Delayed neurologic sequelae resulting from epidemic diethylene glycol poisoning

BACKGROUND

Diethylene glycol (DEG) is a well-known metabolic and renal toxin usually ingested accidentally as an ethanol substitute or as a contaminant in various medicinals. To date, most poisonings have occurred in third-world countries where early death from renal failure is very common. We report a series of seven patients presenting with epidemic DEG poisoning from a correctional facility with varying degrees of metabolic acidemia and acute renal impairment responding to emergent hemodialysis (HD). Significantly, three patients developed delayed neurologic toxicity which has not been well characterized in the past.

CASE SERIES

Seven male patients (age range 19-55) presented over a 36 h period following ingestion of varying quantities of DEG. Initially three patients, ingesting the largest quantities of DEG, presented more than 24 h postingestion with severe metabolic acidemia (pH range 6.8-7.1) and anuric acute renal failure requiring HD. All three remained dialysis-dependent and developed significant cranial neuropathies with bulbar palsy in the second week postingestion. One patient died with cerebral oedema and a progressive encephalopathy. Two further patients presented within 24 h of ingestion with normal renal function and a moderate metabolic acidemia (pH range 7.2-7.28) requiring HD. They remained well. Finally, two further patients presented with a history of trivial DEG ingestion and did not require any therapy. Neurologic signs in the two surviving initial presenters improved over 4-6 months although they remained dialysis-dependent.

CONCLUSION

Unrecognized DEG poisoning may present with metabolic acidemia and anuric acute renal failure. Established renal impairment may predict subsequent delayed neurologic toxicity.

Iatrogenically revealed myasthenia gravis

Myasthenia gravis is rare. When it presents unusually, making a diagnosis is doubly difficult. We present an unusual case where an 'everyday' medication unfortunately precipitated a myasthenic crisis in an unsuspecting individual.

[Acute vincristine neurotoxicity in a non-Hodgkin's lymphoma patient with Charcot-Marie-Tooth disease]

A 44-year-old, previously healthy man with a diagnosis of non-Hodgkin's lymphoma (NHL, diffuse large B-cell type, stage IIA) was treated with combination chemotherapy including vincristine (VCR). After receiving a cumulative dose of VCR, he experienced rapid and marked weakening which progressed to quadriplegia and bulbar palsy. Prior to this therapy, the patient had no neurological problems, and his siblings were asymptomatic. Physical examination identified pes cavus (hollow foot), and electrodiagnostic studies showed markedly slower nerve conduction velocity of myelinated fibers, with abundant "onion bulb" formations. Chromosomal analysis detected 17p11.2-12 duplication, thus yielding a diagnosis of Charcot-Marie-Tooth (CMT) 1A. CMT disease is a familial neuromuscular disorder, and the incidence is approximately 1 in 2,500. We concluded that if CMT disease is diagnosed, vincristine should be avoided due to the potential severity of neurotoxicity to small doses.

Neurological complications of 5-fluorouracil chemotherapy: case report and review of the literature

Neurological complications of 5-fluorouracil (5-FU) chemotherapy are uncommon events. The two patients presented demonstrate two manifestations of 5-FU neurotoxicity, namely a cerebellar syndrome in association with global motor weakness and bulbar palsy, and a bilateral third cranial (oculomotor) nerve palsy. Both highlight the rapid onset and severity of these unusual side effects but also emphasize that, unlike paraneoplastic syndromes or central nervous system involvement by tumour, complete spontaneous recovery is a potential outcome.

A case of acute pulmonary edema and bulbar paralysis after local epinephrine infiltration

An unusual case in which pulmonary edema and intracranial hemorrhage occurred during adenotonsillectomy is presented. The possible causes of this intracranial hemorrhage are discussed, especially in relationship to local epinephrine infiltration.

Epidemiological survey of amyotrophic lateral sclerosis in the province of Reggio Emilia, Italy: influence of environmental exposure to lead

We carried out a retrospective incidence, prevalence and mortality survey of amyotrophic lateral sclerosis (ALS) in the province of Reggio Emilia, northern Italy. Based on 79 patients, the mean incidence per year for the period 1980 through 1992 was 1.5 cases per 100,000. On December 31st, 1992, the prevalence rate was 5.4 per 100,000. In the 10-year period of 1983-1992 the average mortality rate was 1.3 per 100,000 per year. The average age at onset was 61.3 +/- 10.2, the average survival period thereafter was 26.3 months +/- 17.7; 27.3 +/- 17.6 for classic ALS, 19.5 +/- 8.4 for progressive bulbar palsy and 36.3 +/- 41.4 for pseudopolyneuritic ALS. The incidence rate, recorded in public health district No.12, an area with documented lead pollution since the 1970s, was standardized to the sex and age of the population of the province. Its incidence and prevalence rate were comparable to the rates found in the remaining area of the province.

Bulbar and pseudobulbar palsy complicating therapy with high-dose cytosine arabinoside in children with leukemia

Three of 38 children given high-dose cytosine arabinoside therapy developed a previously undescribed complication. Neurological problems are a frequent occurrence in patients given this therapy, particularly cerebellar ataxia, but the development of bulbar and pseudobulbar palsy has not been reported. In two of these cases, it was sufficiently marked for the course of treatment to be curtailed and occurred at a relatively low cumulative dose of the drug. Neurotoxicity can occur at any time using high-dose cytosine therapy.

Cyclosporin-associated akinetic mutism and extrapyramidal syndrome after liver transplantation

Three patients developed akinetic mutism on the third day after the introduction of intravenous cyclosporin A, given for immunosuppression after liver transplantation. One patient in addition developed a florid orofacial dyskinesia, which resolved completely, as did the akinetic mutism, after withdrawal of cyclosporin. In these patients the time course of the akinetic mutism and extrapyramidal syndrome, which developed in the absence of any other identifiable cause, suggests cyclosporin A was the precipitating factor. Subsequently, two of the patients showed signs of pseudobulbar palsy with abnormalities in the pons on MRI scanning, suggesting central pontine myelinolysis (CPM). None of the patients had experienced significant fluctuations in serum sodium or other risk factors for central pontine myelinolysis and the exact relationship to the earlier cyclosporin related mutism was not clear.

Paralytic shellfish poisoning: a case report and serial electrophysiologic observations

We report serial electrophysiologic observations in a patient with acute bulbar and respiratory paralysis following ingestion of saxitoxin-contaminated clams. Prolonged distal motor and sensory latencies, slowed conduction velocities, and moderately diminished amplitudes were present at the outset. All values returned to normal over 5 days. These findings, the result of incomplete sodium channel blockade, distinguish paralytic shellfish poisoning from most other acute paralytic illnesses.

Phenothiazine-induced bulbar palsy-like syndrome and sudden death

There have been periodic case reports of sudden death due to aspiration or asphyxiation in patients receiving phenothiazines. The mechanism of death is unknown. The author reports a case of a drug-induced bulbar palsy-like syndrome in a man receiving fluphenazine enanthate and reviews the literature on sudden respiratory death and phenothiazines. He postulates that phenothiazine-induced bulbar palsy may cause laryngeal and/or pharyngeal dysfunctions that are responsible for aspiration.