Major ketogenesis and the absence of an osmolar gap in an atypical case                of alcoholic ketoacidosis

Renom, Gilles; Maisonneuve, Nadine; Kim, I; Dehon, Betty; Azar, Raymond

doi:10.1258/000456303766477110

Cited by 4 publications

(4 citation statements)

References 12 publications

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“…Estimation of the contribution of ethanol to OG is a complicated and controversial subject with multiple formulae proposed [18,26-28,50] One challenge is that the compounds formed in alcoholic ketoacidosis (e.g., glycerol, acetone, acetal, and 1,2-propanediol) may contribute to osmolality but are not directly measured by routine clinical laboratory testing [23,30-32]. In our study, 19 patients had elevated OG that by clinical history was most likely due to recent heavy ethanol ingestion but with serum ethanol less than 10 mg/dL.…”

Section: Discussionmentioning

confidence: 99%

“…An elevated OG (often defined as greater than a threshold between 10 and 15) suggests the presence of osmotically active substances other than sodium, BUN, glucose, and ethanol. The differential diagnosis for elevated OG includes a variety of conditions other than toxic alcohol ingestion such as alcoholic ketoacidosis [23,30-32], mannitol infusion [33,34], renal failure [35,36], and shock [37,38]. In some of these conditions (e.g., shock), the exact osmotically active compounds are not exactly known.…”

Section: Introductionmentioning

confidence: 99%

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A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

2012

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BackgroundPatients ingesting ethylene glycol, isopropanol, methanol, and propylene glycol ('toxic alcohols') often present with non-specific signs and symptoms. Definitive diagnosis of toxic alcohols has traditionally been by gas chromatography (GC), a technique not commonly performed on-site in hospital clinical laboratories. The objectives of this retrospective study were: 1) to assess the diagnostic accuracy of the osmolal gap in screening for toxic alcohol ingestion and 2) to determine the common reasons other than toxic alcohol ingestion for elevated osmolal gaps.MethodsElectronic medical records from an academic tertiary care medical center were searched to identify all patients in the time period from January 1, 1996 to September 1, 2010 who had serum/plasma ethanol, glucose, sodium, blood urea nitrogen, and osmolality measured simultaneously, and also all patients who had GC analysis for toxic alcohols. Detailed chart review was performed on all patients with osmolal gap of 9 or greater.ResultsIn the study period, 20,669 patients had determination of serum/plasma ethanol and osmolal gap upon presentation to the hospitals. There were 341 patients with an osmolal gap greater than 14 (including correction for estimated contribution of ethanol) on initial presentation to the medical center. Seventy-seven patients tested positive by GC for one or more toxic alcohols; all had elevated anion gap or osmolal gap or both. Other than toxic alcohols, the most common causes for an elevated osmolal gap were recent heavy ethanol consumption with suspected alcoholic ketoacidosis, renal failure, shock, and recent administration of mannitol. Only 9 patients with osmolal gap greater than 50 and no patients with osmolal gap greater than 100 were found to be negative for toxic alcohols.ConclusionsOur study concurs with other investigations that show that osmolal gap can be a useful diagnostic test in conjunction with clinical history and physical examination.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

2012

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“…In methanol intoxication, the normal osmolar gap might be possible but the plasma methanol should not high 3 . The cause of high methanol has also been reported to be a false positive in patients with ketoacidosis or hyperglycemia 4,5 . The alcoholic ketoacidosis may present with a false positive high plasma methanol, acidosis with a normal osmolar gap and lentiform fork sign.…”

Section: Dear Editormentioning

confidence: 99%

Methanol intoxication, lentiform fork sign, plasma methanol and osmolar gap

Sookaromdee¹,

Wiwanitkit

2019

Arq. Neuro-Psiquiatr.

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“…Herein lies another problem with the use of the osmolar gap, that is, how to interpret it in relation to the clinical situation. The osmolar gap is only an indirect marker of poisoning and may also be raised by conditions such as renal failure, 64,65 sepsis or shock, [66][67][68][69] mannitol therapy, 70,71 alcoholic and diabetic ketoacidosis [72][73][74][75][76][77][78][79] and hyperglycaemia. 72 In the undifferentiated patient with a decreased level of consciousness, it is possible for more than one of these processes to be occurring at one time which may yield false-positive results when interpreting the osmolar gap.…”

Section: Indirect Testingmentioning

confidence: 99%

Challenges in the diagnosis of ethylene glycol poisoning

McQuade

Dargan

2013

Ann Clin Biochem

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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.

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Major ketogenesis and the absence of an osmolar gap in an atypical case of alcoholic ketoacidosis

Cited by 4 publications

References 12 publications

A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

Methanol intoxication, lentiform fork sign, plasma methanol and osmolar gap

Challenges in the diagnosis of ethylene glycol poisoning

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