Managing diethylene glycol (non)ingestion
July 6, 2012, 11:20 pm
Diethylene glycol
Management of diethylene glycol ingestion. Hoyte CO, Leikin JB. Clin Toxicol 2012 July;50:525-527.
To start with, the title of this paper is quite misleading. The case that serves as a springboard for discussion here actually displayed no evidence that any significant amount of diethylene glycol (DEG) was ingested at all.
A 35-year-old man presents to the emergency department claiming that 8 hours before he had consumed a full bottle of Valvoline Professional Series Brake Fluid (10-15% diethylene glycol). He did not appear intoxicated, he did not have acidosis or renal failure at any time during his 3 day hospital stay, and his diethylene glycol level on presentation was undetectable.
Nevertheless, the discussants make some interesting points. Although, as with ethylene glycol, DEG can cause severe acidosis and renal failure, the exact cause(s) of these complication is not completely known. It is not even clear if DEG itself — or a metabolite — causes the toxicity. This is important because it impacts potential therapies. Is fomepizole beneficial because it blocks formation of a toxic metabolite? If DEG itself is the culprit, blocking metabolism would be contraindicated.
The authors suggest that if a patient suspected of ingesting diethylene glycol is asymptomatic on presentation, supportive care with close observation and serial measurement of electrolytes (looking for an increasing anion gap) and creatinine levels over 12 hours would be reasonable. I should note that the text Poisoning & Drug Overdose (Olson KR [ed] Fifth Edition] states without reference that after DEG ingestion acidosis can be delayed > 12 hours. One wonders if in such a case the patient had a significant ethanol level, which would slow metabolism of DEG.
[structure of diethylene glycol from wikipedia.org]
Hossein Sanaei-Zadeh Says:
Dear Leon
As the authors stated the patient had an undetectable ethanol level.
July 10th, 2012
Leon Says:
Dr. Sanaei-Zadeh:
Yes, this patient had an undetectable ethanol level – he also had an undetectable diethylene glycol level.
My point was, in the case Olson refers to, in which onset (or detection) of metabolic acidosis was significantly delayed, did that patient have ethanol on board, which could explain delayed acidosis.
July 10th, 2012