Neuroimaging findings in acute ethylene glycol poisoning

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

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.

A Case of Poisoning with Abrus precatarius Complicated with Bilateral Basal Ganglia Haemorrhage

Abrus precatarius is a tropical climber, whose seeds contain abrin, which is known to cause toxicity in humans. We report a case of a young girl, who presented with haemorrhagic enterocolitis, bilateral septal vein thrombosis, and basal ganglia haemorrhage leading to seizures and coma, following ingestion of toxic A. precatarius seeds. To the best of our knowledge, this is the first ever case to describe such an intracranial complication of abrin poisoning.

Reversibility of Severe Cerebral Magnetic Resonance Imaging Changes Associated with Ethylene Glycol Toxicity

Ethylene glycol (EG), commonly found in antifreeze and deicing solutions, continues to be a cause of morbidity and mortality in the pediatric population. EG metabolism produces toxins that cause metabolic acidosis and calcium oxalate deposition throughout the body. Deposition in the central nervous system is associated with significant neurologic sequelae, including altered mental status, seizures, and cerebral edema. We present a case of intentional EG poisoning in a 17-year-old male with resulting cerebral edema and coma. Neuroimaging studies were initially normal but eventually demonstrated diffuse abnormalities on both cranial computed tomography and magnetic resonance imaging (MRI). The patient ultimately made a complete recovery with resolution of the MRI abnormalities noted at the peak of illness. While neuroimaging is often incorporated into the management of EG poisoning, this is the first case report to show the evolution of EG-related MRI changes before, during, and after the resolution of EG-induced intracranial hypertension.

Basal Ganglion Hemorrhage as Delayed Complication of Diethylene Glycol Ingestion

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.

Bilateral putaminal hemorrhages: serious complication of methanol intoxication

Context:

Methanol intoxication is a life-threatening condition. Hallmark of clinical presentations include severe wide anion gap metabolic acidosis with very high serum osmolar gap and visual complication.

Case Report:

We report a case of severe methanol intoxication with bilateral putaminal hemorrhage, an uncommon serious complication. A 56-year-old man presented with altered mental status. Fundus examination showed optic disc edema. Arterial Blood Gas (ABG) revealed severe anion gap metabolic acidosis with osmolal gap. Head computed tomography (CT) showed hypodense lesions in basal ganglia bilaterally. Hemodialysis and intravenous fomepizole were initiated. Serum methanol level was significantly elevated. Unfortunately, patient was lethargic 2 weeks after discharge. Repeated CT of head demonstrated new putaminal hemorrhages.

Conclusion:

Bilateral putaminal hemorrhage is an uncommon but serious complication in methanol intoxication. Clinicians should have high index of suspicion for putaminal hemorrhage when patients with recent methanol intoxication present with altered mental status.