a 3:1:1 mass ratio were the most sensitive. Overall, the response of the sensors depended on the morphology of the nanostructured ZnO materials, the mass ratio of the sensing materials in the composites, and the type of analyte. The sensing mechanism was governed by the surface reaction on the sensing materials rather than pores hindering the analyte molecules from reaching the active site, since the pore size is larger than the kinetic diameter of the analyte molecules. Generally, the sensors responded well to the ethanol analyte, rather than methanol and isopropanol. This is due to ethanol molecules displaying a more enhanced electron-donating ability.

Elevated Anion Gap Metabolic Acidosis With High Osmolar Gap and Increased Serum Acetone Level: A Case Report

Acetone poisoning, although not very common, can present with varied signs and symptoms. High acetone levels in serum can be due to exogenous exposure or endogenous production of acetone. Unlike certain alcohol toxicities, acetone does not cause high anion gap metabolic acidosis.

A 69-year-old male presented to our service with shock and acute encephalopathy and required intensive care support. Initial laboratory investigation showed high anion gap metabolic acidosis with high osmolar gap. Serum acetone level was elevated. Clinicians need to be aware of how to elucidate such metabolic disturbances and associated toxicities.

Case Report: Early Recognition, Treatment, and Occupational Safety Protection are Crucial for Methanol Toxicity

Background

Despite significant progress in treating methanol poisoning, the lack of training, hazard communication, and occupational safety protection education contributes to the risk of occupational exposure and methanol toxicity. In addition, early diagnosis and timely medical care are essential to reduce the risk of morbidity and mortality, yet it remains a challenging procedure.

Case Report

A 35-year-old man working in a fireworks factory came to our emergency department with acute mental change and progressive disturbance of consciousness. The patient's vital signs were stable, and he presented with enlargement of both pupils with a weak reaction to light. Head computed tomography showed low signal intensities in the bilateral basal ganglia. He was admitted to the neurologic intensive care unit, where additional laboratory workup showed high anion-gap metabolic acidosis. Methanol poisoning was thus considered. Before being treated with sodium bicarbonate infusion, hemodialysis, folate, and high-dose vitamin B, the blood and urine samples were collected for toxicity tests, which turned out to be methanol poisoning. After 8 hours of hemodialysis, the patient's consciousness recovered, but he complained of a complete loss of vision in both eyes. Brain and optic nerve magnetic resonance images showed bilateral symmetric putamen lesions and optic neuropathy. Ophthalmic tests indicated visual pathway impairment and optic disc swelling but no fluorescein leakage. The right eye's vision was partially restored on the third day, but he could only count fingers at 20 cm. Unfortunately, his eyesight ceased to improve during the 6 months of follow-up.

Conclusions

Early diagnosis and prompt treatment will improve the prognosis of methanol poisoning in terms of vision and patient survival. Awareness and supervision of commercial alcohol use are indispensable for similar industrial processes.

Lessons of the month 3: Intravenous poppers abuse: case report, management and possible complications

BACKGROUND

Poppers are nitrite-containing liquids, which are inhaled for their aphrodisiac and hallucinogenic effects. Despite some cases of severe poisonings, poppers are often perceived as harmless by consumers. Inhalation and ingestion of poppers are well known, but, according to our literature review, intravenous abuse has not been reported before.

CASE PRESENTATION

A 34-year-old man injected poppers intravenously for recreational purposes. He then suffered from dyspnoea and general discomfort. Upon arrival of emergency medical services, the patient was dyspnoeic with blue-grey skin colour and oxygen saturation was 82% on ambient air. Non-invasive ventilation was necessary, and he was transferred to the intensive care unit. Toluidine blue was administered because of a methaemoglobinaemia of 40% and methaemoglobin levels dropped to 0.4%. He was discharged home after a 24-hour observation. We additionally analysed the contents of the poppers bottle: isopropyl nitrite, isopropanol and acetone were detected. Possible complications and the treatment regarding intravenous administration of poppers are discussed.

CONCLUSION

We present the first published case of intravenous poppers abuse. Our patient suffered from methaemoglobinaemia and was rapidly discharged after treatment with toluidine blue. No specific treatment regarding the contents of the poppers bottle, apart from isopropyl nitrite, was necessary.

Gut instincts: vitamin D/vitamin D receptor and microbiome in neurodevelopment disorders

The gut microbiome regulates a relationship with the brain known as the gut–microbiota–brain (GMB) axis. This interaction is influenced by immune cells, microbial metabolites and neurotransmitters. Recent findings show gut dysbiosis is prevalent in autism spectrum disorder (ASD) as well as attention deficit hyperactivity disorder (ADHD). There are previously established negative correlations among vitamin D, vitamin D receptor (VDR) levels and severity of ASD as well as ADHD. Both vitamin D and VDR are known to regulate homeostasis in the brain and the intestinal microbiome. This review summarizes the growing relationship between vitamin D/VDR signalling and the GMB axis in ASD and ADHD. We focus on current publications and summarize the progress of GMB in neurodevelopmental disorders, describe effects and mechanisms of vitamin D/VDR in regulating the microbiome and synoptically highlight the potential applications of targeting vitamin D/VDR signalling in neurodevelopment disorders.

Intermittent versus continuous renal replacement therapy in acute methanol poisoning: comparison of clinical effectiveness in mass poisoning outbreaks

BACKGROUND

Intermittent hemodialysis (IHD) is the modality of choice in the extracorporeal treatment (ECTR) of acute methanol poisoning. However, the comparative clinical effectiveness of intermittent versus continuous modalities (CRRT) is unknown. During an outbreak of mass methanol poisoning, we therefore studied the effect of IHD versus CRRT on mortality and the prevalence of visual/central nervous system (CNS) sequelae in survivors.

METHODS

The study was designed as prospective observational cohort study. Patients hospitalized with a diagnosis of acute methanol poisoning were identified for the study. Exploratory factor analysis and multivariate logistic regression were applied to determine the effect of ECTR modality on the outcome.

RESULTS

Data were obtained from 41 patients treated with IHD and 40 patients with CRRT. The follow-up time in survivors was two years. Both groups of patients were comparable by age, time to presentation, laboratory data, clinical features, and other treatment applied. The CRRT group was more acidemic (arterial blood pH 6.96 ± 0.08 vs. 7.17 ± 0.07; p < 0.001) and more severely poisoned (25/40 vs. 9/41 patients with Glasgow Coma Scale (GCS) ≤ 8; p < 0.001). The median intensive care unit length of stay (4 (range 1-16) days vs. 4 (1-22) days; p = 0.703) and the number of patients with complications during the treatment (11/41 vs. 13/40 patients; p = 0.576) did not differ between the groups. The mortality was higher in the CRRT group (15/40 vs. 5/41; p = 0.008). The number of survivors without sequelae of poisoning was higher in the IHD group (23/41 vs. 10/40; p = 0.004). There was a significant association of ECTR modality with both mortality and the number of survivors with visual and CNS sequelae of poisoning, but this association was not present after adjustment for arterial blood pH and GCS on admission (all p > 0.05).

CONCLUSIONS

In spite of the faster correction of the acidosis and the quicker removal of the toxic metabolite in intermittent dialysis, we did not find significant differences in the treatment outcomes between the two groups after adjusting for the degree of acidemia and the severity of poisoning on admission. These findings support the strategy of "use what you have" in situations with large outbreaks and limited dialysis capacity.

Osmotic Pressure in Clinical Medicine with an Emphasis on Dialysis

Since the beginning of life of the first multicellular organisms, the preservation of a physiologic milieu for every cell in the organism has been a critical requirement. A particular range of osmolality of the body fluids is essential for the maintenance of cell volume. In humans the stability of electrolyte concentrations and their resulting osmolality in the body fluids is the consequence of complex interactions between cell membrane functions, hormonal control, thirst, and controlled kidney excretion of fluid and solutes. Knowledge of these mechanisms, of the biochemical principles of osmolality, and of the relevant situations occurring in disease is of importance to every physician. This comprehensive review summarizes the major facts on osmolality, its relation to electrolytes and other solutes, and its relevance in physiology and in disease states with a focus on dialysis-related considerations.

Severe Ketoacidosis Associated with Canagliflozin (Invokana): A Safety Concern

Canagliflozin (Invokana) is a selective sodium glucose cotransporter-2 (SGLT-2) inhibitor that was first introduced in 2013 for the treatment of type 2 diabetes mellitus (DM). Though not FDA approved yet, its use in type 1 DM has been justified by the fact that its mechanism of action is independent of insulin secretion or action. However, some serious side effects, including severe anion gap metabolic acidosis and euglycemic diabetic ketoacidosis (DKA), have been reported. Prompt identification of the causal association and initiation of appropriate therapy should be instituted for this life threatening condition.

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.

Metabolic methanol: molecular pathways and physiological roles

Methanol has been historically considered an exogenous product that leads only to pathological changes in the human body when consumed. However, in normal, healthy individuals, methanol and its short-lived oxidized product, formaldehyde, are naturally occurring compounds whose functions and origins have received limited attention. There are several sources of human physiological methanol. Fruits, vegetables, and alcoholic beverages are likely the main sources of exogenous methanol in the healthy human body. Metabolic methanol may occur as a result of fermentation by gut bacteria and metabolic processes involving S-adenosyl methionine. Regardless of its source, low levels of methanol in the body are maintained by physiological and metabolic clearance mechanisms. Although human blood contains small amounts of methanol and formaldehyde, the content of these molecules increases sharply after receiving even methanol-free ethanol, indicating an endogenous source of the metabolic methanol present at low levels in the blood regulated by a cluster of genes. Recent studies of the pathogenesis of neurological disorders indicate metabolic formaldehyde as a putative causative agent. The detection of increased formaldehyde content in the blood of both neurological patients and the elderly indicates the important role of genetic and biochemical mechanisms of maintaining low levels of methanol and formaldehyde.

Recurrent lactic acidosis secondary to hand sanitizer ingestion

Due to their ability to decrease the spread of infection, hand sanitizers are now ubiquitous in health care settings. We present the case of a 50-year-old woman who was admitted with acute alcohol intoxication and had near complete recovery in 12 hrs. Subsequently, she was found unresponsive on the floor of her hospital room on two separate occasions. Evaluations revealed repeatedly elevated levels of ethanol, acetone, and lactate as well as increased anion gap and hypotension, requiring intensive care unit evaluation and intubation for airway protection. During the second episode, she was found next to an empty bottle of ethanol-based hospital hand sanitizer. She confirmed ingesting hand sanitizer in order to become intoxicated.

Determination of sevoflurane and isopropyl alcohol in exhaled breath by thermal desorption gas chromatography-mass spectrometry for exposure assessment of hospital staff

Volatile anaesthetics and disinfection chemicals pose ubiquitous inhalation and dermal exposure risks in hospital and clinic environments. This work demonstrates specific non-invasive breath biomonitoring methodology for assessing staff exposures to sevoflurane (SEV) anaesthetic, documenting its metabolite hexafluoroisopropanol (HFIP) and measuring exposures to isopropanol (IPA) dermal disinfection fluid. Methods are based on breath sample collection in Nalophan bags, followed by an aliquot transfer to adsorption tube, and subsequent analysis by thermal desorption gas chromatography-mass spectrometry (TD-GC-MS). Ambient levels of IPA were also monitored. These methods could be generalized to other common volatile chemicals found in medical environments. Calibration curves were linear (r(2)=0.999) in the investigated ranges: 0.01-1000 ppbv for SEV, 0.02-1700 ppbv for IPA, and 0.001-0.1 ppbv for HFIP. The instrumental detection limit was 10 pptv for IPA and 5 pptv for SEV, both estimated by extracted ion-TIC chromatograms, whereas the HFIP minimum detectable concentration was 0.5 pptv as estimated in SIM acquisition mode. The methods were applied to hospital staff working in operating rooms and clinics for blood draws. SEV and HFIP were present in all subjects at concentrations in the range of 0.7-18, and 0.002-0.024 ppbv for SEV and HFIP respectively. Correlation between IPA ambient air and breath concentration confirmed the inhalation pathway of exposure (r=0.95, p<0.001) and breath-borne IPA was measured as high as 1500 ppbv. The methodology is easy to implement and valuable for screening exposures to common hospital chemicals. Although the overall exposures documented were generally below levels of health concern in this limited study, outliers were observed that indicate potential for acute exposures.

Acute kidney injury with oxalate deposition in a patient with a high anion gap metabolic acidosis and a normal osmolal gap

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.

Brake fluid toxicity feigning brain death

Brake fluid (glycol-based) toxicity is known to have a protean of central and peripheral nervous system manifestations. The principal component of this household poison is ethylene glycol. Toxic effect is generally attributed to peri-vascular deposition of calcium oxalate crystals in various tissues. However, clinical features resembling brain death have rarely been reported. We report a case of brake fluid toxicity simulating brain death in a 21-year-old healthy man who ingested it as a recreational agent.

Ethylene glycol ingestion masked by concomitant ethanol intoxication

An obtunded male with a history of alcohol abuse presented to the emergency department with metabolic acidosis, an osmolar gap and lactic acidosis. The patient was initially treated for alcohol intoxication due to an extremely high blood alcohol level. Following respiratory failure and intubation, a large volume of dark green liquid was removed via nasogastric suction; bedside fluorescence for ethylene glycol was negative. Twenty-four hours later, the patient's glomerular filtration rate decreased significantly, serum osmolality was 807, the osmolar gap was 407, complete metabolic panel showed pH of 6.8, sodium of 156 mmol/l, potassium of 7.3 mmol/l, chloride of 116, CO(2) of 3.9 and anion gap of 30.7. Blood lactic acid was >56 mmol/l. The patient received emergency haemodialysis. Four days after presentation, the patient began to respond to voice commands and was extubated. Currently, the patient still receives haemodialysis due to ongoing renal failure, but no long-term neurologic complications are evident.

An Unusual Cause of Delirium in a Psychiatric Patient: Abrupt Clozapine Discontinuation

Rapid clinical deteriorations have been reported after abrupt discontinuation of clozapine. A 42-year-old psychiatric patient presented with ingestion of hand-disinfectant solutions causing transient impairment of his conscious level. His clozapine therapy was discontinued for a short period of time and he developed delirium with normal results of investigations for underlying organic causes. His delirium resolved rapidly after the reintroduction of clozapine. The withdrawal effects of abrupt discontinuation of clozapine are discussed in this article.

[Acute intoxication with isopropanol]

Isopropanol is an ingredient of commonly used industrial and household agents. Intoxication can occur unintentionally, in suicide attempts or by alcohol abusers when used as a substitute for ethanol. Symptoms involve the gastrointestinal tract, the central nervous system, and the cardiovascular system at higher doses. Mortality is especially high in patients with deep coma and marked hypotension. This report describes a case of life-threatening isopropanol intoxication of a prison inmate successfully treated by haemodialysis.

Cerebral sinovenous thrombosis associated with isopropanol ingestion in an infant

This report describes a 5-week-old female infant who presented with accidental ingestion of rubbing alcohol (which contains about 70% isopropanol), and was subsequently diagnosed with cerebral sinovenous thrombosis. Isopropanol is a clear, volatile 3-carbon alcohol found in varying concentrations in many solvents. Mislabeled rubbing alcohol was mixed with this patient's formula. After ingesting it, she presented with a 1-day history of uncontrolled fussiness and an episode of deviation of the eyes to the right for 30 minutes, followed by rhythmic movements of the arms and legs for 20 minutes. Cerebral imaging demonstrated sinovenous thrombosis. To our knowledge, there have been no reports describing cerebral sinovenous thrombosis as a complication of isopropanol ingestion. The possible association of isopropanol ingestion and sinovenous thrombosis is discussed.

A case of mixed intoxication with isopropyl alcohol and propanol-1 after ingestion of a topical antiseptic solution

We report a mixed intoxication with isopropyl alcohol and propanol-1 in a hospitalized patient who ingested, on two separate days, two 100 ml bottles of a topical antiseptic solution containing isopropyl alcohol and propanol-1. Eight hours after the second ingestion, plasma concentrations of isopropanol, propanol-1 and acetone were 37 mg/dL, <10 mg/dL, and 227 mg/dl, respectively. Despite a lack of severe toxicity, 4-methylpyrazole (fomepizole) was initiated. This case points out the need to limit access to alcohol-containing antiseptic solutions on wards where alcoholic and psychotic patients are hospitalized.

Simple diagnostic tests to detect toxic alcohol intoxications

Methanol, ethylene glycol, and diethylene glycol intoxications can produce visual disturbances, neurologic disturbances, acute renal failure, pulmonary dysfunction, cardiac dysfunction, metabolic acidosis, and death. Metabolic acidosis and an increased serum osmolality are important clues to their diagnosis. The former reflects the organic acids produced by metabolism of the parent alcohol, whereas the latter is caused by accumulation of the offending alcohol. However, neither the clinical nor the laboratory findings are specific for toxic alcohol ingestions. The definitive diagnosis of the alcohol intoxications is commonly based on detection of the alcohol or its metabolites in blood. Early diagnosis is important, because initiation of appropriate treatment can markedly decrease their rates of morbidity and mortality. Currently, detection of the parent alcohol in body fluids is inferred from its measurement in blood. This measurement is often performed by specialty laboratories using expensive equipment, and a long delay between obtaining the specimen and getting the results is not unusual. In this report, we describe liquid-based tests that detect methanol, ethylene glycol, diethylene glycol, and ethanol in saliva. The tests are sensitive, and they have different specificity for each of the alcohols facilitating distinction among them. The relatively high sensitivity and specificity of the tests as a whole will facilitate the rapid diagnosis of each of these alcohol intoxications.

Methanol poisoning: the duality between 'fast and cheap' and 'slow and expensive'

The management of methanol poisoning includes early antidote therapy to inhibit the metabolism of methanol to formate. Ethanol and fomepizole are both effective, but recently fomepizole has been preferred, although there is no scientific evidence that the use of fomepizole is a superior therapeutic strategy compared with the use of ethanol combined with haemodialysis. The same patient was admitted twice to our emergency department with methanol poisoning. The first time (methanol 3.24 g/l), she was treated with fomepizole without dialysis owing to the absence of acidosis. The second time (methanol 5.5 g/l), she received ethanol as an antidote and dialysis was started. For both therapeutic strategies, hospital length of stay, observation unit length of stay and costs are compared. In the Belgian healthcare system, we found that fomepizole treatment was three times as expensive as ethanol treatment, and the majority of costs are not reimbursed. Fomepizole antidote therapy, compared with ethanol, has fewer reported side effects, but is more expensive. In hospitals where dialysis is easily available, ethanol antidote therapy should still be considered, especially if similar cost differences exist within the healthcare system one is working in.

Toxic alcohol ingestions: clinical features, diagnosis, and management

Alcohol-related intoxications, including methanol, ethylene glycol, diethylene glycol, and propylene glycol, and alcoholic ketoacidosis can present with a high anion gap metabolic acidosis and increased serum osmolal gap, whereas isopropanol intoxication presents with hyperosmolality alone. The effects of these substances, except for isopropanol and possibly alcoholic ketoacidosis, are due to their metabolites, which can cause metabolic acidosis and cellular dysfunction. Accumulation of the alcohols in the blood can cause an increment in the osmolality, and accumulation of their metabolites can cause an increase in the anion gap and a decrease in serum bicarbonate concentration. The presence of both laboratory abnormalities concurrently is an important diagnostic clue, although either can be absent, depending on the time after exposure when blood is sampled. In addition to metabolic acidosis, acute renal failure and neurologic disease can occur in some of the intoxications. Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in treatment of several of the alcohol-related intoxications. Administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, a critical enzyme in metabolism of the alcohols, is beneficial in treatment of ethylene glycol and methanol intoxication and possibly diethylene glycol and propylene glycol intoxication. Given the potentially high morbidity and mortality of these intoxications, it is important for the clinician to have a high degree of suspicion for these disorders in cases of high anion gap metabolic acidosis, acute renal failure, or unexplained neurologic disease so that treatment can be initiated early.

Methanol poisoning in Tunisia: report of 16 cases

Methanol poisoning continues to be a public health problem in Tunisia in spite of the different legislative measures. We report a series of 16 cases of methanol poisoning admitted to our Intensive Care Unit between December 2003 and April 2004. The patients' median age was 21.5 years (range 16 to 53 years) with a median SAPS II of 14 (range 12 to 84) and an APACHE II of 8 (range 6 to 36). The median latent period was 9.5 hours (range 4 to 24 hours) with a delay to medical consultation of 36 hours (range 6 to 48 hours), and a median serum methanol concentration of 1.4 g/L (range 0.19 to 3.62 g/L). Clinical signs included central nervous system symptoms (69%), gastrointestinal complaints (87%), visual disturbances (69%) and metabolic acidosis (94%). Three patients (19%) required mechanical ventilation because of deep coma or shock and died within 6 hours. Hemodialysis was performed in eleven patients (69%) because of visual disturbances and/or metabolic acidosis. One patient developed irreversible bilateral blindness and another unilateral blindness secondary to optic neuropathy. Statistical significant risk factors for the developing of visual disturbances were found to be the ingested quantity of methanol, the latent period, acidosis and serum methanol concentration on admission.

The management of severe toxic alcohol ingestions at a tertiary care center after the introduction of fomepizole

INTRODUCTION

Ethylene glycol and methanol ingestions are relatively uncommon but potentially lethal poisonings. Recent trials have demonstrated that fomepizole effectively blocks alcohol dehydrogenase (ADH) in toxic alcohol overdoses, and may eliminate the need for emergent hemodialysis and intensive care unit admission. However, controversy remains in the role of fomepizole in clinical practice. The purpose of this study was to describe the presentation, management and clinical course of toxic alcohol ingestions at a tertiary care referral center after the introduction of fomepizole to hospital formulary.

METHODS

Data was collected on all patents treated for toxic alcohol ingestions for a 1-year period in a tertiary care referral center. Patients who received fomepizole or ethanol infusions, or who underwent hemodialysis were identified by ED, pharmacy, hemodialysis and ICU databases. The patients' medical records were reviewed, and data was recorded on a predetermined computerized data collection form.

RESULTS

Overall, twenty (20) toxic ingestions (14 methanol; 6 ethylene glycol) were identified over the one year period. Fomepizole was used for ADH blockade in 12/20 cases; ETOH infusions in 15/20 cases (combined ETOH and fomepizole use in 7/20). The majority of toxic alcohol exposures were admitted to an intensive care unit (19/20) and received emergent hemodialysis (19/20). All patients were discharged from hospital alive.

CONCLUSIONS

Patients with methanol and ethylene glycol ingestions who presented to our centers had significant toxicity and received both HD and ICU admission. Further research is required to determined if the method of ADH blockade affects the need for hemodialysis or ICU admission in toxic alcohol ingestions.

Transplacental isopropanol exposure: case report and review of metabolic principles

Isopropanol, a known central nervous system depressant has been reported to cause toxicity via multiple routes including ingestion, inhalation and dermal exposure. We present a case of transplacental isopropanol exposure in a neonate. A woman reported polysubstance abuse in the 1 to 2 days before precipitously delivering a newborn infant. The neonate developed hypotension, hypotonia and seizure activity within the first few hours of life. Blood samples from the infant revealed toxic levels of isopropanol. Similar symptoms have been reported in infants with isopropanol toxicity from other routes of exposure.

The role of continuous renal replacement therapy in the treatment of poisoning

Extracorporeal elimination of drugs and toxins is a critical component in the management of poisonings, though specific techniques and indications remain a matter of debate. Conventional hemodialysis is frequently the treatment of choice because of its widespread availability and proven effectiveness for certain drugs and toxins. With the increased availability of continuous renal replacement therapy (CRRT) modalities, there is yet another therapeutic option, but one that has yet to find a definitive role in this field. The continuous nature of these therapies is attractive for the management of acute renal failure, but the relatively slower clearance rates as compared to conventional hemodialysis is a distinct drawback in patients with acute xenobiotic-induced toxicity. There are abundant case reports as well as a few small case series in the medical literature documenting the use of CRRT, but specific techniques and the clinical outcomes vary considerably. Therefore one cannot draw definitive conclusions regarding benefit. Some patients, particularly those who are hemodynamically unstable and are not candidates for conventional hemodialysis, may warrant a trial of CRRT. However, at the present time, routine use for the treatment of poisoning is not supported. Controlled trials to better clarify its role would be beneficial, though such studies would be extremely difficult to conduct in this field. We believe that the intelligent application of extracorporeal modalities requires a thorough knowledge of drug pharmacokinetics, of the techniques utilized, and a skeptical analysis of the available literature.

Acute Ethanol Intoxication After Consumption of Hairspray

A 61-year-old woman with a history of alcohol dependence came to the emergency department with ethanol intoxication. Her serum ethanol concentration was 322 mg/dl. When questioned, she admitted to consuming a 14-oz bottle of hairspray mixed with water because of its denatured alcohol content. The woman had used nonbeverage sources of alcohol on a regular basis for a number of years after learning of the practice from fellow attendees of Alcoholics Anonymous meetings. Her primary reason for this behavior was to hide her continued alcohol abuse from her family. She consumed hairspray that contained 50% denatured alcohol by volume; the amount she ingested was equal to 7 fluid oz of ethanol, the equivalent of 14 1.25-oz shots of 80-proof liquor. Her serum ethanol concentration was consistent with that predicted by pharmacokinetic equations based on the consumption of one bottle of hairspray. The hairspray product contained specially denatured alcohol 40-B, which consists of ethanol and small quantities of t-butyl alcohol and denatonium benzoate. Ethanol is the substance of primary toxicologic concern. Clinicians need to be aware that numerous nonbeverage sources of alcohol exist and should be considered when a patient presents with acute intoxication. The source and its components should be identified as soon as possible in order to assess other potential toxicities.

Isopropyl alcohol intoxication: a diagnostic challenge

Isopropyl alcohol (IPA) is an ingredient of commonly used household solutions. Accidental and suicidal ingestion of IPA sometimes can be fatal if it goes unrecognized and untreated. There are few published reports on IPA intoxication. We describe a case of repeated IPA ingestion in a single individual, followed by a review of the literature on the subject. The differential diagnosis, diagnostic pitfalls, and therapeutic interventions in patients with IPA intoxications are discussed.