Snow White and ethylene glycol – or was it really diethylene glycol?

August 3, 2012, 12:11 am


Brake fluid toxicity feigning brain death. Nahrir S et al. BMJ Case Reports 2012 Jul 10; doi: 10.1136/bcr-02-2012-5926.


This case report describes a 21-year-old man who presented to the emergency department with vomiting, flank pain, oliguria, and acute renal failure. Laboratory results showed an osmolar gap (20 mOsm/kg), an anion gap (38 mEq/l), and a metabolic acidosis (pH 7.15). Head CT was normal, and nerve conduction studies showed severe axonal sensorimotor polyneuropathy.  Over the days following admission he developed bilateral sensorineural deafness, and facial palsy, and fixed dilated pupils. A declaration of brain death was considered but rejected because of the normal head CT and presence of activity on the EEG.

Diagnoses considered included Guillain-Barré syndrome, botulism, tick paralysis, and myasthenic crisis. On the 9th hospital day family members disclosed that before presentation the patient had ingested brake fluid (ethylene glycol).

Because of renal failure, the patient had received hemodialysis shortly after admission. He did not begin to regain brainstem function until 2 months had passed. By 9 months he had recovered some function be bilateral deafness persisted, as did mild quadreparesis.

The authors make the obvious point that toxic alcohol ingestion should have been suspected based on the high osmolar gap and anion gap. They also note that only a single case of ethylene glycol toxicity mimicking brain death (Snow White syndrome) has been reported previously.

ADDENDUM: [8/3/2012 – 11:06 am] – After posting the above and then going to bed, I woke up with a start at 4 am, filled with dread and the realization that I had missed the obvious — this case almost certainly didn’t involve ethylene glycol at all. Brake fluid usually contains diethylene glycol (DEG)and other glycol ethers. (Ethylene glycol is commonly a component of antifreeze, not brake fluid.)  DEG is extremely nephrotoxic. Toxic effects include renal failure, coma, metabolic acidosis (sometimes delayed), and delayed neurological deficits. Specific neurologic effects include peripheral neuropathy, demyelination, and axonal degeneration. Nerve conduction studies are consistent with axonal degeneration. These typical findings fit the case here exactly.

This report gives no information about the exact product consumed or its ingredients. There is no laboratory confirmation or any other support presented for the authors’ claim that the brake fluid contained ethylene glycol. In all, a remarkably sloppy performance by the authors (from King Fahad Medical City in Riyadh) and by BMJ Case Reports. I have downgraded the article from the original 3 skulls. What was I thinking?


One Comment:

  1. Rosalind Says:

    It may be concluded that your sleeping brain functions better than the awake brains of the authors and the peer-reviewers.