University of Southern Denmark Rapid diagnosis of ethylene glycol poisoning by urine microscopy Sheta, Hussam Mahmoud; Al-Najami, Issam; Christensen, Heidi Dahl; Madsen, Jonna Skov Published in: American Journal of Case Reports DOI: 10.12659/AJCR.908569 Publication date: 2018 Document version: Final published version Document license: CC BY-NC-ND Citation for pulished version (APA): Sheta, H. M., Al-Najami, I., Christensen, H. D., & Madsen, J. S. (2018). Rapid diagnosis of ethylene glycol poisoning by urine microscopy. American Journal of Case Reports, 19, 689-693. https://doi.org/10.12659/AJCR.908569 Go to publication entry in University of Southern Denmark's Research Portal Terms of use This work is brought to you by the University of Southern Denmark. Unless otherwise specified it has been shared according to the terms for self-archiving. 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Sep. 2021 e-ISSN 1941-5923 © Am J Case Rep, 2018; 19: 689-693 DOI: 10.12659/AJCR.908569 Received: 2017.12.17 Accepted: 2018.03.21 Rapid Diagnosis of Ethylene Glycol Poisoning by Published: 2018.06.14 Urine Microscopy Authors’ Contribution: ABEF 1 Hussam Mahmoud Sheta 1 Department of Anaesthesia and Intensive Care, Lillebaelt Hospital, Kolding, Study Design A EF 2 Issam Al-Najami Denmark Data Collection B 2 Department of Surgery, Odense University Hospital, Svendborg, Denmark Statistical Analysis C EF 3 Heidi Dahl Christensen 3 Department of Nephrology, Hospital of South West Jutland, Esbjerg, Denmark Data Interpretation D ABEF 4,5 Jonna Skov Madsen 4 Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark Manuscript Preparation E 5 Institute of Regional Health Research, University of Southern Denmark, Odense, Literature Search F Denmark Funds Collection G Corresponding Author: Heidi Dahl Christensen, e-mail: [email protected] Conflict of interest: None declared Patient: Male, 57 Final Diagnosis: Ethylene glycol poisoning Symptoms: Unconsciousness and high anion gap Medication: Bicarbonate • electrolyte correction • intravenous ethyl alcohol infusion • hemodialysis Clinical Procedure: icroscopy of calcium oxalate monohydrate crystals Specialty: Nephrology • Intensive Care Unit • Biochemistry and Immunology Objective: Challenging differential diagnosis Background: Ethylene glycol poisoning remains an important presentation to Emergency Departments. Quick diagnosis and treatment are essential to prevent renal failure and life-threating complications. Case Report: In this case report, we present a patient who was admitted unconscious to the hospital. Ethylene glycol poi- soning was immediately suspected, because the patient had previously been hospitalized with similar symp- toms after intake of antifreeze coolant. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. The patient was treated with continuous intravenous ethyl alcohol infusion and hemodialysis. Two days after admission, the patient was awake and in clinical recovery. Conclusions: Demonstration of COM crystals using microscopy of a urine sample adds valuable information supporting the clinical suspicion of ethylene glycol poisoning, and may serve as an easy, quick, and cheap method that can be performed in any emergency setting. MeSH Keywords: Acute Kidney Injury • Calcium Oxalate • Ethylene Glycol • Poisoning Full-text PDF: https://www.amjcaserep.com/abstract/index/idArt/908569 1514 1 1 15 This work is licensed under Creative Common Attribution- Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) [Web of Science by Clarivate] 689 Sheta H.M. et al.: Rapid diagnosis of ethylene glycol poisoning © Am J Case Rep, 2018; 19: 689-693 Background On arrival, the patient had Glasgow coma scale 3/15; he was cyanotic and hypothermic (temperature 34.7°C), had Kussmaul Ethylene glycol is a common ingredient in many household breathing with frequency 28 breaths per min, blood pressure products such as household cleaners, cosmetics, and antifreeze was 150/90 mmHg, and heart rate was fluctuating at 75–150 coolant [1, 2]. In the United States there are nearly 6000 year- beats per min. ECG showed atrial fibrillation with frequen- ly cases of ethylene glycol poisoning reported to poison con- cy of 92 beats per min, and no other ECG abnormalities were trol centers, with most cases of accidental poisoning occur- described. The neurological examination revealed rigid limbs, ring in children [3, 4]. Ethylene glycol poisoning is associated and pupils with absent light reflex. with risk of severe morbidity and it continues to occur in many countries around the world [3]. Several deaths have been de- Computed tomography of the cerebrum and chest X-ray was scribed occurring 11–18 h after intake of ethylene glycol [2], performed and findings were unremarkable. Initial laborato- and early diagnosis and treatment are therefore essential. ry tests (Table 1) showed hyperkalemia (K+=5.1 mmol/L), high anion gap (anion gap 34.7mEq/L) and elevated lactic acid (lac- Ethylene glycol is metabolized in the liver by alcohol dehydro- tic acid >30 mmol/L). An arterial blood gas test suggested high genase to glycol aldehyde and then oxidized to glycolic acid, anion gap metabolic acidosis (pH 7.07, HCO3– 6.4 mmol/L). which is then metabolized to glyoxylic acid and finally to ox- alic acid. Oxalic acid binds with calcium to form calcium oxa- Bladder catheterization showed clear urine and urine drug late monohydrate (COM) crystals, which may deposit and cause screening was positive for benzodiazepines. The patient was tissue damage, especially in the kidneys [5]. immediately intubated and transmitted to the Intensive Care Unit (ICU). Treatment with bicarbonate and electrolyte correc- When COM crystals accumulate in renal tubules, they can lead tion was initiated, and, due to the suspicion of ethylene glycol to cell necrosis and serious renal failure [6]. The treatment for poisoning, the patient received continuously intravenous ethyl ethylene glycol poisoning is often commenced based on clin- alcohol infusion [7,8]. Due to the high level of lactic acid, the ical suspicion because diagnostic testing, such as measuring suspicion of sepsis could not be ruled out and treatment with the ethylene glycol concentration in blood, is not available in intravenous antibiotics (Meropenem and Metronidazole) was emergency settings [3,7]. The suspicion of ethylene glycol poi- initiated. Within 6 h after arrival, the first signs of renal fail- soning is often supported by indirect findings in blood sam- ure were observed by increasing creatinine values from 90 to ples, such as an increased serum osmolal gap and severe un- 138 µmol/L, decreasing urine production, and hyperkalemia. explained anion gap metabolic acidosis [1]. Furthermore, a worsening of acidosis (pH 6.90) and increased anion gap (35.5 mEq/L) was observed, and hemodialysis was Guidelines recommended quickly testing for ethylene glycol poi- therefore initiated. The patient developed hypotension and soning within 4 h and initiation of treatment within 6 h after increased heart rate, which were treated according the local intoxication, which is a challenge in clinical settings [4]. Ideally, guidelines in the ICU. A new urine sample was sent for exam- the validated biochemical diagnostics test would be preferred ination of urine sediment by means of light microscopy and to measuring the ethylene glycol concentration in blood, but showed multiple COM crystals, supporting the diagnosis of eth- such a method is not available in most hospitals [3,7]. A feasi- ylene glycol poisoning. The morphologic features of the COM ble and quick diagnostic approach is therefore needed in most crystals are presented in Figure 1 and are indicated by arrows. Emergency Departments. Two days after admission, the patient was in clinical recovery. The patient was extubated, hemodialysis and ethyl alcohol in- Case Report fusion were discontinued, and the patient had regained ac- ceptable urine production under furosemide stimulation. Blood A 57-year-old man was brought unconscious to our Emergency analyses showed normalized creatinine and calcium, the aci- Department. dosis was corrected, lactate was decreasing, and the patient was transferred from the ICU to the medical ward. The patient The patient was known to abuse alcohol and to have alcohol was later discharged to home in stable condition. dementia and arterial hypertension. Earlier that day, he was described by relatives as fully conscious but became increas- ingly confused before becoming unresponsive for no known Discussion reason. Noteworthy, the patient was previously hospitalized with a similar picture after intake of antifreeze coolant, and Ethylene glycol poisoning remains an important presentation at that time, ethylene glycol poisoning was suspected and lat- in Emergency Departments; quick diagnosis and treatment are er confirmed by the patient. necessary to prevent serious harm [9,10]. The