Ethylene glycol poisoning requiring critical care: Three case reports

Abstract

Rapid diagnosis and treatment of ethylene glycol poisoning can be challenging and is critical for reducing the morbidity and the mortality of this intoxication. Cases from our center were retrospectively reviewed. From the 12 cases of ethylene glycol poisoning found since 2007, we present here three with significant toxicity and requiring critical care. Case 1 was an accidental intoxication in a 67 year-old male presenting dysarthria and altered level of consciousness. The patient mistakenly drank a bottle of beer containing a blue liquid 15 h before admission. Case 2 was a voluntary intoxication in a 56 year-old male with coma. The patient was found unconscious under a bridge with 9 wine bottles near him. An open bottle of car antifreeze was found at his home. Case 3 was a voluntary intoxication in a 46 year-old female presenting dyspnea. Ingestion amount was around 3 L of antifreeze 2 days before. Ethylene glycol plasma level was measured using liquid chromatography with ultraviolet detection after benzoyl chloride derivatization. At admission, case 1 showed metabolic acidosis (pH = 7.01) with very high serum lactate (> 20 mmol/L, acute renal failure (serum creatinine = 141 μmol/mL) and acute respiratory failure. The patient was transferred to an intensive care unit (ICU) where he was intubated and received renal replacement therapy (RRT). Ethylene glycol plasma level was 614 mg/L. Fomepizole was started 10 hours after admission. The patient was hospitalized for 35 days. Evolution was favorable but marked with an acute coronary syndrome. Cardiac function was recovered afterward. At admission in the ICU, case 2 was in a coma (Glasgow coma scale 3), and presented dyspnea, metabolic acidosis (pH = 6.90) with very high serum lactate (> 20 mmol/L), acute renal failure (serum creatinine = 141 μmol/mL) and hyperkaliemia (6.6 mmol/L). The patient was intubated and received RRT. Ethylene glycol plasma level was 402 mg/L. Fomepizole was started 18 h after admission. The patient was hospitalized for 21 days. Evolution was favorable except for a lower lip pressure ulcer and chronic kidney injury. Follow up at 2 months showed a partial recovery of renal function. Case 3 presented at admission metabolic acidosis (pH = 7.14) with high serum lactate (8.1 mmol/L), acute respiratory failure and acute renal failure (serum creatinine = 114 μmol/L). After transfer to the ICU, the patient was intubated and received RRT. Ethylene glycol plasma level was 607 mg/L. Fomepizole was started about 4 h after admission. The patient was hospitalized for 23 days. Evolution was marked by a ventilator-associated pneumonia but was favorable otherwise. These 3 cases have in common a severe acidosis associated with an acute renal failure and respiratory disorders. High serum lactate has to be interpreted with caution due to analytical interference [1] . Neurological toxicity was characterized for case 1 and 2. The long hospitalization duration (21 to 35 days) reflects the severity of the intoxications. Fomepizole antidote treatment must be started as soon as possible. Ethylene glycol plasma concentration should be obtained to confirm the diagnosis if available. Even though ethylene glycol poisoning is well known, cases are rare but nonetheless can currently be life-threatening. They require fast diagnostic and treatment to avoid morbidity [2] .