Challenges in the diagnosis of ethylene glycol poisoning

Abstract

Ethylene glycol poisoning, while uncommon, is clinically significant due to the associated risk of severe morbidity or lethality and it continues to occur in many countries around the world. The clinical presentation of ethylene glycol toxicity, while classically described in three phases, varies widely and when combined with the range of differential diagnoses that must be considered makes diagnosis challenging. Early and accurate detection is important in these patients, however, as there is a need to start antidotal treatment early to prevent serious harm. In this article, we will review the literature and provide guidance regarding the diagnosis of ethylene glycol poisoning. While gas chromatography is the gold standard, the usefulness of this test is hampered by delays in access due to availability. Consequently, there are several surrogate markers that can give an indication of ethylene glycol exposure but these must be interpreted with caution and within the clinical context. An in-depth review of these tests, particularly the detection of a raised osmolar gap or an raised anion gap acidosis, will form the main focus of this article.

Characteristics of Laboratory Confirmed Ethylene Glycol and Methanol Exposures Reported to a Regional Poison Control Center

“…While measurements of serum levels of EG or MET can distinguish these two toxic alcohols, analysis can take several days, which is problematic for many emergency departments and hospitals. 6…”

Diagnosis of toxic alcohols: limitations of present methods

“…14 Intoxication in children (ages 0-11 years) or adolescents (11-19 years) is less frequent and can be due to accidental ingestion of this fluid or purposely given to the child by a care giver. 15,16 Diethylene glycol has been illegally used as a diluent in medications, but is also present in some brake fluids and artificial fog solutions. 17 Poisoning with diethylene glycol is rare, but most commonly is reported in children given medication in which it is illegally used as a diluent.…”

Ethylene glycol: Evidence of glucuronidation in vivo shown by analysis of clinical toxicology samples

“…Recognition of clinical symptoms of EG intoxication is often difficult, leaving clinicians − in countries where clinical analysis of EG is not available (eg, Denmark with 5 million inhabitants) − to rely on surrogate biochemical parameters with insufficient specificity and sensitivity, such as lactate gap, anion gap or osmolar gap . Generally, well‐organized, fast analytical services and antidote supplies are needed, since a delay in testing may also cause delays in proper treatment …”

“…19 Generally, well-organized, fast analytical services and antidote supplies are needed, since a delay in testing may also cause delays in proper treatment. 20 Poisonings with EG can be diagnosed by quantitative analysis of EG with gas chromatography (GC), in serum, plasma, post-mortem blood and urine. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] This may involve different pre-treatment techniques, like liquid-liquid extraction (LLE), ultrafiltration, and/or derivatization followed by head-space sampling, direct thermal desorption, or injection of extracts on a GC apparatus coupled to flame ionization (GC−FID) or mass spectrometry (GC-MS).…”