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AlSamh DA, Kramer AH. Neurologic Complications in Critically Ill Patients with Toxic Alcohol Poisoning: A Multicenter Population-Based Cohort Study. Neurocrit Care 2024; 40:734-742. [PMID: 37697128 DOI: 10.1007/s12028-023-01821-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Toxic alcohol poisoning is regularly encountered in emergency departments and intensive care units (ICUs). Most patients present with an altered level of consciousness, but the subsequent course and spectrum of neurologic complications and outcomes is highly variable. METHODS We performed a population-based, multicenter retrospective cohort study of critically ill patients with toxic alcohol poisoning admitted to ICUs in Alberta, Canada, between 2007 and 2019 to describe neurologic sequelae, including seizures, coma, neuroimaging abnormalities, persistent cognitive or visual impairment, and mortality. Multivariate analysis was performed to identify predictors of poor outcome. RESULTS We identified 104 patients, including 55 (53%) with methanol ingestion, 36 (35%) with ethylene glycol ingestion, and 13 (13%) with isopropanol ingestion. In patients who underwent neuroimaging, abnormalities were detected in 9 of 24 (38%) with methanol toxicity, 5 of 20 (25%) with ethylene glycol toxicity, and 0 of 10 with isopropanol toxicity (p = 0.07). Basal ganglia were commonly involved with both methanol and ethylene glycol poisoning, but prominent subcortical involvement and restricted diffusion were observed only with methanol poisoning. The composite of death, persistent cognitive impairment, or visual loss occurred in 13 (24%) patients with methanol poisoning, compared with one (3%) with ethylene glycol poisoning and none with isopropanol poisoning (p = 0.006). Among patients with methanol toxicity, greater elevation of the anion gap and lower Glasgow Coma Scale score were independent predictors of poor outcome. No patient with an anion gap ≥ 28 at presentation had a favorable recovery. Progression to death by neurologic criteria occurred in 3 of 55 (5%) patients with methanol poisoning and in none with other toxic alcohols. CONCLUSIONS Methanol overdose is the most common form of toxic alcohol poisoning to result in ICU admission. Poor neurologic outcomes may occur especially with methanol poisoning, with more than one in five patients dying or having persistent cognitive or visual impairment. A wide anion gap independently predicts poor outcome, emphasizing the importance of expeditious recognition and treatment.
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Affiliation(s)
- Danah Abo AlSamh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, McCaig Tower, Foothills Medical Center, University of Calgary, 3134 Hospital Drive NW Calgary, Calgary, AB, T2N 2T9, Canada.
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2
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Ezhilarasu P, Srinivasan R. Beyond the Usual Suspects: Ethylene Glycol Poisoning Complicated by Rare Neurological Sequelae. Cureus 2024; 16:e57868. [PMID: 38725760 PMCID: PMC11081402 DOI: 10.7759/cureus.57868] [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] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
Ethylene glycol poisoning is a known clinical entity with established diagnostic and management protocols. However, instances presenting with rare neurological complications pose diagnostic challenges and necessitate prompt recognition and intervention. This report details the case of ethylene glycol poisoning in a 38-year-old male patient who initially presented with a history of brake oil consumption at his residence, followed by a delayed presentation with vomiting, abdominal pain, and reduced urine output, and subsequently developed unusual neurological sequelae, including unsteadiness, hearing difficulties, and an inability to close his eyes. Diagnostic assessment revealed cerebellar ataxia with bilateral sensory-neural hearing loss and facial nerve palsy. The patient was subsequently managed primarily for ethylene glycol poisoning, with conservative management for the neurological sequelae, and improved with no residual deficits. This case underscores the importance of promptly managing ethylene poisoning to prevent complications and sequelae as well as reduce morbidity for patients.
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Affiliation(s)
- Preetham Ezhilarasu
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Ragunanthanan Srinivasan
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
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3
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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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Klarendić M, Kojović M. Reply to: "Neither Friend Nor Foe: Beekeeping and Parkinson's Disease". Mov Disord 2022; 37:1575. [PMID: 35856725 DOI: 10.1002/mds.29075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/08/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Maja Klarendić
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maja Kojović
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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5
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Histopathological evidence that diethylene glycol produces kidney and nervous system damage in rats. Neurotoxicology 2022; 91:200-210. [DOI: 10.1016/j.neuro.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 04/14/2022] [Accepted: 05/20/2022] [Indexed: 11/21/2022]
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Peters J, Staff NP. Update on Toxic Neuropathies. Curr Treat Options Neurol 2022; 24:203-216. [PMID: 36186669 PMCID: PMC9518699 DOI: 10.1007/s11940-022-00716-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose of Review Toxic neuropathies are an important preventable and treatable form of peripheral neuropathy. While many forms of toxic neuropathies have been recognized for decades, an updated review is provided to increase vigilant in this area of neurology. A literature review was conducted to gather recent information about toxic neuropathies, which included the causes, clinical findings, and treatment options in these conditions. Recent Findings Toxic neuropathies continue to cause significant morbidity throughout the world and the causative agents, particularly with regards to medications, do not appear to be diminishing. A wide variety of causes of toxic neuropathies exist, which include alcohol, industrial chemicals, biotoxins, and medications. Unfortunately, no breakthrough treatments have been developed and prevention and symptom management remain the standard of care. Summary A detailed medication, occupational and hobby exposure history is critical to identifying toxic neuropathies. Increased research is warranted to identify mechanisms of neurotoxic susceptibility and potential common pathomechanistic pathways for treatment across diverse toxic neuropathies.
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Affiliation(s)
- Jannik Peters
- Department of Neurology, Mayo Clinic Rochester, MN USA
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7
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Baj J, Forma A, Kobak J, Tyczyńska M, Dudek I, Maani A, Teresiński G, Buszewicz G, Januszewski J, Flieger J. Toxic and Nutritional Optic Neuropathies—An Updated Mini-Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053092. [PMID: 35270784 PMCID: PMC8910489 DOI: 10.3390/ijerph19053092] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/27/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
Abstract
Optic neuropathies constitute a group of conditions with various etiologies and might be caused by different factors; we can distinguish the genetic and acquired causes of optic neuropathies. Even though the symptoms are not highly specific, this condition is primarily characterized by unilateral or bilateral vision loss with worsening color detection. The loss may be acute or gradual depending on the causation. In this article, we included a specification of toxic optic neuropathy (TON) mainly triggered by alcohol abuse and also the usage of other substances, including drugs or methanol, as well as intoxication by metals, organic solvents, or carbon dioxide. Nutritional deficiencies, vitamin absorption disorder, and anemia, which usually appear during excessive alcohol intake, and their effect on the etiology of the optic neuropathy have been likewise discussed.
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Affiliation(s)
- Jacek Baj
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
- Correspondence:
| | - Joanna Kobak
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Magdalena Tyczyńska
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Iga Dudek
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Amr Maani
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland; (J.B.); (A.M.)
| | - Grzegorz Teresiński
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Grzegorz Buszewicz
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jacek Januszewski
- Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland; (J.K.); (M.T.); (I.D.); (G.T.); (G.B.); (J.J.)
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland;
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8
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Jamison CN, Dayton RD, Latimer B, McKinney MP, Mitchell HG, McMartin KE. Diethylene glycol produces nephrotoxic and neurotoxic effects in female rats. Clin Toxicol (Phila) 2022; 60:324-331. [PMID: 34278906 PMCID: PMC9661884 DOI: 10.1080/15563650.2021.1953049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Diethylene glycol (DEG) is an organic compound found in household products but also as a counterfeit solvent in medicines. DEG poisonings are characterized by acute kidney injury (AKI) and by neurological sequelae such as decreased reflexes or face and limb weakness. Previous studies in male rats have demonstrated that neurotoxic effects develop only with the establishment of AKI, but the dose sensitivity of females to DEG toxicity is unknown. OBJECTIVES Assessing whether subacute administration of DEG in female rats would delineate any sex-differences in neuropathy or in kidney injury. METHODS Female Wistar-Han rats were orally administered doses of 4 - 6 g/kg DEG every 12 h and monitored for 7 days. Urine was collected every 12 h and endpoint blood and cerebrospinal fluid (CSF) were collected for renal plasma parameters and total protein estimation, respectively. Motor function tests were conducted before and after treatment. Kidney and brain tissue were analyzed for metabolite content. RESULTS Of 12 animals treated with DEG, 3 developed AKI as confirmed by increased BUN and creatinine concentrations. Renal and brain DGA contents were increased in animals that developed AKI compared to animals without AKI. Total CSF protein content in animals with AKI was markedly elevated compared to control and to treated animals without AKI. Decreases in forelimb grip strength and in locomotor and rearing activity were observed in animals with AKI compared to control and to animals without AKI. DISCUSSION Repeated dosing with DEG in a female model produced nephrotoxic effects at a dose similar to that in males. The decrease in motor function and increase in CSF protein were only present in females that developed AKI. However, kidney and neurologic effects were assessed only at the end of the treatments, thus limiting determination of which effect occurs first. Limb function and coordination were measured globally and more sensitive tests such as nerve conduction studies might offer a detailed neurotoxicity assessment of the effects of DEG. CONCLUSIONS These studies show that DEG toxicity does not appear to be sex-specific and that, in males and females, neurological symptoms are present only when DGA accumulation and kidney injury also occur.
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Affiliation(s)
- Courtney N. Jamison
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Robert D. Dayton
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Brian Latimer
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Mary P. McKinney
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Hannah G. Mitchell
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Kenneth E. McMartin
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
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9
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Vadysinghe AN, Kumarasinghe WGGB, Kodikara S, Wickramasinghe N. Suicide by ethylene glycol/brake oil poisoning—a case report. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2021. [DOI: 10.1186/s41935-021-00244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Brake fluid is used for automobiles. It is a mixture of different glycol derivatives including ethylene glycol and diethylene glycol (DEG) which are metabolized into various toxic metabolites. Fatalities following brake fluid ingestion are rare in forensic practice. Here, we report a case of suicide by brake fluid ingestion complicated with severe renal failure and esophageal and gastric erosions.
Case presentation
A 52-year-old male, with a history of alcohol dependence and comorbid moderate depression, ingested a bottle of brake fluid (100ml) mixed with alcohol. He had defaulted psychiatric follow-up. He developed severe metabolic acidosis and acute renal failure which necessitated intensive care, other supportive management, and the antidote; ethyl alcohol. On the 2nd day of admission, he developed upper gastrointestinal bleeding with melena. He also had seizures and cardiovascular complications. He died 12 days after hospital admission, and the manner of death was concluded as suicidal. The autopsy revealed congested and edematous brain, flabby and pale heart without evidence of infarction, erythematous trachea, bilateral diffuse pulmonary edema, congested liver, ulcer over the lower 1/3 of the esophagus, and few ulcers in the stomach. Also, the kidneys were edematous, diffusely necrosed, and there were adrenal hemorrhages.
Conclusions
This case report highlights the severity of effects of brake fluid poisoning including the corrosive effect on gastrointestinal mucosa which is rarely encountered in clinical practice.
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10
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Bini M, Rajesh B, Babu TD. Chronic exposure of industrial grade calcium carbide and ethylene glycol alter histological architecture of systemic organs by disrupting redox balance in rat. J Basic Clin Physiol Pharmacol 2021; 33:265-271. [PMID: 33770829 DOI: 10.1515/jbcpp-2020-0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/09/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The threat to human health or the surroundings by the use of artificial fruit ripening agents has become a global concern. Calcium carbide (CaC2) and ethylene glycol (EG) are the two widely using ripening agents. The present study evaluates the toxic effect of chronic exposures of CaC2 and EG in rats. METHODS CaC2 and EG were administered to the rats for 180 days orally. The alterations in oxido-reduction status, haematological, biochemical and histopathological parameters were analysed. Arsenic content in CaC2 and animal samples were detected by atomic absorption spectrometer and phosphorus by molybdate-UV method. RESULTS At chronic doses, there were no significant alterations in haematological and biochemical parameters except in creatinine level especially by EG. However, histological details revealed microvesicular fatty change in liver, corpuscles degeneration in kidney and lymphocytes infiltration in various tissues. In intestine, the mucosal lesion scoring was found high (p<0.01). SOD and CAT activities and GSH level was reduced significantly by CaC2 administration (p<0.01). Arsenic and phosphorus detected is above the toxic level: 7.222 and 13.91 mg/dL in CaC2, 1.634 and 6.22 mg/dL in blood and 0.563 and 6.99 mg/dL in liver, respectively. CONCLUSIONS The study suggests that the industrial grade CaC2 and EG induce systemic toxicity to rats and the liver is the most susceptible organ. The CaC2 and EG toxicity is mediated through the upset of redox balance and subsequent inflammatory responses. This could be due to the presence of arsenic and phosphorus contents that detected above the normal level in the industrial grade CaC2.
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Affiliation(s)
- Markose Bini
- Department of Anatomy, Bharath Institute of Higher Education and Research, Chennai, India.,Department of Anatomy, Amala Institute of Medical Sciences, Thrissur, India
| | - Bhargavan Rajesh
- Department of Anatomy, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India
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11
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Bazurto JV, Riazi S, D’Alton S, Deatherage DE, Bruger EL, Barrick JE, Marx CJ. Global Transcriptional Response of Methylorubrum extorquens to Formaldehyde Stress Expands the Role of EfgA and Is Distinct from Antibiotic Translational Inhibition. Microorganisms 2021; 9:347. [PMID: 33578755 PMCID: PMC7916467 DOI: 10.3390/microorganisms9020347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
The potency and indiscriminate nature of formaldehyde reactivity upon biological molecules make it a universal stressor. However, some organisms such as Methylorubrum extorquens possess means to rapidly and effectively mitigate formaldehyde-induced damage. EfgA is a recently identified formaldehyde sensor predicted to halt translation in response to elevated formaldehyde as a means to protect cells. Herein, we investigate growth and changes in gene expression to understand how M. extorquens responds to formaldehyde with and without the EfgA-formaldehyde-mediated translational response, and how this mechanism compares to antibiotic-mediated translation inhibition. These distinct mechanisms of translation inhibition have notable differences: they each involve different specific players and in addition, formaldehyde also acts as a general, multi-target stressor and a potential carbon source. We present findings demonstrating that in addition to its characterized impact on translation, functional EfgA allows for a rapid and robust transcriptional response to formaldehyde and that removal of EfgA leads to heightened proteotoxic and genotoxic stress in the presence of increased formaldehyde levels. We also found that many downstream consequences of translation inhibition were shared by EfgA-formaldehyde- and kanamycin-mediated translation inhibition. Our work uncovered additional layers of regulatory control enacted by functional EfgA upon experiencing formaldehyde stress, and further demonstrated the importance this protein plays at both transcriptional and translational levels in this model methylotroph.
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Affiliation(s)
- Jannell V. Bazurto
- Department of Biological Sciences, University of Idaho, Moscow, ID 83844, USA; (J.V.B.); (S.R.); (E.L.B.)
- Institute for Modeling Collaboration and Innovation, University of Idaho, Moscow, ID 83844, USA
- Institute for Bioinformatics and Evolutionary Studies, University of Idaho, Moscow, ID 83844, USA
- Department of Plant and Microbial Biology, University of Minnesota, Twin Cities, MN 55108, USA
- Microbial and Plant Genomics Institute, University of Minnesota, Twin Cities, MN 55108, USA
- Biotechnology Institute, University of Minnesota, Twin Cities, MN 55108, USA
| | - Siavash Riazi
- Department of Biological Sciences, University of Idaho, Moscow, ID 83844, USA; (J.V.B.); (S.R.); (E.L.B.)
- Institute for Modeling Collaboration and Innovation, University of Idaho, Moscow, ID 83844, USA
- Institute for Bioinformatics and Evolutionary Studies, University of Idaho, Moscow, ID 83844, USA
| | - Simon D’Alton
- Center for Systems and Synthetic Biology, Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX 78712, USA; (S.D.); (D.E.D.); (J.E.B.)
| | - Daniel E. Deatherage
- Center for Systems and Synthetic Biology, Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX 78712, USA; (S.D.); (D.E.D.); (J.E.B.)
| | - Eric L. Bruger
- Department of Biological Sciences, University of Idaho, Moscow, ID 83844, USA; (J.V.B.); (S.R.); (E.L.B.)
- Institute for Modeling Collaboration and Innovation, University of Idaho, Moscow, ID 83844, USA
- Institute for Bioinformatics and Evolutionary Studies, University of Idaho, Moscow, ID 83844, USA
| | - Jeffrey E. Barrick
- Center for Systems and Synthetic Biology, Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX 78712, USA; (S.D.); (D.E.D.); (J.E.B.)
| | - Christopher J. Marx
- Department of Biological Sciences, University of Idaho, Moscow, ID 83844, USA; (J.V.B.); (S.R.); (E.L.B.)
- Institute for Modeling Collaboration and Innovation, University of Idaho, Moscow, ID 83844, USA
- Institute for Bioinformatics and Evolutionary Studies, University of Idaho, Moscow, ID 83844, USA
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12
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Jamison CN, Dayton RD, Latimer B, McKinney MP, Mitchell HG, McMartin KE. Neurotoxic effects of nephrotoxic compound diethylene glycol. Clin Toxicol (Phila) 2021; 59:810-821. [PMID: 33475432 DOI: 10.1080/15563650.2021.1874403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
CONTEXT Diethylene glycol (DEG) is an organic compound found in household products but also as an adulterant in medicines by acting as a counterfeit solvent. DEG poisonings have been characterized predominately by acute kidney injury (AKI), but also by delayed neurological sequelae such as decreased reflexes or face and limb weakness. OBJECTIVES Characterizing the neurological symptoms of DEG poisoning in a subacute animal model would create a clearer picture of overall toxicity and possibly make mechanistic connections between kidney injury and neuropathy. METHODS Male Wistar-Han rats were orally administered doses of 4 - 6 g/kg DEG every 12 or 24 h and monitored for 7 days. Urine was collected every 12 h and endpoint blood and cerebrospinal fluid (CSF) were collected for a renal plasma panel and total protein estimation, respectively. Motor function tests were conducted before and after treatment. Kidney and brain tissue was harvested for metabolic analysis. RESULTS Of the 43 animals treated with DEG, 11 developed AKI as confirmed by increased BUN and creatinine levels. Renal and brain DGA accumulation was markedly increased in animals that developed AKI compared to animals without AKI. The total protein content in CSF in animals with kidney injury was markedly elevated compared to control and to treated animals without AKI. Significant decreases in forelimb grip strength and decreases in locomotor and rearing activity were observed in animals with AKI compared to control and to animals without AKI. DISCUSSION Repeated dosing with DEG in an animal model produced nephrotoxic effects like those in studies with acute DEG administration. The decrease in motor function and increase in CSF protein were only present in animals that developed AKI. CONCLUSIONS These studies show development of neurotoxicity in this DEG animal model and suggest that neurological symptoms are observed only when DGA accumulation and kidney injury also occur.
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Affiliation(s)
- Courtney N Jamison
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Robert D Dayton
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Brian Latimer
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Mary P McKinney
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Hannah G Mitchell
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
| | - Kenneth E McMartin
- Department of Pharmacology, Toxicology and Neuroscience, LSU Health Sciences Center, Shreveport, LA, USA
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Mulroy E, Anderson NE. Altered mental status in "Guillain-Barré syndrome" -a noteworthy clinical clue. Ann Clin Transl Neurol 2020; 7:2489-2507. [PMID: 33136342 PMCID: PMC7732251 DOI: 10.1002/acn3.51226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 01/01/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is widely regarded as a "pure" peripheral nervous system disorder. However, this simplistic interpretation belies the fact that central nervous system involvement, often manifesting as derangements in mental status can occur as a complication of the "pure" form of the disorder, as part of GBS variants, as well as in a number of mimic disorders. Despite being common in clinical practice, there is no guidance in the literature as to how to approach such scenarios. Herein, we detail our approach to these cases.
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Affiliation(s)
- Eoin Mulroy
- UCL Queen Square Institute of NeurologyLondonUK
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14
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Kotikova K, Zogala D, Ptacnik V, Trnka J, Kupka K, Vaneckova M, Seidl Z, Diblik P, Heissigerova J, Navratil T, Komarc M, Zak I, Polakova K, Brozova H, Zakharov S. Efficiency of 123I-ioflupane SPECT as the marker of basal ganglia damage in acute methanol poisoning: 6-year prospective study. Clin Toxicol (Phila) 2020; 59:235-245. [PMID: 32762574 DOI: 10.1080/15563650.2020.1802033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
CONTEXT Investigate whether 123I-ioflupane SPECT (DaT SPECT) has the potential as a marker of basal ganglia damage in acute methanol poisoning. METHODS Prospective, single-centre, cohort study of patients with confirmed methanol poisoning was conducted. DaT SPECT was performed twice with semi-quantification using DaTQUANTTM and MRI-based volumetry was calculated. Specific binding ratios (SBR) of striatum, caudate nucleus, and putamen were correlated with laboratory parameters of outcome, volumetric data, and retinal nerve fibres layer (RNFL) thickness measurements. RESULTS Forty-two patients (mean age 46.3 ± 4.2 years; 8 females), including 15 with MRI-detected putamen lesions (group I) and 27 patients with intact putamen (group II), underwent DaT SPECT. Volumetry was calculated in 35 of the patients assessed. SBR values for the left putamen correlated with putamen volume (r = 0.665; p < 0.001). Decreased bilateral SBR values were determined for the striatum and the putamen, but not for the nucleus caudate, in group I (p < 0.05). Significant correlation was observed between the SBR of the posterior putamen and arterial blood pH (r = 0.574; p < 0.001) and other toxicological parameters of severity of poisoning/outcome including serum lactate, glucose, and creatinine concentrations (p < 0.05). The SBR of the posterior putamen positively correlated with the global RNFL thickness (p < 0.05). ROC analysis demonstrated a significant discriminatory ability of SBR of the posterior putamen with AUC = 0.753 (95%CI 0.604-0.902; p = 0.007). The multivariate regression model demonstrated that arterial blood pH, age, and gender were the most significant factors associated with SBR of the posterior putamen. CONCLUSION DaT SPECT demonstrates significant potential for the diagnosis of methanol-induced basal ganglia damage.
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Affiliation(s)
- Katerina Kotikova
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - David Zogala
- Institute of Nuclear Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vaclav Ptacnik
- Institute of Nuclear Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jiri Trnka
- Institute of Nuclear Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Karel Kupka
- Institute of Nuclear Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zdenek Seidl
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Diblik
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jarmila Heissigerova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Navratil
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Electrochemistry at the Nanoscale, J. Heyrovsky Institute of Physical Chemistry of the Czech Academy of Sciences, Prague, Czech Republic
| | - Martin Komarc
- Department of Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Ivan Zak
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Kamila Polakova
- Department of Neurology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hana Brozova
- Department of Neurology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Sergey Zakharov
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
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15
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Kotikova K, Klepis P, Ridzon P, Hlusicka J, Navratil T, Rulisek J, Zak I, Zakharov S. Peripheral polyneuropathy after acute methanol poisoning: Six-year prospective cohort study. Neurotoxicology 2020; 79:67-74. [DOI: 10.1016/j.neuro.2020.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023]
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16
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Rulisek J, Waldauf P, Belohlavek J, Balik M, Kotikova K, Hlusicka J, Vaneckova M, Seidl Z, Diblik P, Bydzovsky J, Heissigerova J, Urban P, Miovsky M, Sejvl J, Pelclova D, Zakharov S. Health-related quality of life determinants in survivors of a mass methanol poisoning outbreak: six-year prospective cohort study. Clin Toxicol (Phila) 2020; 58:870-880. [PMID: 31913708 DOI: 10.1080/15563650.2019.1702994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose: The effect of acute methanol poisoning on the follow-up quality of life of survivors in mass poisoning outbreaks is not known. The objective of this is to study the impact of visual and central nervous system (CNS) sequelae of methanol poisoning on long-term health-related quality of life (QoL) of survivors, its clinical determinants, and dynamics.Materials and methods: A total of 54 patients with confirmed methanol poisoning (mean age 46.7 ± 13.4 years, 9 females) were examined consequently three times within six-year prospective cohort study and compared to 23 controls with the history of chronic alcohol abuse. The following tests were performed: SF-36 QoL questionnaire, visual evoked potentials (VEP) of optic nerve, ocular examination with retinal nerve fiber layer (RNFL) thickness measurement, brain magnetic resonance imaging (MRI), and biochemical and toxicological tests.Results: Acute methanol poisoning led to significant decrease in physical component summary (PCS) compared to PCS of age-adjusted controls (mean score with SD 46.8 ± 11.0 versus 52.3 ± 9.4 points; p = .003). In 17/40 (42.5%) patients with three rounds of examination, signs of severe disability (≤30 points in at least one score) were present six years after discharge, with negative dynamics of PCS score during the observation period. The patients with abnormal RNFL thickness had lower PCS (mean difference 10.5 points; 95%CI 3.5-17.5, p = .004) and mental component summary score (9.5 points; 95%CI 1.9-17.1, p = .015) compared to the patients with normal RNFL. Signs of physical and mental adaptation to long-term visual sequelae were registered with gradual reduction of difference in most of physical and mental components scores compared to the patients with normal RNFL during six years of observation. Signs of hemorrhagic brain lesions were associated with permanent decrease of PCS score (mean difference 7.4 points; 95%CI 0.6-14.0; p = .033), bodily pain (8.7 points; 95%CI 1.6-17.6; p = .018), and social functioning (8.2 points; 95%CI 3.0-17.4; p = .005) six years after discharge. No effect of type of antidote (fomepizole versus ethanol) and extracorporeal enhanced elimination modality (intermittent hemodialysis versus continuous renal replacement therapy) applied in hospital on long-term QoL was found (all p > .05).Conclusion: Acute methanol poisoning was associated with a significant decrease of health-related quality of life of survivors persisting for at least six years after discharge. The more pronounced decrease in QoL scores was observed in the patients with hemorrhagic brain lesions and visual sequelae of poisoning with abnormal RNFL thickness.
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Affiliation(s)
- Jan Rulisek
- Department of Anesthesia and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anesthesia and Intensive Care, Third Faculty of Medicine, Charles University and Royal Vinohrady Teaching Hospital, Prague, Czech Republic
| | - Jan Belohlavek
- Department of Cardiology and Angiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Balik
- Department of Anesthesia and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Katerina Kotikova
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Jiri Hlusicka
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zdenek Seidl
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Diblik
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Bydzovsky
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jarmila Heissigerova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Urban
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Michal Miovsky
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jaroslav Sejvl
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Daniela Pelclova
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Sergey Zakharov
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
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Wittschieber D, Heuberger K, Schulz R, Köhler H, Varchmin-Schultheiß K. Fatal poisoning with diethylene glycol in an unusual setting. Forensic Sci Med Pathol 2019; 15:649-652. [DOI: 10.1007/s12024-019-00123-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 11/30/2022]
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18
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Wittler M, O'Brien MC, Masneri DA. Toxic Alcohol Ingestion/Methanol Ingestion. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10740. [PMID: 30800940 PMCID: PMC6342378 DOI: 10.15766/mep_2374-8265.10740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/19/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Methanol poisoning is an uncommon life-threatening ingestion associated with significant morbidity and requires prompt diagnosis and management for the best possible outcome. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an anion gap metabolic acidosis, narrow the differential based on reasoning, and empirically initiate management. METHODS The simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. First-year residents managed the case as a team of two. Second- and third-year residents and fellows managed the case alone. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, provide stabilization of life threats, and initiate specific interventions based on a presumptive diagnosis. The simulation was followed by a 20-minute facilitated debrief session that reviewed key learning points and learner performance based on an evaluation checklist. RESULTS Residents completed a six-question, 5-point Likert-scale postparticipation questionnaire. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap. DISCUSSION This simulation experience successfully exposed residents to the uncommon presentation of methanol poisoning. The simulation experience effectively closed the identified educational gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.
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Affiliation(s)
- Mary Wittler
- Assistant Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
| | - Mary Claire O'Brien
- Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
| | - David A. Masneri
- Assistant Professor, Department of Emergency Medicine, Wake Forest Baptist Medical Center
- Emergency Medicine Simulation Director, Wake Forest Baptist Medical Center
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19
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Affiliation(s)
- Jeffrey A Kraut
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
| | - Michael E Mullins
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
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20
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Ortega-Atienza S, Krawic C, Watts L, McCarthy C, Luczak MW, Zhitkovich A. 20S immunoproteasomes remove formaldehyde-damaged cytoplasmic proteins suppressing caspase-independent cell death. Sci Rep 2017; 7:654. [PMID: 28381880 PMCID: PMC5429636 DOI: 10.1038/s41598-017-00757-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/09/2017] [Indexed: 01/08/2023] Open
Abstract
Immunoproteasomes are known for their involvement in antigen presentation. However, their broad tissue presence and other evidence are indicative of nonimmune functions. We examined a role for immunoproteasomes in cellular responses to the endogenous and environmental carcinogen formaldehyde (FA) that binds to cytosolic and nuclear proteins producing proteotoxic stress and genotoxic DNA-histone crosslinks. We found that immunoproteasomes were important for suppression of a caspase-independent cell death and the long-term survival of FA-treated cells. All major genotoxic responses to FA, including replication inhibition and activation of the transcription factor p53 and the apical ATM and ATR kinases, were unaffected by immunoproteasome inactivity. Immunoproteasome inhibition enhanced activation of the cytosolic protein damage sensor HSF1, elevated levels of K48-polyubiquitinated cytoplasmic proteins and increased depletion of unconjugated ubiquitin. We further found that FA induced the disassembly of 26S immunoproteasomes, but not standard 26S proteasomes, releasing the 20S catalytic immunoproteasome. FA-treated cells also had higher amounts of small activators PA28αβ and PA28γ bound to 20S particles. Our findings highlight the significance of nonnuclear damage in FA injury and reveal a major role for immunoproteasomes in elimination of FA-damaged cytoplasmic proteins through ubiquitin-independent proteolysis.
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Affiliation(s)
- Sara Ortega-Atienza
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA
| | - Casey Krawic
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA
| | - Lauren Watts
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA
| | - Caitlin McCarthy
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA
| | - Michal W Luczak
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA
| | - Anatoly Zhitkovich
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, 02912, USA.
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21
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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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Galvez-Ruiz A, Elkhamary SM, Asghar N, Bosley TM. Visual and neurologic sequelae of methanol poisoning in Saudi Arabia. Saudi Med J 2016; 36:568-74. [PMID: 25935177 PMCID: PMC4436753 DOI: 10.15537/smj.2015.5.11142] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives: To present the visual sequelae of methanol poisoning and to emphasize the characteristics of methanol exposure in the Kingdom of Saudi Arabia (KSA). Methods: A retrospective case series was carried out on 50 sequential patients with methanol poisoning seen at the King Khaled Eye Specialist Hospital and King Saud University Hospitals in Riyadh, KSA between 2008 and 2014. All patients were examined by a neuro-ophthalmologist at least one month after methanol intoxication. Results: All 50 patients were young or middle-aged males. All admitted to drinking unbranded alcohol within 2-3 days before profound or relatively profound, painless, bilateral visual loss. Mean visual acuity in this group was hand motions (logMAR 2.82; range 0.1 - 5.0) with some eye to eye variability within individuals. Worse visual acuity was correlated with advancing age (Pearson correlation: oculus dextrus [right eye] - 0.37, p=0.008; oculus sinister [left eye] - 0.36, p=0.011). All patients had optic atrophy bilaterally, and all tested patients had visual field defects. Tremors with or without rigidity were present in 12 patients, and 11 of 30 patients who had neuroimaging performed had evidence of putaminal necrosis. Conclusion: Methanol intoxication causes visual loss within 12-48 hours due to relatively severe, painless, bilateral optic nerve damage that may be somewhat variable between eyes, and is generally worse with advancing age. The coincidence of bilateral optic nerve damage and bilateral putaminal necrosis in a young or middle-aged male is very suspicious for methanol-induced damage.
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Affiliation(s)
- Alberto Galvez-Ruiz
- Department of Ophthalmology, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia. Tel. +966 (11) 4821234. Fax. +966 (11) 4821908. E-mail.
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Ortega-Atienza S, Rubis B, McCarthy C, Zhitkovich A. Formaldehyde Is a Potent Proteotoxic Stressor Causing Rapid Heat Shock Transcription Factor 1 Activation and Lys48-Linked Polyubiquitination of Proteins. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:2857-2868. [PMID: 27639166 DOI: 10.1016/j.ajpath.2016.06.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/24/2016] [Accepted: 06/30/2016] [Indexed: 11/29/2022]
Abstract
Endogenous and exogenous formaldehyde (FA) has been linked to cancer, neurotoxicity, and other pathophysiologic effects. Molecular and cellular mechanisms that underlie FA-induced damage are poorly understood. In this study, we investigated whether proteotoxicity is an important, unrecognized factor in cell injury caused by FA. We found that irrespective of their cell cycle phases, all FA-treated human cells rapidly accumulated large amounts of proteins with proteasome-targeting K48-linked polyubiquitin, which was comparable with levels of polyubiquitination in proteasome-inhibited MG132 controls. Both nuclear and cytoplasmic proteins were damaged and underwent K48-polyubiquitination. There were no significant changes in the nonproteolytic K63-polyubiquitination of soluble and insoluble cellular proteins. FA also rapidly induced nuclear accumulation and Ser326 phosphorylation of the main heat shock-responsive transcription factor HSF1, which was not a result of protein polyubiquitination. Consistent with the activation of the functional heat shock response, FA strongly elevated the expression of HSP70 genes. In contrast to the responsiveness of the cytoplasmic protein damage sensor HSF1, FA did not activate the unfolded protein response in either the endoplasmic reticulum or mitochondria. Inhibition of HSP90 chaperone activity increased the levels of K48-polyubiquitinated proteins and diminished cell viability after FA treatment. Overall, our results indicate that FA is a strong proteotoxic agent, which helps explain its diverse pathologic effects, including injury in nonproliferative tissues.
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Affiliation(s)
- Sara Ortega-Atienza
- Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island
| | - Blazej Rubis
- Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island
| | - Caitlin McCarthy
- Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island
| | - Anatoly Zhitkovich
- Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island.
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Moral AR, Çankayalı İ, Sergin D, Boyacılar Ö. Neuromuscular Functions on Experimental Acute Methanol Intoxication. Turk J Anaesthesiol Reanim 2015; 43:337-43. [PMID: 27366524 PMCID: PMC4894235 DOI: 10.5152/tjar.2015.13471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/01/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The incidence of accidental or suicidal ingestion of methyl alcohol is high and methyl alcohol intoxication has high mortality. Methyl alcohol intoxication causes severe neurological sequelae and appears to be a significant problem. Methyl alcohol causes acute metabolic acidosis, optic neuropathy leading to permanent blindness, respiratory failure, circulatory failure and death. It is metabolised in the liver, and its metabolite formic acid has direct toxic effects, causing oxidative stress, mitochondrial damage and increased lipid peroxidation associated with the mechanism of neurotoxicity. Methanol is known to cause acute toxicity of the central nervous system; however, the effects on peripheral neuromuscular transmission are unknown. In our study, we aimed to investigate the electrophysiological effects of experimentally induced acute methanol intoxication on neuromuscular transmission in the early period (first 24 h). METHODS After approval by the Animal Experiment Ethics Committee of Ege University, the study was carried out on 10 Wistar rats, each weighing about 200 g. During electrophysiological recordings and orogastric tube insertion, the rats were anaesthetised using intra-peritoneal (IP) injection of ketamine 100 mg kg(-1) and IP injection of xylazine 10 mg kg(-1). The rats were given 3 g kg(-1) methyl alcohol by the orogastric tube. Electrophysiological measurements from the gastrocnemius muscle were compared with baseline. RESULTS Latency measurements before and 24 h after methanol injection were 0.81±0.11 ms and 0.76±0.12 ms, respectively. CMAP amplitude measurements before and 24 h after methanol injection were 9.85±0.98 mV and 9.99±0.40 mV, respectively. CMAP duration measurements before and 24 h after methanol injection were 9.86±0.03 ms and 9.86±0.045 ms, respectively. CONCLUSION It was concluded that experimental methanol intoxication in the acute phase (first 24 h) did not affect neuromuscular function.
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Affiliation(s)
- Ali Reşat Moral
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Ege University Faculty of Medicine, İzmir, Turkey
| | - İlkin Çankayalı
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Ege University Faculty of Medicine, İzmir, Turkey
| | - Demet Sergin
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Ege University Faculty of Medicine, İzmir, Turkey
| | - Özden Boyacılar
- Department of Anaesthesiology and Reanimation, Division of Intensive Care, Ege University Faculty of Medicine, İzmir, Turkey
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25
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Zakhari R. Ethylene Glycol Poisoning: Resolution of Cranial Nerve Deficit. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Imam YZB, Kamran S, Karim H, Elalamy O, Sokrab T, Osman Y, Deleu D. Neurological manifestation of recreational fatal and near-fatal diethylene glycol poisonings: case series and review of literature. Medicine (Baltimore) 2014; 93:e62. [PMID: 25170933 PMCID: PMC4616334 DOI: 10.1097/md.0000000000000062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Diethylene glycol is a common industrial solvent which is responsible for accidental and epidemic poisoning as early as the 1930s. Due to the unavailability and unaffordability of ethanol, people in Qatar among the low income group are consuming household chemicals, some of which contain diethylene glycol, for recreational purposes.The history of ingestion is usually not volunteered and the initial clinical presentation is usually nonspecific, making it difficult to diagnose from the clinical presentation. Moreover, the biochemical profile varies with time, making the diagnosis more difficult. The neurological course and toxicity is less well characterized than its renal counterpart. Moreover, reports in the literature of such recreational poisoning is lacking particularly in the region.Three cases of recreational diethylene glycol poisoning seen in Hamad General Hospital, Doha, Qatar from 2009 to 2012 are detailed here.These illustrate the clinical course with emphasis on the neurological sequelae that include encephalopathy and multiple cranial and peripheral neuropathies with fatal and near-fatal outcomes. Neuroimaging in 2 were initially normal, but follow-up imaging showed brain atrophy. The third patient's neuroimaging showed diffuse brain edema with evidence of transtentorial herniation. Nerve conduction studies were performed in 2 of the 3 cases and showed evidence of mixed sensorimotor neuropathy. The outcomes were death in 1 and severe neurological morbidity and disability in 2 cases.Diethylene glycol is a dangerous substance when ingested and can result in mortality and severe morbidity, particularly from the renal and neurological manifestations. Whereas the mechanism of damage is less well known, the damage is likely dose related. The typical clinical pattern of evolution of the poisoning in the absence of cost-effective ways to detect it in the serum can help clinicians in making the diagnosis.Neurological manifestations may include encephalopathy and multiple cranial and peripheral neuropathies with subsequent brain atrophy. Public awareness of the danger of such recreational use should be raised.
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Affiliation(s)
- Yahia Zakaria Bashier Imam
- Neurology Section (YZI, SK, OE, TES, YO, DD); Department of Medicine (HK), Hamad Medical Corporation; and Weill Cornell Medical College in Qatar (SK, OE, TES, DD), Doha, Qatar
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Sosa NR, Rodriguez GM, Schier JG, Sejvar JJ. Clinical, Laboratory, Diagnostic, and Histopathologic Features of Diethylene Glycol Poisoning—Panama, 2006. Ann Emerg Med 2014; 64:38-47. [DOI: 10.1016/j.annemergmed.2013.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/11/2013] [Accepted: 12/05/2013] [Indexed: 10/25/2022]
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Separation of oxalate, formate and glycolate in human body fluid samples by capillary electrophoresis with contactless conductometric detection. J Chromatogr A 2014; 1325:241-6. [DOI: 10.1016/j.chroma.2013.12.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/11/2013] [Accepted: 12/13/2013] [Indexed: 01/14/2023]
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Lung DD, Kearney TE, Brasiel JA, Olson KR. Predictors of Death and Prolonged Renal Insufficiency in Ethylene Glycol Poisoning. J Intensive Care Med 2013; 30:270-7. [DOI: 10.1177/0885066613516594] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 09/20/2013] [Indexed: 12/17/2022]
Abstract
Background: We assessed the predictive value of selected factors on the outcomes of death and prolonged renal insufficiency (RI) from ethylene glycol poisoning. Methods: Retrospective, observational California Poison Control System study, over a 10-year period (1999-2008). We compared 2 groups. The first group (D/RI) included 59 patients who died (9 patients) or had prolonged RI (50 patients). Prolonged RI was defined as kidney injury in which dialysis was required for greater than 3 days after presentation. The second group (RECOV) of 62 patients had an uncomplicated recovery. Secondarily, we evaluated the association of time to antidote (ethanol and/or fomepizole) and time to dialysis with these outcomes. Results: The D/RI group was more likely than the RECOV group to present comatose, have seizures, and require intubation. The D/RI group had a lower mean initial arterial pH of 7.03 (standard deviation [SD] 0.20), compared to 7.27 (SD 0.14) for the RECOV group. The D/RI group had a higher initial creatinine (1.7 mg/dL, SD 0.71) than that of the RECOV group (1.0 mg/dL, SD 0.33). Patients with a time to antidote greater than 6 hours had a higher odds of dying or having prolonged RI (OR 3.34, 95% CI : 1.21-9.26) Patients with a time to dialysis greater than 6 hours had a lower odds of dying or having prolonged RI (OR 0.36, 95% CI : 0.15-0.87). Conclusion: Compared to survivors with an uncomplicated recovery, patients poisoned with ethylene glycol who died or had prolonged RI were more likely to exhibit clinical signs such as coma, seizures, and acidosis. Antidote administration within 6 hours is associated with better outcomes, unlike earlier time to dialysis.
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Affiliation(s)
- Derrick D. Lung
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
- California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA
| | - Thomas E. Kearney
- California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA
| | - James A. Brasiel
- California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA
| | - Kent R. Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, CA, USA
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Abstract
Accidental or intentional ingestion of substances containing methanol and ethylene glycol can result in death, and some survivors are left with blindness, renal dysfunction, and chronic brain injury. However, even in large ingestions, a favorable outcome is possible if the patient arrives at the hospital early enough and the poisoning is identified and appropriately treated in a timely manner. This review covers the common circumstances of exposure, the involved toxic mechanisms, and the clinical manifestations, laboratory findings, and treatment of methanol and ethylene glycol intoxication.
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Kubáň P, Foret F, Bocek R. Capillary electrophoresis with contactless conductometric detection for rapid screening of formate in blood serum after methanol intoxication. J Chromatogr A 2013; 1281:142-7. [DOI: 10.1016/j.chroma.2013.01.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/04/2013] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
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Lock EA, Zhang J, Checkoway H. Solvents and Parkinson disease: a systematic review of toxicological and epidemiological evidence. Toxicol Appl Pharmacol 2013; 266:345-55. [PMID: 23220449 PMCID: PMC3621032 DOI: 10.1016/j.taap.2012.11.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 11/12/2012] [Accepted: 11/14/2012] [Indexed: 12/25/2022]
Abstract
Parkinson disease (PD) is a debilitating neurodegenerative motor disorder, with its motor symptoms largely attributable to loss of dopaminergic neurons in the substantia nigra. The causes of PD remain poorly understood, although environmental toxicants may play etiologic roles. Solvents are widespread neurotoxicants present in the workplace and ambient environment. Case reports of parkinsonism, including PD, have been associated with exposures to various solvents, most notably trichloroethylene (TCE). Animal toxicology studies have been conducted on various organic solvents, with some, including TCE, demonstrating potential for inducing nigral system damage. However, a confirmed animal model of solvent-induced PD has not been developed. Numerous epidemiologic studies have investigated potential links between solvents and PD, yielding mostly null or weak associations. An exception is a recent study of twins indicating possible etiologic relations with TCE and other chlorinated solvents, although findings were based on small numbers, and dose-response gradients were not observed. At present, there is no consistent evidence from either the toxicological or epidemiologic perspective that any specific solvent or class of solvents is a cause of PD. Future toxicological research that addresses mechanisms of nigral damage from TCE and its metabolites, with exposure routes and doses relevant to human exposures, is recommended. Improvements in epidemiologic research, especially with regard to quantitative characterization of long-term exposures to specific solvents, are needed to advance scientific knowledge on this topic.
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Affiliation(s)
- Edward A Lock
- Liverpool John Moores University, School of Pharmacy and Biomolecular Sciences, Byrom Street, Liverpool, UK.
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Abstract
PURPOSE OF REVIEW Although medication, toxic, and vitamin-related neuropathies are rare causes of neuropathy, they are important to recognize because they are treatable and preventable. It is often difficult to conclusively demonstrate that a particular agent is the cause of neuropathy, but understanding the specific electrodiagnostic and clinical patterns produced by these agents is critical for making these assessments. RECENT FINDINGS The clinical and electrodiagnostic features for many of these neuropathies have been well established. The exact mechanism by which some of these agents produce neuropathy is only now beginning to be revealed. These mechanisms are critical for both understanding the normal function of nerves as well as eventually devising specific treatments. SUMMARY A large number of medications and toxins can produce neuropathy. This article reviews the clinical characteristics, electrodiagnostic features, and mechanism of action (when known) of those agents that produce the most severe, or perhaps the most unique features of, neuropathy.
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Affiliation(s)
- Brett Morrison
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland 21287, USA
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Abstract
The CT and MR findings of a patient with acute ethylene glycol poisoning are presented. Basal ganglia hemorrhagic infarction especially involving the putamen was detected. The differential diagnosis includes other toxic and hypoxic encephalopathies.
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Affiliation(s)
- Peter Corr
- Faculty of Medicine, UAE University, Tawam Hospital, Al Ain, United Arab Emirates.
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Industrial toxicants and Parkinson's disease. Neurotoxicology 2012; 33:178-88. [PMID: 22309908 DOI: 10.1016/j.neuro.2012.01.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/19/2012] [Accepted: 01/23/2012] [Indexed: 11/22/2022]
Abstract
The exposure of the human population to environmental contaminants is recognized as a significant contributing factor for the development of Parkinson's disease (PD) and other forms of parkinsonism. While pesticides have repeatedly been identified as risk factors for PD, these compounds represent only a subset of environmental toxicants that we are exposed to on a regular basis. Thus, non-pesticide contaminants, such as metals, solvents, and other organohalogen compounds have also been implicated in the clinical and pathological manifestations of these movement disorders and it is these non-pesticide compounds that are the subject of this review. As toxic exposures to these classes of compounds can result in a spectrum of PD or PD-related disorders, it is imperative to appreciate shared clinico-pathological characteristics or mechanisms of action of these compounds in order to further delineate the resultant disorders as well as identify improved preventive strategies or therapeutic interventions.
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Porter WH. Ethylene glycol poisoning: quintessential clinical toxicology; analytical conundrum. Clin Chim Acta 2011; 413:365-77. [PMID: 22085425 DOI: 10.1016/j.cca.2011.10.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/21/2011] [Accepted: 10/25/2011] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- William H Porter
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY, United States.
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